Pharmaceutical Benefits Under State Medical Assistance Programs, 2004

Pharmaceutical Benefits Under State Medical Assistance Programs

2004

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

©2005 by the National Pharmaceutical Council

This compilation of data on State Medical Assistance Programs (Title XIX) presents a general overview of the characteristics of State programs, together with detailed information on the pharmaceutical benefits provided. The data collection effort covers all States with Medicaid programs and the District of Columbia. Information for this compilation was acquired from multiple sources, including a survey of Medicaid prescription drug programs administered for the National Pharmaceutical Council by Muse & Associates, Washington, DC with assistance from Total Compensation Solutions and StateScape. While we have checked all secondary data in the book for consistency relative to the original source, we have not validated the original data reported by the Centers for Medicare and Medicaid Services (CMS) and other organizations. The data were compiled and the book prepared for publication by Donald Muse, Ph.D., David Goldenberg, Ph.D., Anne Marie Hummel, Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A., Jaclyn S. Kuwada, M.P.P, Steven Heath, M.P.A., Errica Philpott, Liz Segall, and Tiffany Crawford of Muse & Associates. Paul Gavejian and Matthew Leach of Total Compensation Solutions prepared and conducted the 2004 survey. James Elliott at StateScape supervised the compilation of information on State officials, State professional associations, and expanded drug programs for elderly and disabled beneficiaries. Gary Persinger and Kimberly Westrich of the National Pharmaceutical Council provided valuable input and support.

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TABLE OF CONTENTS INTRODUCTION......................................................................................................................................v SECTION 1: ESTIMATES OF MEDICAID EXPENDITURES AND RECIPIENTS: FY 2003 TO FY 2005 BY STATE ................................................................................ 1-1 SECTION 2: THE MEDICAID PROGRAM ..................................................................................... 2-1 Medicaid Program Overview.................................................................................................... 2-3 -

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

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

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

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

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

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

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

Health Care Delivery System − − − −

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

SECTION 4: PHARMACY PROGRAM CHARACTERISTICS..................................................... 4-1 Medicaid Drug Program ........................................................................................................... 4-3 − − − − − − −

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

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

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

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

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

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

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

SECTION 5: STATE PHARMACY PROGRAM PROFILES ......................................................... 5-1 SECTION 6: STATE PHARMACY ASSISTANCE PROGRAMS .................................................. 6-1 APPENDIXES Appendix A: State and Federal Medicaid Contacts.................................................................... A-1 Appendix B: Medicaid Program Statistics – CMS MSIS Tables ................................................B-1 Appendix C: Medicaid Rebate Law.............................................................................................C-1 Appendix D: Federal Upper Limits for Multiple Source Products............................................. D-1 Appendix E: Glossary ..................................................................................................................E-1

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INTRODUCTION The 2004 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 39th year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest sources of information on pharmacy programs within the State Medical Assistance Programs (Title XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled team and countless contributors, the “Medicaid Compilation” has become a standard reference and invaluable resource in government offices, research libraries, consultancies, the pharmaceutical industry, numerous businesses, and policy organizations. The data used to create each edition of the Compilation are assembled from numerous sources. The Compilation incorporates information on each State pharmacy program from an annual NPC survey of State Medicaid program administrators and pharmacy consultants, statistics from the Centers for Medicare and Medicaid Services (CMS), and information from other Federal agencies and organizations. In order to give a better understanding of the content of the “Medicaid Compilation,” the information contained in this version of the book is summarized below by section: •

Section 1: Presents estimates of Medicaid expenditures and recipients for FY 2003 to FY 2005 by State.

•

Section 2: Contains an overview of the Medicaid program, details about Medicaid managed care enrollment, including a breakdown by plan type and enrollment by plan type, and a synopsis of 1915(b) waivers and 1115 demonstrations.

•

Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and employment, for the fifty States and the District of Columbia for calendar year 2003. Additionally, a description of the Medicaid certified facilities in each State, including the number of hospitals, skilled nursing facilities, and intermediate care facilities for the mentally retarded (ICFs-MR), home health agencies, and rural health clinics are presented.

•

Section 4: Provides Medicaid pharmacy program characteristics, drawn largely from the 2004 NPC annual survey of State pharmacy program administrators. In addition, this section provides Medicaid eligibility statistics from CMS for fiscal year 2002 and program expenditure data for fiscal years 2002 and 2003. Medicaid pharmacy programs are characterized by estimates of total expenditures, drug payments, drug benefit design, and pharmacy payment and patient cost sharing.

•

Section 5: Contains detailed profiles of the States’ Medicaid pharmacy programs. This section contains a description of medical assistance benefits and eligibles, drug payments and recipients, benefit design, pharmacy payment and patient cost sharing, use of managed care, and State contacts.

•

Section 6: Profiles the “expanded” drug programs in States that are providing pharmaceutical coverage or discounts to the elderly and/or disabled persons.

The book also contains a series of appendices. Appendix A features a list of State contacts, CMS regional offices and Medicaid program personnel. Appendix B provides a national level summary on total Medicaid program recipients by type of service for FY 2001 and FY 2002 and data on total number of drug recipients for each State and the nation as a whole for the period 1996-2002. Appendix C provides the current Medicaid drug rebate law. Appendix D contains the list of CMS upper limits on multiple source products. Appendix E is a glossary and list of acronyms.

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Each year, finding and compiling current, relevant information for inclusion in the Compilation presents a challenge. This year was no exception. For example, CMS makes available on its website the Medicaid Statistical Information System (MSIS) Statistical Reports for the most recent enrollment and expenditure data available. MSIS tables are used in several sections of the Compilation as a secondary data source. This year, CMS released MSIS reports on Federal Fiscal Year 2002. However, the 2002 MSIS data have been reformatted to appear more like the older Health Care Financing Administration (HCFA) 2082 reports. Hence, we requested, and CMS provided, a special version of the 2002 MSIS Report in original MSIS format. This enabled us to compile 2002 data on pharmaceutical expenditures and recipients for inclusion in each State profile. Also, CMS has yet to release an update of The CMS 64-Report, a major data source used throughout the Compilation. However, we were fortunate to obtain a pre-release version of the 2003 CMS 64-Report and thank CMS for making it available to us. For the past several years, the Health Resources and Services Administration’s (HRSA) Area Resource File (ARF) has served as the primary source for statistics on physicians and registered nurses. Unfortunately, HRSA was not able to obtain updated physician information for the 2004 version of the ARF. Therefore, we have repeated last year’s data on physicians and registered nurses. As we continue to update and discover data, we are able to improve the Compilation with new tables and sources that we believe enhance its overall significance to the user. These new tables and sources include: • • •

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

NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program officials and their staffs. With their cooperation, we were able to achieve a 94 percent response rate to the 2004 Survey. Unfortunately, not all States were able to submit revised/updated information. In such instances, we have incorporated the most recently available data from other sources. However, for these States, much of the information may reflect data that have been presented in previous versions of the Compilation. We would also like to thank Muse & Associates and their subcontractors, Total Compensation Solutions, and StateScape, for administering the survey, compiling the information, and analyzing the data. We hope you continue to find the information contained in this compilation useful and, as always, we welcome your suggestions and comments. Gary Persinger Vice President, Health Care Systems National Pharmaceutical Council

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

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

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

SUMMARY The analysis presented in this Section is based on State reports to CMS. Table 1 contains aggregate data on total expenditures and number of recipients by fiscal year. Estimates by Muse & Associates are indicated by the bolded text. All other data are State actual, or estimated by the authors. Table 1 Total Program Expenditures and Recipients by Source By Fiscal Year: FY 2000 through FY 2005 Fiscal Year 2000 2001 2002 2003 2004 2005

Expenditures ($ billions) $195.2 $215.8 $245.7 $259.9 $289.8* $316.2*

Percent Increase NA** 11% 14% 6% 12% 9%

Recipients (millions) 42.9 46.2 49.8 53.4 57.5 62.0

Percent Increase NA** 8% 8% 7% 8% 8%

Source: CMS, State data reported to CMS (CMS-37, 64 and MSIS Reports) and Office of the Actuary, National Health Expenditures Estimates. The 2003-2005 recipient estimates were generated by Muse & Associates. *CMS, Office of the Actuary, January 2005. **Not Applicable 1

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

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

DATA The analysis presented in this Section is based on State data submitted to CMS. We assume that the States are in the best position to predict the future of their programs. Actual expenditure and recipient data for FY 2000 through FY 2002 were available from the Medicaid Statistical Information System (MSIS). Aggregate expenditure data for FY 2003 were available from State reports known as the CMS-64s. Expenditure estimates for FY 2004 and FY 2005 were compiled from State reports known as CMS-37s. Aggregate data by type of service and recipient estimates by State were prepared by Muse & Associates. Each of these sources is discussed below. MSIS Data MSIS files are used by CMS to produce data on Medicaid program characteristics and utilization information by State. The MSIS system collects, manages, analyzes, and disseminates information on eligibles, beneficiaries, utilization, and payment for services covered by each State Medicaid program. These data provide CMS with a large-scale database of State eligibles and services for many types of analyses. States provide CMS with quarterly computer files containing specified data elements for: (1) eligible persons who received services covered by Medicaid (recipient files); and (2) adjudicated claims (paid claims files) for medical services reimbursed with Title XIX funds. These data are furnished on the Federal fiscal year quarterly schedule, which begins October 1 of each year. Each State recipient file contains one record for each person covered by Medicaid for at least one day during the reporting quarter. Individual recipient records consist of demographic and monthly enrollment data. Paid claims files contain information from adjudicated medical service related claims and capitation payments. Each State submits to CMS four types of claims files representing inpatient, long-term care, prescription drugs, and non-institutional services. These are claims that have completed the State's payment processing cycle for which the State has determined it has a liability to reimburse the provider from Title XIX funds. Claims records contain information on the types of services provided, providers of services, service dates, costs, types of reimbursement, and epidemiological variables. The data files are subjected to quality assurance edits to ensure that the data are within acceptable error tolerances. A distributional review verifies the reasonableness of the data. Once accepted, valid tape files are created which serve as the historical source of detailed Medicaid eligibility and paid claims data maintained by CMS. The individual paid claims and eligible information are used for program analysis and research and to produce various public use reports that represent national Medicaid populations and expenditures. After processing, CMS creates the tables and publishes the data. The MSIS system was our primary source for expenditure and recipient data for FY 2000 through FY 2002.

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CMS-37s and 64s The primary source of data for our estimates for FY 2003 through FY 2005 is the CMS-37 Report, a financial reporting form submitted by the States to CMS. This form is submitted on a quarterly basis and requires the States to project their expenditures for two fiscal years. The single State agency must attest to the accuracy of the estimates. The data in the CMS-37s are used by CMS to set the amount the State may withdraw from the Federal Reserve for Federal Medicaid matching. The data on this form have known strengths and weaknesses. As with all State submitted data, some States appear to provide more accurate data than others. Not surprisingly, the States are clearly more accurate at predicting the present year, at this writing FY 2005, than they are at predicting the following year, FY 2006. States have, as of this writing, yet to adjust their FY 2006 Medicaid prescription drug expenditures for the implementation of the Medicare Modernization Act (MMA) which will transfer the fiscal responsibility for those recipients eligible for both Medicare and Medicaid to the Federal government. The limitations of the data led us not to attempt to estimate FY 2006. A third source of data was the CMS-64s, another fiscal reporting form submitted by the States which contains details of their past expenditures. These reports contain expenditures, reversals, disallowances, third-party collections and a variety of other adjustments. However, they represent the most current statement of State-by-State expenditures available for FY 2003. Hence, they were used for FY 2003 expenditure estimates. It must be noted that while the data from the three sources (the MSIS, CMS-37, and CMS-64) are highly correlated, they are not identical. The data do not match for a variety of reasons. Some are prospective and some are retrospective, some contain adjustments and other do not. Table 2 compares the three sources at the aggregate expenditure level. Table 2 Total Program Expenditures by Source By Fiscal Year: FY 2000 through FY 2005

($ billions) Fiscal Year

37s

64s

MSIS

2000

$168.3

$195.2

$168.3

2001

$185.8

$215.8

$185.8

2002

$213.5

$245.7

$213.5

2003

$268.5

$259.9

N/A**

2004*

$290.7

N/A**

N/A**

2005*

$315.7

N/A**

N/A**

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

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

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METHODOLOGY Muse & Associates has accumulated Medicaid data from the CMS-37, CMS-64, MSIS, and the forerunner to the MSIS, the HCFA 2082, for more than two decades. To create the estimates, we explored two methodological approaches. The first approach was regression based. Several different types of regressions were considered, including log-based approaches. The problem we encountered with regression analysis was that the regression model was over specified.6 This is primarily due to the fact that the number of States being estimated (fifty-one) is much larger than the small number of years (three) of data selected for use.7 Five years was selected because of the cyclical nature of the Medicaid program. CMS published an analysis that clearly shows the trend in drug spending between the first and second half of the 1990s.8 Their observations and our own analysis show that the optimum period that State trends appear stable is four years. The regression approach did not yield results with statistically significant predictability as measured by R2, a measure of the predictive ability of the regression model. Hence, this approach was abandoned. The approach that yielded more stable and predictive results was employing the cube root of the change over a four year period for each state with outliers trimmed.. However, several States had very significant programmatic changes in recent years that required data trimming. A total of four States required trimming.9 Outliers were defined as changes of more than 20 percent from year to year for year to year increase. These were trimmed to 20 percent. Two States, Tennessee and New Mexico presented special problems. The statistical portions of their data processing systems had considerable problems over the last five years. The estimates for these States were developed through direct conversations with State Medicaid officials. Factors Leading to Year-to-Year Variation in State Estimates The CMS-37 and CMS-64 reports from States often show significant swings for both total program and prescription drugs expenditures. State expenditures for Medicaid can have significant swings in spending for a variety of reasons. For example, all of the Medicaid data systems are on a cash basis rather than an accrual basis. States often have cash flow concerns that require that they pay claims on one side or the other at the end of the State fiscal year. Many States have the same Fiscal Year as the Federal government, which can result in FY data showing decreases followed by substantial increases in expenditures. In addition, States may incur large settlements with CMS and/or providers in a particular year. These, and a variety of other factors, lead to real swings in the expenditure data.

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

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In non-statistical terms, a regression model becomes over specified when the number of points being estimates exceeds the number of data points available for the analysis. 7 The District of Columbia was included in the analysis but Puerto Rico and the Trust Territories were excluded. 8 David Baugh, M.A, Penelope I. Pine, Steve Blackwell, Ph.D., J.D. R.Ph. and Gary Ciborowski, M.A.. Medicaid Prescription Drug Spending in the 1990s: A Decade of Change, Health Care Financing Review, Spring 2004, Volume 25, Number 3, page 5 to 23. 9 The States were Connecticut, Delaware, and Nevada. The District of Columbia also required trimming 1-6

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Medicaid expenditures, number of recipients, recipients of prescription drugs, and Medicaid program payments for prescription drugs. Tables 3 & 4 Table 3 shows the distribution of Medicaid expenditures by service category from the CMS-64s and the National Health Expenditures Accounts for the period FY 2000 through FY 2005. The data show that total Medicaid program expenditures have or are expected to increase annually by 6 to 14 percent per year between FY 2000 and FY 2005, or at an average annual increase of approximately 10 percent per year. Our estimates indicate that total Medicaid program expenditures will exceed $316 billion in FY 2005. The data from the CMS-64s indicate that pharmaceuticals are the third highest Medicaid program expenditure category in each fiscal year, exceeded only by nursing facility expenditures and payments for inpatient acute care hospital services. For FY 2005, we estimate that Medicaid program expenditures for pharmaceutical will be $44.3 billion. Table 4 presents national-level data from the MSIS system on the number of Medicaid recipients by type of service. Between FY 2000 and FY 2005, the number of Medicaid recipients has or is expected to increase at annual rates of between 6.4 percent and 7.8 percent, or at an average annual rate of about seven percent. In FY 2005, it is estimated that 62 million beneficiaries will receive medical services through the Medicaid program. Aside from capitated payment services (i.e., per capita payments to managed care organizations), the service category with the highest number of recipients is pharmaceuticals. It is estimated that 29.9 million Medicaid beneficiaries will receive pharmaceutical services during FY 2005. Tables 5 & 6 Presented in Tables 5 and 6 are data on total Medicaid expenditures and number of Medicaid recipients on a State-by-State basis for the period FY 2000 to FY 2005. The data source for the expenditures distributions in Table 5 is the CMS-37s. Based on State data submitted to CMS in their quarterly CMS-37 submissions, Medicaid program expenditures for FY 2005 are expected to total $315.7 billion, similar to the $316.2 billion FY 2005 estimate derived from the CMS-64s. Also shown in Table 5 are year-by-year data on total Medicaid expenditures by State for the period. A review of the State-by-State data indicates that in most States, Medicaid program spending has increased from one year to the next. There are few instances over the entire period where total Medicaid program spending has declined from one year to the next. The MSIS system was the primary source for data on the distribution Medicaid recipients by State (Table 6). CMS has released MSIS data through FY 2002. FY 2003, FY 2004, and FY 2005 are estimates, based on the cubed root of change over a 4 year period methodology discussed above. As shown in Table 6, the total number of Medicaid recipients, like the expenditure data in Table 5, has increased or is estimated to increase each year between FY 2005 and FY 2006. Likewise, with few exceptions, the number of Medicaid recipients has increased each year in each State over the period. Tables 7 & 8 Tables 7 and 8 present MSIS data on State-by-State prescription drug payments and the number of drug recipients for the period FY 2000-FY 2005. As shown in Table 7, Medicaid program payments for prescription drugs have more than doubled over the period, from approximately $20 billion in FY 2000 to an estimated $44.3 billion in FY 2005. Few states experienced any declines in prescription drug payments between one year and the next. The total number of Medicaid recipients receiving prescription drug services has increased by slightly more than 50 percent between FY 2000 and FY 2005 (Table 8). For FY 2005, it is estimated that 29.8

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million beneficiaries will receive prescription drug services under the Medicaid program. Most States are expected to experience increases in the number of Medicaid prescription drug recipients over the period. However, in a small number of States, including Kansas and Massachusetts, the number of Medicaid prescription drug recipients are expected to remain relatively constant or even decline slightly between FY 2000 and FY 2005. How Good are the Estimates? One way to ascertain whether an estimation methodology is accurate is to apply it to earlier years where the estimated year is known. We chose this methodology as way to address the question of the probable accuracy of our estimates. We applied the final estimation method to the years FY 1999 to FY 2002. Specifically, we used FY 1999, FY 2000, and FY 2001 data to predict FY 2002, a year in which we had actual values for aggregate and State-by-State data. The results were that the actual aggregate totals were within 0.3 percent of the estimated totals. The State-by-State estimates were less accurate but still within what we judge as acceptable limits. Forty-two States were within plus or minus five percent. Seven States were within plus or minus twenty percent, and two States exceeded twenty percent. Despite these limitations and the variations inherent in the use of different data systems, we believe that our estimates provide useful information on Medicaid program expenditures and recipients that is more up to date than that which is currently available from CMS.

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

FY 2000*

FY 2001*

FY 2002*

FY 2003*

FY 2004**

FY 2005**

Nursing Facility

$39,607,169,035

$43,317,811,704

$47,466,264,432

$44,345,682,144

$46,047,973,158

$46,995,743,244

Inpatient Acute Care Hospital

$36,650,532,554

$39,586,413,122

$43,690,502,629

$45,839,127,080

$49,388,028,311

$53,167,576,794

Pharmaceuticals

$20,551,215,451

$24,656,812,921

$29,339,050,970

$33,794,520,738

$39,601,058,000

$44,308,084,000

HCBS Waivers

$12,628,550,113

$14,864,788,473

$17,169,137,673

$19,302,698,045

$22,235,122,443

$25,429,224,889

ICF-Mentally Retarded

$10,184,590,576

$10,686,809,919

$11,205,483,449

$11,614,424,195

$12,134,327,720

$12,659,161,248

Hospital Outpatient

$7,055,207,899

$7,709,540,429

$9,245,799,624

$9,394,646,018

$10,335,637,983

$11,396,554,078

Inpatient Mental Health Hospital

$7,331,896,067

$6,862,423,184

$7,559,242,098

$7,299,165,193

$7,288,287,404

$7,436,036,077

Clinic

$5,863,580,557

$6,689,968,278

$7,499,886,627

$7,582,867,230

$8,261,463,159

$8,863,418,884

Physicians

$5,892,807,109

$6,670,379,109

$7,446,842,170

$7,863,653,436

$8,657,484,947

$9,443,626,907

Personal Care Services

$4,566,864,434

$5,251,140,806

$6,037,450,986

$7,881,552,380

$9,453,870,484

$11,500,806,850

Home Health Care

$2,311,780,853

$2,613,356,673

$2,766,480,497

$2,886,980,643

$3,108,920,442

$3,294,174,359

Dental

$1,795,228,321

$2,193,475,415

$2,630,870,620

$3,015,702,590

$3,584,908,827

$4,222,729,183

Other Practitioners

$1,030,135,204

$1,141,272,064

$1,413,870,565

$1,438,109,885

$1,607,279,303

$1,801,601,525

$829,205,382

$935,836,328

$1,007,637,056

$1,079,836,415

$1,179,206,654

$1,273,659,272

$612,378,794 $38,245,755,438

$660,398,684 $41,969,472,522

$781,820,930 $50,437,280,350

$856,521,207 $55,700,409,296

$957,879,281 $65,958,551,884

$1,084,290,467 $73,323,312,221

$245,697,620,676

$259,895,896,495

$289,800,000,000

$316,200,000,000

14%

6%

12%

9%

EPSDT Lab/X-ray Other Total Expenditures*** Percent Change from Year to Year

$195,156,897,787

$215,809,899,631 11%

*Source: CMS-64 Reports **Source: CMS, Office of the Actuary, National Health Expenditures Estimates, January 2005 and Muse & Associates Estimat ***T otals may not add due to rounding

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

FY 1999*

FY 2000*

FY 2001*

FY 2002*

FY 2003**

FY 2004**

FY 2005**

Capitated Payment Services

20,678,898

21,292,179

23,355,569

25,863,748

27,866,311

30,481,238

33,310,411

Pharmaceuticals

19,428,344

20,324,675

21,910,532

24,424,493

26,027,090

27,929,225

Physicians

18,052,586

18,965,002

20,021,029

22,102,682

23,645,409

25,449,435

29,946,171 27,568,220

Hospital Outpatient

12,323,540

13,169,841

13,731,009

14,861,211

15,818,323

16,814,621

17,989,342

Lab/X-ray

10,103,678

11,438,835

12,339,065

14,067,422

15,708,192

17,459,869

19,601,707

Other Care^

8,781,097

9,232,630

9,897,625

11,195,848

12,140,216

13,300,258

14,676,970

Clinic

6,660,804

7,677,662

8,463,753

9,498,844

10,691,832

11,939,693

13,390,698

Dental

5,577,468

5,922,244

7,018,692

7,885,538

8,850,397

10,118,626

11,430,801

PCCM Services

3,962,942

5,649,174

6,377,864

7,177,583

8,749,134

10,122,593

11,807,662

Hospital Inpatient

4,479,391

4,912,833

4,879,194

5,051,356

5,257,803

5,378,094

5,555,483

Other Practitioners

3,945,721

4,758,086

5,102,653

5,570,691

6,249,376

6,843,917

7,547,579

Personal Support Services

4,061,799

4,558,732

4,977,823

5,688,386

6,364,231

7,112,898

8,011,532

Nursing Facility

1,624,163

1,705,947

1,702,251

1,765,700

1,815,569

1,853,653

1,907,056

Home Health Care

808,751

1,007,025

1,013,796

1,065,050

1,167,405

1,226,353

1,306,684

ICF-Mentally Retarded Mental Health Facility

121,318 96,904

118,857 99,521

116,610 91,209

117,497 99,403

116,250 100,250

115,394 100,495

114,992

40,300,394

42,886,999

46,163,776

49,754,619

53,446,822

57,546,074

61,991,626

6%

8%

8%

7%

8%

8%

Total Unduplicated Recipients*** Percent Change from Year to Year

*Source: CMS Medicaid Statistical Information System ** Source Muse & Asscoiates Estimates *** Since any recipient can get any number of different typess of service, the unduplicated total is not a sum.

^ includes sterilizations and unknown care

1-9

103,795

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Table 5 Total Medicaid Expenditures in thousands of dollars by Fiscal Year by State S tate National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana M aine M aryland M assachusetts M ichigan M innesota M ississippi M issouri M ontana Nebraska Nevada New Hampshire New Jersey New M exico 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

FY 2000 $168,307,231 $2,391,195 $470,250 $2,111,770 $1,510,080 $17,060,494 $1,808,569 $2,839,310 $528,340 $792,584 $7,350,363 $3,577,903 $535,163 $593,751 $7,807,447 $2,976,177 $1,476,340 $1,226,211 $2,912,792 $2,630,563 $1,306,809 $3,585,781 $5,397,153 $4,880,769 $3,277,014 $1,807,392 $3,270,152 $433,208 $958,490 $515,444 $650,594 $4,706,929 $1,248,764 $26,147,613 $4,830,026 $356,185 $7,090,396 $1,603,789 $1,700,409 $6,365,806 $1,069,994 $2,672,146 $401,175 $3,490,957 $9,075,306 $959,100 $479,259 $2,483,931 $2,432,050 $1,391,731 $2,905,599 $213,958

FY 2001

FY 2002

$185,786,851 $2,950,096 $557,399 $2,453,184 $1,684,718 $19,824,989 $1,952,709 $2,962,088 $601,182 $830,258 $8,398,160 $3,815,267 $535,163 $713,433 $8,150,021 $3,355,996 $1,660,864 $1,370,248 $3,235,073 $2,881,578 $1,457,466 $3,855,003 $5,765,108 $5,316,249 $3,766,605 $2,180,662 $3,626,213 $482,543 $1,089,788 $565,300 $691,196 $5,011,795 $1,476,538 $27,497,918 $5,499,094 $374,197 $7,772,738 $2,004,799 $1,878,673 $7,634,325 $1,095,853 $3,096,854 $426,634 $4,059,332 $9,644,600 $1,059,730 $541,283 $2,715,962 $2,432,050 $1,565,009 $3,029,723 $241,187

$213,491,313 $3,204,064 $686,795 $2,881,870 $2,015,437 $23,636,240 $2,166,200 $3,245,143 $651,385 $1,027,022 $9,827,004 $4,796,005 $695,279 $791,864 $9,121,713 $3,725,258 $1,855,817 $1,501,270 $3,459,366 $3,234,422 $1,716,582 $3,662,090 $6,387,100 $5,918,817 $4,439,494 $2,499,641 $4,071,544 $532,886 $1,255,040 $723,957 $745,754 $5,497,284 $1,796,901 $31,488,930 $6,041,011 $422,745 $9,186,331 $2,238,213 $2,136,401 $8,523,928 $1,251,440 $3,382,951 $503,947 $4,747,550 $11,121,020 $1,215,620 $607,250 $3,017,870 $4,373,171 $1,577,698 $3,605,542 $280,452

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

1-10

FY 2003 $268,496,116 $3,603,097 $774,755 $4,253,304 $2,394,653 $29,897,092 $2,597,187 $3,691,626 $737,360 $1,072,802 $11,041,401 $7,055,152 $759,731 $853,256 $8,954,270 $4,584,428 $2,360,040 $1,789,086 $3,864,583 $4,858,435 $1,680,703 $4,359,399 $8,632,074 $8,150,661 $5,117,771 $3,028,552 $5,578,991 $519,065 $1,351,142 $989,559 $1,014,956 $8,358,844 $2,030,060 $40,551,353 $7,139,629 $463,348 $10,601,589 $2,402,648 $2,757,488 $13,168,602 $1,472,595 $3,766,709 $546,789 $6,639,519 $15,289,859 $1,123,620 $713,582 $3,706,653 $5,180,773 $1,873,502 $4,806,489 $337,334

FY 2004

FY 2005

$290,680,584 $3,445,986 $909,840 $5,135,647 $2,762,943 $32,173,749 $2,703,792 $3,866,361 $752,775 $1,165,242 $12,340,063 $7,045,377 $846,973 $905,311 $10,073,437 $4,699,660 $2,196,622 $1,754,285 $4,075,918 $4,633,523 $1,916,751 $4,494,121 $8,987,848 $8,507,062 $5,225,883 $3,280,007 $5,966,126 $601,474 $1,354,239 $1,053,794 $1,180,678 $7,883,350 $2,230,879 $49,425,404 $7,613,812 $496,642 $12,030,919 $2,720,199 $2,535,181 $14,422,482 $1,533,600 $3,576,207 $579,726 $6,735,962 $16,621,374 $1,258,360 $766,279 $4,156,487 $5,304,530 $1,912,439 $4,478,875 $342,390

$315,701,965 $3,850,214 $942,281 $5,772,557 $2,989,172 $36,362,263 $2,902,011 $4,103,564 $855,737 $1,241,190 $13,790,043 $7,154,685 $1,026,277 $1,058,487 $11,400,358 $5,563,225 $2,448,931 $2,096,225 $4,464,305 $4,990,753 $2,072,414 $4,708,992 $9,968,515 $8,850,936 $5,719,244 $3,658,914 $6,744,680 $700,806 $1,424,542 $1,160,591 $1,272,117 $8,416,526 $2,416,959 $49,312,629 $8,901,127 $535,293 $12,595,864 $2,860,078 $3,057,873 $16,466,731 $1,771,549 $4,097,262 $666,494 $7,837,560 $17,735,949 $1,428,054 $862,161 $4,723,322 $5,762,663 $2,157,688 $4,403,336 $398,818

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Table 6 Total Unduplicated Medicaid Recipients by State by Fiscal Year State National Total Alabama Alaska

FY 2000*

FY 2001*

FY 2002*

FY 2003**

FY 2004**

FY 2005**

42,886,999

46,163,776

49,754,619

53,446,822

57,546,074

61,991,626

619,480

882,105

765,328

836,803

925,028

939,796

96,432

105,464

109,641

119,836

128,838

137,728 1,244,229

Arizona

681,258

763,422

878,362

976,625

1,101,200

Arkansas

489,325

531,533

579,278

622,674

674,759

730,614

7,918,151

8,583,027

9,301,001

10,323,828

11,278,372

12,353,265

Colorado

381,018

393,160

425,878

450,793

476,784

508,439

Connecticut

419,968

685,246

479,051

502,652

533,685

533,685

Delaware

115,267

122,947

167,162

193,885

230,582

276,698

California

District of Columbia

138,677

140,719

193,494

218,982

255,002

306,002

Florida

2,372,585

2,471,771

2,676,235

2,833,382

3,006,073

3,208,707

Georgia

2,106,303

1,369,006

1,514,398

1,637,329

1,777,775

1,939,549

Hawaii

194,376

191,533

199,966

198,658

200,106

203,048

Idaho

131,077

157,121

176,499

200,665

231,270

263,077

Illinois

1,519,313

1,657,954

1,731,398

1,834,859

1,953,984

2,063,973

Indiana

706,476

777,418

849,427

940,652

1,034,840

1,138,359

Iowa

313,648

319,740

352,635

368,428

388,738

414,900

Kansas

262,557

272,783

289,349

296,359

308,567

321,509

Kentucky

763,587

806,578

808,294

847,565

877,563

902,586

Louisiana

761,252

804,996

898,824

966,003

1,045,831

1,141,171

Maine

193,582

251,511

275,826

316,222

372,421

424,483

Maryland

625,863

656,307

692,539

732,052

771,312

813,962

Massachusetts

1,059,612

1,054,916

1,065,636

1,073,987

1,078,821

1,086,909

Michigan

1,606,888

1,351,852

1,352,610

1,449,915

1,490,027

1,539,155

Minnesota

558,089

600,686

620,652

641,859

672,488

698,281

Mississippi

605,078

707,911

712,457

794,881

870,561

932,694

Missouri

890,338

978,656

1,036,150

1,128,728

1,221,614

1,315,332

Montana

104,354

108,409

103,617

106,048

106,619

106,029

Nebraska

229,379

243,421

255,771

270,822

286,238

302,123

Nevada

138,076

153,777

202,306

231,948

275,728

330,873

96,935

97,062

104,138

108,072

112,062

117,561

New Jersey

821,579

881,468

954,491

1,002,879

1,071,803

1,143,978

New Mexico

375,585

385,180

798,665

958,398

1,150,078

1,380,093

New York

3,419,983

3,590,999

3,920,718

4,180,420

4,469,771

4,808,120

North Carolina

1,214,174

1,309,810

1,355,269

1,424,834

1,502,884

1,573,372

63,165

63,566

70,132

73,108

76,759

81,739

1,304,886

1,498,322

1,656,124

1,805,943

2,012,556

2,220,558

New Hampshire

North Dakota Ohio Oklahoma

507,060

589,363

631,498

699,125

778,132

853,644

Oregon

557,809

582,112

621,462

649,472

683,258

720,739

Pennsylvania

1,492,352

1,557,801

1,627,261

1,652,312

1,709,355

1,763,081

Rhode Island

178,859

188,228

199,014

213,572

226,581

241,029

South Carolina

689,159

760,805

809,136

871,535

942,482

1,012,216

South Dakota

102,039

109,516

117,631

130,669

141,898

154,694

T ennessee

1,568,318

1,602,027

1,732,381

1,797,473

1,881,071

1,984,497

T exas

2,633,498

2,659,932

2,952,569

3,113,488

3,292,193

3,534,736

Utah

224,732

232,997

274,707

294,790

322,698

359,703

Vermont

139,351

149,763

153,731

161,978

170,309

177,766

Virginia

626,996

619,727

665,203

680,602

699,471

728,271

Washington

895,567

957,731

1,039,070

1,105,389

1,185,735

1,273,217

West Virginia

342,189

349,229

362,030

367,825

376,790

386,452

Wisconsin Wyoming

576,636 46,451

637,069 50,950

716,298 59,071

793,773

883,002

984,509

64,164

71,459

79,989

*Source: Data from M edicaid Statistical Information System 2000 to 2002. ** Source: M use and Associates Estimates

1-11

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Table 7 Medicaid Prescription Drug Payments, Before Rebates are Deducted in thousands of dollars by State by Fiscal Year S tate National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana M aine M aryland M assachusetts M ichigan M innesota M ississippi M issouri M ontana Nebraska Nevada New Hampshire New Jersey New M exico 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

FY 2000*

FY 2001*

FY 2002*

FY 2003**

FY 2004***

FY 2005***

$19,898,312 $331,577 $53,404 $1,953 $209,933 $2,316,407 $153,250 $264,645 $66,264 $55,095 $1,368,714 $586,864 $58,839 $83,568 $846,986 $464,985 $194,212 $167,632 $465,788 $477,852 $176,215 $222,250 $682,873 $374,353 $221,522 $370,355 $602,457 $59,250 $135,402 $51,683 $80,560 $585,892 $57,504 $2,366,916 $794,630 $38,079 $882,955 $178,254 $163,523

$23,764,447 $392,483 $66,768 $4,668 $248,391 $2,808,442 $178,063 $304,481 $81,623 $62,296 $1,490,096 $702,719 $71,232 $105,497 $934,231 $562,127 $231,010 $189,946 $599,970 $556,393 $204,015 $267,760 $796,341 $604,782 $265,098 $494,809 $682,958 $69,742 $161,820 $63,364 $90,928 $649,650 $70,202 $2,782,394 $971,104 $43,288 $1,118,120 $216,827 $222,392

$28,408,182 $454,370 $83,324 $4,339 $279,645 $3,402,508 $202,286 $356,980 $100,113 $68,051 $1,736,992 $749,552 $81,454 $121,781 $1,222,947 $636,358 $277,754 $220,801 $661,410 $682,557 $250,332 $320,314 $952,791 $674,898 $294,839 $568,084 $799,910 $77,981 $196,526 $90,135 $98,837 $686,302 $92,674 $3,413,405 $1,069,141 $51,750 $1,330,569 $267,549 $269,937

$33,794,521 $536,223 $69,512 $4,744 $310,709 $4,219,505 $225,298 $403,802 $109,845 $81,763 $2,018,037 $1,073,715 $97,386 $132,143 $1,469,191 $627,575 $331,222 $228,921 $685,230 $827,713 $268,548 $429,589 $946,211 $758,267 $276,731 $568,007 $941,522 $79,772 $210,200 $106,821 $112,949 $766,996 $86,408 $4,218,812 $1,291,263 $56,960 $1,520,147 $301,294 $262,335

$39,601,058 $605,511 $116,150 $5,548 $387,052 $4,750,190 $257,798 $398,722 $93,525 $124,842 $2,429,764 $1,193,822 $110,648 $149,492 $1,961,260 $731,105 $378,817 $270,542 $800,000 $881,272 $258,764 $495,397 $1,024,485 $864,623 $413,889 $772,523 $1,102,434 $90,075 $234,619 $127,271 $124,977 $1,074,306 $99,646 $4,942,274 $1,567,559 $60,718 $1,804,931 $274,858 $214,588

$44,308,084 $605,879 $121,760 $6,267 $434,360 $5,317,841 $295,078 $472,331 $111,529 $134,209 $2,674,708 $1,218,423 $125,751 $170,886 $2,056,659 $824,891 $430,892 $304,050 $887,357 $978,547 $253,115 $524,293 $1,001,318 $999,294 $420,785 $750,000 $1,292,349 $103,011 $253,346 $149,591 $145,276 $1,143,626 $113,460 $5,602,883 $1,493,467 $68,164 $2,087,450 $486,920 $238,388

$533,534

$690,559

$719,243

$791,054

$904,875

$1,100,066

$89,482

$104,918

$126,331

$140,687

$160,000

$186,000

$334,746

$438,502

$456,977

$558,129

$624,704

$571,057

$44,651 $0 $1,125,248 $101,145 $92,391 $381,391 $389,977

$52,611 $0 $1,327,255 $117,478 $105,994 $419,148 $464,083

$63,655 $573,588 $1,591,828 $140,520 $115,624 $453,663 $549,216

$71,223 $1,280,130 $1,920,866 $163,218 $127,764 $506,414 $592,437

$83,503 $1,793,149 $2,202,804 $192,000 $147,557 $595,258 $659,706

$94,589 $2,536,901 $2,554,080 $233,000 $181,165 $672,205 $711,718

$216,077 $349,560 $27,466

$256,395 $389,374 $32,100

$274,613 $455,721 $38,009

$345,831 $592,295 $49,106

$388,383 $601,206 $53,916

$446,874 $676,921 $55,354

*Source: Data from M edicaid Statistical Information System. **FY 2003 Data from CM S-64 Report. ***FY 2004 andFY 2005 are M use & Associates estimates.

1-12

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Table 8 Medicaid Recipients Receiving Prescription Drugs by State by Fiscal Year S tate National Total Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana M aine M aryland M assachusetts M ichigan M innesota M ississippi M issouri M ontana Nebraska Nevada New Hampshire New Jersey New M exico 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

FY 1999* 19,428,344 405,330 52,070 5,545 280,552 2,252,441 151,537 108,754 73,093 37,862 991,927 843,353 35,837 81,980 966,790 361,661 213,144 153,054 366,051 551,698 143,548 159,779 671,741 436,848 184,075 375,573 412,597 59,182 155,136 48,534 71,039 301,022 55,018 2,024,870 812,234 37,780 796,720 222,456 174,931 520,221 49,277 446,893 50,780 0 1,853,348 130,682 89,547 377,588 301,907 274,894 224,165 33,280

FY 2000* 20,324,675 438,529 60,273 7,034 290,749 2,491,537 160,265 113,101 78,167 38,129 1,078,631 882,309 37,316 92,776 1,013,387 420,071 212,178 158,334 425,721 581,356 149,262 163,410 671,716 435,723 179,879 415,925 447,068 58,918 166,031 51,170 73,313 299,356 67,239 2,173,856 827,389 38,964 777,632 221,985 193,924 416,498 49,809 474,470 53,666 0 1,852,828 133,224 103,635 344,877 339,611 262,675 267,417 33,342

FY 2001* 21,910,532 464,695 65,278 9,761 321,920 2,489,050 143,167 116,785 85,350 35,324 1,165,866 978,404 39,288 112,357 1,068,687 464,975 221,690 158,515 476,774 628,574 194,288 171,747 671,756 551,680 187,854 478,409 472,645 63,352 178,634 58,699 73,489 305,962 75,892 2,458,197 907,741 39,758 934,632 252,025 223,580 461,114 50,411 542,768 58,212 0 1,917,398 136,719 109,578 334,008 385,408 269,174 262,238 36,704

*Source: Data from Medicaid Statistical Information System. **Source: Muse & Associates Estimates.

1-13

FY 2002* 24,424,493 500,789 70,550 7,805 356,233 2,651,229 153,520 123,704 125,461 45,216 1,245,841 1,076,904 39,320 125,537 1,199,933 490,386 245,711 157,618 489,416 689,973 224,664 181,101 659,626 577,785 190,577 526,923 493,230 67,365 194,889 71,950 78,861 296,059 122,098 2,567,595 949,795 44,428 997,246 276,111 242,865 464,848 53,729 576,136 64,948 916,968 2,153,316 152,268 112,227 319,196 423,758 276,338 309,795 42,652

FY 2003** 26,027,090 537,366 78,067 8,747 385,752 2,799,273 154,187 129,131 150,217 47,972 1,344,178 1,168,332 40,555 144,697 1,289,531 542,771 257,637 159,169 539,167 743,377 260,843 188,823 655,636 634,227 192,795 589,881 523,469 70,337 210,287 82,040 81,655 294,423 146,518 2,779,092 1,000,644 46,894 1,074,734 296,731 270,935 447,733 55,301 627,045 70,500 916,968 2,263,730 160,228 120,998 301,812 474,460 276,821 345,072 46,330

FY 2004** 27,929,225 575,035 85,097 9,406 423,875 2,910,077 152,212 134,964 186,761 51,788 1,446,499 1,282,965 41,696 167,804 1,397,390 591,173 274,860 159,449 583,342 806,860 314,187 198,144 650,363 718,770 197,303 662,747 551,734 74,615 227,520 96,020 84,642 292,797 175,821 3,016,202 1,066,112 49,882 1,197,136 326,871 302,883 458,656 57,263 688,117 77,212 916,968 2,420,033 170,396 127,410 288,688 530,402 281,704 375,679 51,699

FY 2005** 29,946,171 617,357 92,960 9,291 464,587 3,065,689 155,353 141,632 242,463 58,833 1,554,324 1,404,258 42,530 191,809 1,528,058 640,437 295,279 159,761 623,917 876,890 368,782 207,815 643,384 785,038 200,557 738,807 580,935 78,798 246,626 113,137 88,724 288,535 210,985 3,229,051 1,124,820 53,800 1,300,103 356,469 335,137 457,840 59,747 744,752 84,836 916,968 2,615,316 183,373 133,977 274,991 589,975 286,009 423,504 57,952

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Section 2: The Medicaid Program

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

MEDICAID ELIGIBILITY Medicaid Eligibility: Medicaid is a “means tested program for low-income individuals.” To qualify, a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits prescribed in the law and regulations. Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition, the State has the option of providing Medicaid benefits to certain additional categories of persons. These are the “optional” categorically needy. An additional category of Medicaid recipients that a State may choose to include in its program is the “medically needy.” Mandatory Categorically Needy: There are numerous and detailed categories under which the “categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory categorically needy are: •

Low-income families with children;

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Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and Disabled (this includes disabled children);

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Individuals qualified for adoption assistance agreements or foster care maintenance payments under Title IV-E of the Social Security Act;

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Qualified pregnant women;

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Newborn children of Medicaid-eligible women;

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Various categories of low-income children; and

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Certain low-income Medicare beneficiaries.

Optional Categorically Needy: These are groups of individuals who meet the characteristics of the mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in determining their incomes and resources, they are allowed to exclude certain kinds of income. The “optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives, and pregnant women who meet the SSI income and resources requirements but are not receiving SSI cash payments. Medically Needy: The “medically needy” are those individuals who meet the definitional requirements described above, except that their income or resources exceed the limitations applicable to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct their medical bills from their income and resources until they meet the applicable income and resources requirements. Their Medicaid benefits can then begin. Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special categories of individuals. In general, these are individuals whose income and resources would otherwise be too high to qualify for full Medicaid benefits under the regular provisions.

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

MEDICAID SERVICES Title XIX lists the many types of medical care that a State may select for inclusion into its Medicaid State Plan, thus qualifying for Federal matching payments. However, the law requires that certain basic benefits must be available to all “categorically needy” recipients. These services include: • • • • • • • • • • • •

Inpatient and outpatient hospital services; Physician services; Medical and surgical dental services; Laboratory and X-ray services; Nursing facility services (for persons 21 years of age or older); Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21; Family planning services and supplies; Home health services for persons eligible for nursing facility services; Rural health clinic services and any other ambulatory services offered by a rural health clinic that are otherwise covered under the State Plan; Nurse-midwife services (to the extent authorized under State law); Pediatric and family nurse practitioners services; and Federally-qualified health center (FQHC) services and any other ambulatory services offered by an FQHC that are otherwise covered under the State Plan.

If a State chooses to include the “medically needy” population, the State Plan must provide, as a minimum, the following services: • • • •

Prenatal care and delivery services for pregnant women; Ambulatory services to individuals under age 18 and individuals entitled to institutional services; Home health services to individuals entitled to nursing facility services; and If the State Plan includes services either in institutions for mental diseases or in intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically needy groups certain specified services provided to the categorically needy.

States may also receive Federal funding if they elect to provide other optional services. The most commonly covered optional services under the Medicaid program include: • • • • •

Clinic services; Services of ICFs/MR; Nursing facility services (children under 21 years old); Prescribed drugs; Optometrist services and eyeglasses; 2-4

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TB-related services for TB infected persons; Prosthetic devices; and Dental services.

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

CHARACTERISTICS OF BENEFITS PROVIDED Inpatient Hospital Services Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of inpatients. The facility is one maintained primarily for the care and treatment of patients with disorders other than mental diseases. There are several general Federal limitations on inpatient hospital services that apply to all States with Medicaid programs (42 CFR 440.10): • • • •

•

The facility must be licensed or formally approved as a hospital by an officially designated authority for State standard setting; The facility must meet the requirements for participation in Medicare as a hospital; The care and treatment of inpatients must be under the direction of a physician or dentist; and The facility must have in effect an approved utilization review plan, applicable to all Medicaid patients, unless a waiver has been granted by the Secretary of Health and Human Services, because the State’s own utilization review procedures are adequate. A peer review organization (PRO) may satisfy these requirements.

In addition to the Federal limitations, each State may impose further limitations on inpatient hospital services.

Outpatient Hospital Services Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient. Three Federal limitations are imposed on these services, though States are free to specify other limits on outpatient hospital services and many have chosen to do so. • •

The services must be provided under the direction of a physician or dentist; The facility must be licensed or formally approved as a hospital by an officially designated authority for State standard setting; and

•

The facility must meet the requirements for participation in Medicare as a hospital.

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

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

Other Laboratory and X-Ray Services Other laboratory and X-ray services are professional and technical laboratory and radiological services. These services must be: •

• • •

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

Nursing Facility Services Nursing facility (NF) services are provided to individuals age 21 or older. They do not include services provided in institutions for mental diseases. These services must be needed on a daily basis and must be provided in an inpatient facility. Federal regulations require that the services be: • •

Provided by a facility or a distinct part of a facility that is certified to meet the requirements for participation in the Medicaid program as a NF; and Ordered by and furnished under the direction of a physician.

Early and Periodic Screening, Diagnostic and Treatment Services Early and periodic screening, diagnostic and treatment (EPSDT) refers to screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care, treatment and other measures to correct or ameliorate any defects and chronic conditions discovered (42 CFR 440.40(b)). Certain basic screening and treatment services must be provided by each State as a minimum (42 CFR 441.56). These services include: Screening: • • • • • •

Comprehensive health and developmental history screening; Comprehensive unclothed physical examination; Appropriate vision testing; Appropriate hearing testing; Appropriate laboratory tests; Dental screening services furnished by direct referral to a dentist for children beginning at 3 years of age.

Diagnosis and Treatment: In addition to any diagnostic and treatment services included in the State Medicaid Plan, the State must provide to eligible EPSDT recipients the following services, the need for which is indicated by screening, even if the services are not included in the Plan: • Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and hearing aids; • Dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health; and 2-6

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Appropriate immunizations. (If it is determined at the time of screening that immunization is needed and appropriate to administer at the time of screening, then immunization treatment must be provided at that time.)

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

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

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

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

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

Home Health Services Home health services are provided to a recipient at his or her place of residence. This does not include a hospital, nursing facility, or (ordinarily) an ICF/MR. Services provided must be on physicians’ orders as part of a written plan of care that is reviewed by the physician every 60 days. Home health services include three mandatory services (part-time nursing, home health aide, medical supplies and equipment) and four optional services (physical therapy, occupational therapy, speech pathology, and audiology services) (42 CFR 440.70). These services are defined as follows: •

• • •

•

Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a home health agency. If there is no home health agency in the area, services may be provided by a registered nurse who is currently licensed to practice in the State, receives written orders from the patient’s physician, documents the care and services provided, and has had orientation to acceptable clinical and administrative record keeping from a health department nurse. Home Health Aide: Home health aide services provided by a home health agency. Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are suitable for use in the home. Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology Services: PT, OT, speech and hearing services provided by a home health agency or a facility licensed by the State to provide medical rehabilitation. Home health services are provided to categorically needy recipients age 21 and over and to those under 21 only if the State Plan provides SNF services for them.

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

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

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

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

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

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

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

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

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Total Medicaid Eligibles by Maintenance Assistance Status, 20021 Receiving Total Cash Medically Poverty 1115 MAS State Eligibles Needy Related Assistance Other Demonstration Unknown National Total 51,552,491 18,215,830 4,401,790 15,073,035 8,638,035 5,222,626 1,175 Alabama 845,125 285,853 0 415,276 37,583 106,412 1 Alaska 121,400 51,076 0 59,975 10,349 0 0 Arizona 1,053,602 464,480 0 261,509 191,223 136,390 0 Arkansas 608,017 157,551 10,178 240,028 53,153 147,107 0 California 9,336,447 4,248,290 954,214 515,990 1,439,123 2,178,830 0 Colorado 438,670 219,239 0 163,359 56,072 0 0 Connecticut 487,989 90,988 37,438 77,862 281,701 0 0 Delaware 147,197 69,003 0 13,727 42,564 21,903 0 District of Columbia 204,591 121,320 37,458 35,262 10,551 0 0 Florida 2,691,502 1,113,402 73,312 978,702 387,399 138,672 15 Georgia 1,459,631 525,736 11,140 647,738 275,017 0 0 Hawaii 195,684 97,250 2,434 44,997 15,949 35,054 0 Idaho 196,406 27,994 0 112,074 56,338 0 0 Illinois 2,076,146 293,787 464,565 907,285 247,823 162,686 0 Indiana 881,942 346,171 0 334,326 201,445 0 0 Iowa 358,708 153,913 10,470 111,512 82,813 0 0 Kansas 305,110 106,986 20,423 125,774 51,927 0 0 Kentucky 769,826 343,646 34,626 313,097 78,457 0 0 Louisiana 990,286 347,677 12,207 526,815 103,587 0 0 Maine 346,449 75,324 2,281 89,232 63,619 115,993 0 Maryland 752,065 208,927 91,591 396,639 54,907 0 1 Massachusetts 1,204,312 330,017 21,919 444,390 154,005 253,981 0 Michigan 1,527,627 438,127 128,552 524,624 436,113 0 211 Minnesota 680,627 227,569 55,720 47,787 229,354 120,197 0 Mississippi 707,986 305,857 0 380,081 22,009 0 39 Missouri 1,098,525 679,410 0 128,970 170,202 119,943 0 Montana 106,229 45,831 8,812 25,458 26,119 0 9 Nebraska 266,245 62,809 43,608 130,929 28,238 0 661 Nevada 203,251 78,290 0 65,462 59,499 0 0 New Hampshire 115,517 26,064 11,039 53,280 25,134 0 0 New Jersey 982,676 359,040 5,133 373,027 145,072 100,404 0 New Mexico 462,878 184,972 0 206,152 59,022 12,713 19 New York 4,139,898 1,337,584 1,883,373 420,071 100,457 398,413 0 North Carolina 1,389,455 601,045 42,021 678,924 67,465 0 0 North Dakota 71,619 36,148 14,690 5,330 15,451 0 0 Ohio 1,754,379 430,980 0 363,075 960,324 0 0 Oklahoma 677,788 108,330 7,706 463,661 98,091 0 0 Oregon 637,140 146,559 9,472 171,403 129,447 180,084 175 Pennsylvania 1,710,999 699,940 114,369 574,506 322,184 0 0 Rhode Island 204,789 82,419 4,330 29,368 47,524 41,148 0 South Carolina 895,863 295,611 0 382,483 217,753 0 16 South Dakota 113,925 40,732 0 48,892 24,301 0 0 Tennessee 1,700,384 485,216 121,968 252,406 181,966 658,809 19 Texas 3,202,171 930,165 77,768 1,618,830 574,504 904 0 Utah 233,156 85,897 5,558 87,040 54,661 0 0 Vermont 156,958 30,893 13,253 48,162 14,078 50,572 0 Virginia 727,784 141,198 8,395 422,709 155,481 0 1 Washington 1,104,813 260,809 16,819 394,375 361,851 70,959 0 West Virginia 362,264 133,188 5,087 198,667 25,322 0 0 Wisconsin 776,638 263,555 39,861 124,246 177,525 171,443 8 Wyoming 69,802 18,962 0 37,548 13,283 9 0 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

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Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Age Group, 20021 65 Years and State Total Eligibles <20 Years 21-64 Years Older National Total 51,552,491 27,830,240 18,033,921 5,544,601 Alabama 845,125 455,093 269,582 120,450 Alaska 121,400 82,578 31,688 7,134 Arizona 1,053,602 574,000 421,245 58,356 Arkansas 608,017 365,392 178,945 63,680 California 9,336,447 4,230,729 4,277,322 828,384 Colorado 438,670 262,328 127,620 48,718 Connecticut 487,989 259,235 166,009 62,740 Delaware 147,197 75,237 60,665 11,295 District of Columbia 204,591 104,485 80,275 19,822 Florida 2,691,502 1,520,203 817,314 353,617 Georgia 1,459,631 945,513 378,997 135,099 Hawaii 195,684 99,110 76,962 19,611 Idaho 196,406 136,581 47,020 12,803 Illinois 2,076,146 1,171,404 585,568 319,048 Indiana 881,942 562,820 240,101 79,021 Iowa 358,708 201,581 115,218 41,908 Kansas 305,110 190,189 81,486 33,431 Kentucky 769,826 424,499 251,029 94,298 Louisiana 990,286 653,260 231,482 105,540 Maine 346,449 120,724 149,048 76,640 Maryland 752,065 459,015 225,256 67,777 Massachusetts 1,204,312 532,861 527,402 144,049 Michigan 1,527,627 916,024 480,234 131,296 Minnesota 680,627 367,223 221,524 91,869 Mississippi 707,986 426,575 186,397 95,014 Missouri 1,098,525 622,881 374,782 100,861 Montana 106,229 59,726 35,435 11,066 Nebraska 266,245 169,018 67,742 23,966 Nevada 203,251 114,834 67,557 20,857 New Hampshire 115,517 71,933 30,875 12,709 New Jersey 982,676 533,051 308,299 141,326 New Mexico 462,878 310,835 121,019 31,011 New York 4,139,898 1,781,762 1,729,739 491,484 North Carolina 1,389,455 778,046 432,309 179,100 North Dakota 71,619 36,026 25,492 10,101 Ohio 1,754,379 1,014,369 593,119 146,891 Oklahoma 677,788 460,532 152,105 64,717 Oregon 637,140 291,300 299,144 46,682 Pennsylvania 1,710,999 917,552 580,664 212,783 Rhode Island 204,789 104,208 76,806 23,773 South Carolina 895,863 528,384 288,446 78,998 South Dakota 113,925 74,224 27,550 12,151 Tennessee 1,700,384 782,478 759,130 158,776 Texas 3,202,171 2,069,588 745,796 386,784 Utah 233,156 148,783 71,488 12,882 Vermont 156,958 72,887 62,894 21,176 Virginia 727,784 429,053 196,691 102,023 Washington 1,104,813 679,132 346,020 79,661 West Virginia 362,264 202,204 126,548 33,512 Wisconsin 776,638 395,964 266,229 114,377 Wyoming 69,802 44,811 19,653 5,334 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-12

Age Unknown 143,729 0 0 1 0 12 4 5 0 9 368 22 1 2 126 0 1 4 0 4 37 17 0 73 11 0 1 2 5,519 3 0 0 13 136,913 0 0 0 434 14 0 2 35 0 0 3 3 1 17 0 0 68 4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Gender, 20021 State Total Eligibles Female Male Gender Uknown National Total 51,552,491 30,707,492 20,705,398 139,601 Alabama 845,125 531,748 307,660 5,717 Alaska 121,400 67,277 54,120 3 Arizona 1,053,602 595,081 458,521 0 Arkansas 608,017 381,241 226,535 241 California 9,336,447 5,988,836 3,347,600 11 Colorado 438,670 262,530 176,140 0 Connecticut 487,989 290,201 197,788 0 Delaware 147,197 87,751 59,446 0 District of Columbia 204,591 127,262 77,296 33 Florida 2,691,502 1,596,454 1,093,453 1,595 Georgia 1,459,631 876,947 582,681 3 Hawaii 195,684 106,664 89,020 0 Idaho 196,406 111,449 84,957 0 Illinois 2,076,146 1,239,054 837,092 0 Indiana 881,942 521,432 360,510 0 Iowa 358,708 209,128 149,580 0 Kansas 305,110 176,354 128,712 44 Kentucky 769,826 445,886 323,935 5 Louisiana 990,286 570,955 419,254 77 Maine 346,449 186,109 160,089 251 Maryland 752,065 455,274 296,791 0 Massachusetts 1,204,312 691,423 512,889 0 Michigan 1,527,627 883,138 644,489 0 Minnesota 680,627 393,589 287,038 0 Mississippi 707,986 419,267 288,704 15 Missouri 1,098,525 642,307 456,217 1 Montana 106,229 61,106 45,120 3 Nebraska 266,245 149,431 111,756 5,058 Nevada 203,251 118,988 83,534 729 New Hampshire 115,517 67,520 47,997 0 New Jersey 982,676 589,014 393,662 0 New Mexico 462,878 270,390 192,481 7 New York 4,139,898 2,307,595 1,707,302 125,001 North Carolina 1,389,455 841,783 547,672 0 North Dakota 71,619 42,289 29,329 1 Ohio 1,754,379 1,028,389 725,990 0 Oklahoma 677,788 395,398 282,390 0 Oregon 637,140 349,494 287,642 4 Pennsylvania 1,710,999 1,002,800 708,199 0 Rhode Island 204,789 120,816 83,973 0 South Carolina 895,863 560,528 335,099 236 South Dakota 113,925 64,800 49,125 0 Tennessee 1,700,384 974,861 725,523 0 Texas 3,202,171 1,883,560 1,318,539 72 Utah 233,156 137,218 95,573 365 Vermont 156,958 87,283 69,675 0 Virginia 727,784 432,806 294,978 0 Washington 1,104,813 657,323 447,461 29 West Virginia 362,264 206,131 156,078 55 Wisconsin 776,638 459,856 316,781 1 Wyoming 69,802 40,756 29,002 44 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-13

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Race/Ethnicity, 20021 American Indian/ Total Black/African Alaska Hispanic or State Eligibles White American Native Asian Latino National Total 51,552,491 22,476,575 12,282,148 743,956 1,222,704 10,694,241 Alabama 845,125 386,692 413,920 2,204 3,651 13,566 Alaska 121,400 51,974 6,275 44,388 5,695 4,449 Arizona 1,053,602 385,624 62,086 137,230 12,181 436,283 Arkansas 608,017 378,477 194,146 4,844 5,151 21,159 California 9,336,447 2,136,678 943,186 43,312 460,010 4,871,320 Colorado 438,670 203,858 31,916 3,275 4,264 163,887 Connecticut 487,989 227,213 108,673 946 10,545 140,416 Delaware 147,197 63,923 63,337 288 2,042 17,181 District of Columbia 204,591 3,166 180,962 25 1,568 11,859 Florida 2,691,502 1,015,714 807,949 1,271 13,788 552,750 Georgia 1,459,631 595,614 735,738 1,084 13,586 12,675 Hawaii 195,684 41,169 2,973 469 57,127 5,882 Idaho 196,406 158,930 1,547 5,082 861 29,782 Illinois 2,076,146 837,072 779,474 3,752 50,926 383,503 Indiana 881,942 609,861 197,903 579 3,173 60,867 Iowa 358,708 261,289 27,993 1,874 3,504 8,402 Kansas 305,110 201,217 51,148 4,073 2,696 36,404 Kentucky 769,826 626,904 97,351 297 1,913 11,867 Louisiana 990,286 346,283 574,364 1,780 3,425 5,539 Maine 346,449 334,640 5,131 3,005 2,274 1,399 Maryland 752,065 254,437 397,418 1,284 20,551 51,213 Massachusetts 1,204,312 592,131 127,243 2,646 39,039 188,078 Michigan 1,527,627 863,660 520,060 7,779 22,142 79,963 Minnesota 680,627 413,244 105,466 27,520 44,513 2,140 Mississippi 707,986 241,923 424,485 2,901 2,786 5,042 Missouri 1,098,525 773,021 283,495 2,204 7,027 351 Montana 106,229 78,698 730 23,975 435 2,336 Nebraska 266,245 180,346 32,801 9,318 2,845 95 Nevada 203,251 114,714 37,657 3,362 6,727 40,791 New Hampshire 115,517 106,887 2,032 95 832 3,342 New Jersey 982,676 342,642 306,819 3,263 20,462 200,015 New Mexico 462,878 116,769 10,384 87,040 2,627 236,470 New York 4,139,898 1,250,339 898,747 52,389 154,509 648,943 North Carolina 1,389,455 607,557 569,579 23,854 12,478 94,973 North Dakota 71,619 54,016 1,367 15,907 294 0 Ohio 1,754,379 1,142,733 529,489 1,788 8,405 51,314 Oklahoma 677,788 421,204 111,899 87,341 5,973 51,371 Oregon 637,140 469,028 27,287 14,161 17,365 102,107 Pennsylvania 1,710,999 1,020,844 470,098 1,961 32,235 129,568 Rhode Island 204,789 92,982 17,997 327 5,046 37,098 South Carolina 895,863 359,348 480,943 1,294 1,757 13,314 South Dakota 113,925 68,633 2,346 39,991 651 2,120 Tennessee 1,700,384 1,121,661 471,076 3,605 11,783 36,923 Texas 3,202,171 855,101 606,560 11,602 41,413 1,650,717 Utah 233,156 163,596 4,815 10,234 9,678 41,538 Vermont 156,958 92,535 1,023 244 425 302 Virginia 727,784 333,733 335,288 1,125 18,601 37,338 Washington 1,104,813 709,195 68,751 29,629 52,419 148,121 West Virginia 362,264 335,086 18,575 180 719 702 Wisconsin 776,638 378,877 130,331 11,703 20,320 41,865 Wyoming 69,802 55,337 1,315 5,456 267 6,901 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2002.

2-14

Other 4,132,867 25,092 8,619 20,198 4,240 881,941 31,470 196 426 7,011 300,030 100,934 88,064 204 21,419 9,559 55,646 9,572 31,494 58,895 0 27,162 255,175 34,023 87,744 30,849 32,427 55 40,840 0 2,329 109,475 9,588 1,134,971 81,014 35 20,650 0 7,192 56,293 51,339 39,207 184 55,336 36,778 3,295 62,429 1,699 96,698 7,002 193,542 526

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Basis of Eligibility, 20021 Blind/ Foster Care State Disabled Children Total Eligibles Aged Children Adults National Total 51,552,491 4,759,065 8,055,109 24,583,011 13,245,645 901,951 Alabama 845,125 98,709 191,405 411,324 137,462 6,224 Alaska 121,400 6,569 12,271 73,962 26,602 1,938 Arizona 1,053,602 43,667 109,978 505,858 386,179 7,920 Arkansas 608,017 50,510 108,792 304,343 138,152 6,206 California 9,336,447 664,023 989,758 3,462,819 4,058,935 157,995 Colorado 438,670 47,555 66,257 219,718 87,722 17,297 Connecticut 487,989 61,797 60,596 255,429 102,704 7,372 Delaware 147,197 10,769 17,642 64,174 52,705 1,876 District of Columbia 204,591 13,747 43,794 88,534 51,827 6,689 Florida 2,691,502 255,655 522,310 1,331,626 538,542 43,369 Georgia 1,459,631 108,680 232,728 844,963 252,563 19,550 Hawaii 195,684 17,396 23,627 86,034 62,685 5,942 Idaho 196,406 12,968 26,651 124,773 29,809 2,205 Illinois 2,076,146 279,046 300,341 1,016,068 395,940 84,506 Indiana 881,942 78,441 116,543 521,163 152,889 12,730 Iowa 358,708 41,577 60,717 175,535 70,565 10,314 Kansas 305,110 30,702 52,879 161,499 47,647 12,383 Kentucky 769,826 72,121 207,955 370,090 110,257 9,403 Louisiana 990,286 105,311 177,258 588,077 110,170 9,470 Maine 346,449 71,964 119,321 97,156 55,101 2,907 Maryland 752,065 55,354 121,570 415,260 142,405 17,373 Massachusetts 1,204,312 116,164 243,326 482,300 361,857 665 Michigan 1,527,627 99,714 297,112 804,779 285,805 40,006 Minnesota 680,627 69,759 93,872 333,759 174,200 8,983 Mississippi 707,986 74,033 161,410 384,360 84,985 3,159 Missouri 1,098,525 98,744 150,368 566,155 258,115 25,143 Montana 106,229 10,102 17,688 52,662 21,852 3,829 Nebraska 266,245 23,526 29,885 150,254 51,584 10,267 Nevada 203,251 19,562 33,202 95,730 46,638 8,119 New Hampshire 115,517 12,654 14,611 68,911 16,632 2,709 New Jersey 982,676 111,710 178,819 462,890 207,270 21,926 New Mexico 462,878 23,371 55,032 290,553 90,085 3,771 New York 4,139,898 398,070 688,012 1,737,279 1,241,408 75,129 North Carolina 1,389,455 178,258 236,259 699,139 259,289 16,510 North Dakota 71,619 10,032 9,841 31,859 18,097 1,790 Ohio 1,754,379 144,622 279,463 924,487 371,476 33,937 Oklahoma 677,788 63,837 81,293 432,322 93,949 6,387 Oregon 637,140 44,325 68,379 247,763 261,511 14,987 Pennsylvania 1,710,999 212,480 386,422 779,880 283,257 48,635 Rhode Island 204,789 19,667 38,418 88,794 52,218 5,522 South Carolina 895,863 78,066 122,846 463,859 222,576 8,423 South Dakota 113,925 10,139 16,420 67,273 18,157 1,922 Tennessee 1,700,384 90,398 340,155 723,890 531,554 14,368 Texas 3,202,171 383,307 379,541 1,870,141 534,638 34,544 Utah 233,156 12,102 28,075 130,577 55,627 6,676 Vermont 156,958 19,661 19,109 66,331 49,235 2,610 Virginia 727,784 98,274 139,382 378,035 97,000 14,946 Washington 1,104,813 79,445 145,928 579,607 283,313 16,520 West Virginia 362,264 29,678 89,755 176,277 59,878 6,676 Wisconsin 776,638 95,507 139,297 335,343 188,479 17,910 Wyoming 69,802 5,297 8,796 39,397 14,099 2,213 1 Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. Source: CMS, MSIS Report, FY 2002.

2-15

BCCA Women 5,931 0 58 0 0 2,917 24 91 31 0 0 1,147 0 0 245 176 0 0 0 0 0 0 0 0 54 0 0 87 68 0 0 61 47 0 0 0 0 0 0 325 170 77 14 0 0 99 0 146 0 0 94 0

BOE Unknown 1,779 1 0 0 14 0 97 0 0 0 0 0 0 0 0 0 0 0 0 0 0 103 0 211 0 39 0 9 661 0 0 0 19 0 0 0 394 0 175 0 0 16 0 19 0 0 12 1 0 0 8 0

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles Per 1000 Population, 2002 Total State Total State Population Eligibles1 National Total 287,973,924 51,552,491 Alabama 4,478,896 845,125 Alaska 641,482 121,400 Arizona 5,441,125 1,053,602 Arkansas 2,706,268 608,017 California 35,001,986 9,336,447 Colorado 4,501,051 438,670 Connecticut 3,458,587 487,989 Delaware 805,945 147,197 District of Columbia 566,157 204,591 Florida 16,691,701 2,691,502 Georgia 8,544,005 1,459,631 Hawaii 1,240,663 195,684 Idaho 1,343,124 196,406 Illinois 12,586,447 2,076,146 Indiana 6,156,913 881,942 Iowa 2,935,840 358,708 Kansas 2,711,769 305,110 Kentucky 4,089,822 769,826 Louisiana 4,476,192 990,286 Maine 1,294,894 346,449 Maryland 5,450,525 752,065 Massachusetts 6,421,800 1,204,312 Michigan 10,043,221 1,527,627 Minnesota 5,024,791 680,627 Mississippi 2,866,733 707,986 Missouri 5,669,544 1,098,525 Montana 910,372 106,229 Nebraska 1,727,564 266,245 Nevada 2,167,455 203,251 New Hampshire 1,274,405 115,517 New Jersey 8,575,252 982,676 New Mexico 1,852,044 462,878 New York 19,134,293 4,139,898 North Carolina 8,305,820 1,389,455 North Dakota 636,911 71,619 Ohio 11,408,699 1,754,379 Oklahoma 3,489,700 677,788 Oregon 3,520,355 637,140 Pennsylvania 12,328,827 1,710,999 Rhode Island 1,068,326 204,789 South Carolina 4,103,770 895,863 South Dakota 760,437 113,925 Tennessee 5,789,796 1,700,384 Texas 21,736,925 3,202,171 Utah 2,318,789 233,156 Vermont 616,408 156,958 Virginia 7,287,829 727,784 Washington 6,067,060 1,104,813 West Virginia 1,804,884 362,264 Wisconsin 5,439,692 776,638 Wyoming 498,830 69,802 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Eligibles per 1000 Population 179.0 188.7 189.2 193.6 224.7 266.7 97.5 141.1 182.6 361.4 161.2 170.8 157.7 146.2 164.9 143.2 122.2 112.5 188.2 221.2 267.6 138.0 187.5 152.1 135.5 247.0 193.8 116.7 154.1 93.8 90.6 114.6 249.9 216.4 167.3 112.4 153.8 194.2 181.0 138.8 191.7 218.3 149.8 293.7 147.3 100.6 254.6 99.9 182.1 200.7 142.8 139.9

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

2-16

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Net U.S. Medical Assistance Expenditures by Type of Service, FY 2002 & FY 2003 Service

Percent of Total

FY 2003

FY 2002

Percent of Total

Percent Change

Inpatient Acute Care Hospital

$45,839,127,080

17.6%

$43,690,502,629

17.8%

4.9%

Nursing Facility

$44,345,682,144

17.1%

$47,466,264,432

19.3%

-6.6%

Pharmaceuticals

$33,794,520,738

13.0%

$29,339,050,970

11.9%

15.2%

HCBS Waivers

$19,302,698,045

7.4%

$17,169,137,673

7.0%

12.4%

ICF-Mentally Retarded

$11,614,424,195

4.5%

$11,205,483,449

4.6%

3.6%

Hospital Outpatient

$9,394,646,018

3.6%

$9,245,799,624

3.8%

1.6%

Personal Care Services

$7,881,552,380

3.0%

$6,037,450,986

2.5%

30.5%

Physicians

$7,863,653,436

3.0%

$7,559,242,098

3.1%

4.0%

Clinic*

$7,582,867,230

2.9%

$7,499,886,627

3.1%

1.1%

Inpatient Mental Health Hospital

$7,299,165,193

2.8%

$7,446,842,170

3.0%

-2.0%

Dental

$3,015,702,590

1.2%

$2,630,870,620

1.1%

14.6%

Home Health Care

$2,886,980,643

1.1%

$2,766,480,497

1.1%

4.4%

Other Practitioners

$1,438,109,885

0.6%

$1,413,870,565

0.6%

1.7%

EPSDT

$1,079,836,415

0.4%

$1,007,637,056

0.4%

7.2%

$856,521,207

0.3%

$781,820,930

0.3%

9.6%

$55,700,409,296

21.4%

$50,437,280,350

20.5%

10.4%

Lab/X-ray Other**

$259,895,896,495 100% ‡ $245,697,620,676 100% ‡ 5.8% Total Expenditures ‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands excluded. * Clinic includes clinics, FQHCs, and rural health clinics. ** Other includes hospice, other care services, payments to managed care organizations, etc. Source: CMS, CMS-64 Report, FY 2002 and FY 2003.

2-17

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Federal Medical Assistance Percentage (FMAP), FY 2005 and FY 2006

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

2005 FMAP 70.83% 57.58% 67.45% 74.75% 50.00% 50.00% 50.00% 50.38% 70.00% 58.90% 60.44% 58.47% 70.62% 50.00% 62.78% 63.55% 61.01% 69.60% 71.04% 64.89% 50.00% 50.00% 56.71% 50.00% 77.08% 61.15% 71.90% 59.64% 55.90% 50.00% 50.00% 74.30% 50.00% 63.63% 67.49% 59.68% 70.18% 61.12% 53.84% 55.38% 69.89% 66.03% 64.81% 60.87% 72.14% 60.11% 50.00% 50.00% 74.65% 58.32% 57.90%

2005 Enhanced FMAP* 79.58% 70.31% 77.22% 82.33% 65.00% 65.00% 65.00% 65.27% 79.00% 71.23% 72.31% 70.93% 79.43% 65.00% 73.95% 74.49% 72.71% 78.72% 79.73% 75.42% 65.00% 65.00% 69.70% 65.00% 83.96% 72.81% 80.33% 71.75% 69.13% 65.00% 65.00% 82.01% 65.00% 74.54% 77.24% 71.78% 79.13% 72.78% 67.69% 68.77% 78.92% 76.22% 75.37% 72.61% 80.50% 72.08% 65.00% 65.00% 82.26% 70.82% 70.53%

2006 FMAP 69.51% 50.16% 66.98% 73.77% 50.00% 50.00% 50.00% 50.09% 70.00% 58.89% 60.00% 58.81% 69.91% 50.00% 62.98% 63.61% 60.41% 69.26% 69.79% 62.90% 50.00% 50.00% 56.59% 50.00% 76.00% 61.93% 70.54% 59.68% 54.76% 50.00% 50.00% 71.15% 50.00% 63.49% 65.85% 59.88% 67.91% 61.57% 55.05% 54.45% 69.32% 65.07% 63.99% 60.66% 70.76% 58.49% 50.00% 50.00% 72.99% 51.65% 54.23%

2006 Enhanced FMAP* 78.66% 65.11% 76.89% 81.64% 65.00% 65.00% 65.00% 65.06% 79.00% 71.22% 72.42% 71.17% 78.94% 65.00% 74.09% 74.53% 72.29% 78.48% 78.85% 74.03% 65.00% 65.00% 69.61% 65.00% 83.20% 73.35% 79.38% 71.78% 68.33% 65.00% 65.00% 79.81% 65.00% 74.44% 76.10% 71.92% 77.54% 73.10% 68.54% 68.12% 78.52% 75.55% 74.79% 72.46% 79.53% 70.94% 65.00% 65.00% 81.09% 70.36% 67.96%

* The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3). ** The values for Alaska and the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is 53.23% and for the District of Columbia is 50.00%. Source: Federal Register, December 3, 2003, Vol. 68, No. 232, pages 67676-67678 and November 24, 2004, Vol. 69, No. 226, pages 68370–68373.

2-18

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Total Net Expenditures and Eligibles, 2002 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 Net Medical Assistance Expenditures

Total 1 Eligibles

$245,697,620,676 51,552,491 $3,093,270,640 845,125 $685,772,985 121,400 $3,541,598,721 1,053,602 $2,237,817,554 608,017 $26,890,540,967 9,336,447 $2,323,068,699 438,670 $3,456,338,545 487,989 $634,046,351 147,197 $1,021,772,693 204,591 $9,871,508,234 2,691,502 $6,241,211,454 1,459,631 $740,007,314 195,684 $773,534,776 196,406 $8,809,060,004 2,076,146 $4,448,318,143 881,942 $2,575,146,342 358,708 $1,836,717,196 305,110 $3,763,204,047 769,826 $4,885,971,853 990,286 $1,430,109,134 346,449 $3,613,476,100 752,065 $8,063,005,258 1,204,312 $7,562,053,407 1,527,627 $4,414,511,470 680,627 $2,877,013,521 707,986 $5,360,607,640 1,098,525 $571,456,455 106,229 $1,339,132,070 266,245 $808,198,344 203,251 $1,016,094,814 115,517 $7,745,877,997 982,676 $1,776,811,688 462,878 $36,295,107,368 4,139,898 $6,723,598,560 1,389,455 $461,401,546 71,619 $9,658,040,587 1,754,379 $2,260,403,490 677,788 $2,571,560,664 637,140 $12,130,925,035 1,710,999 $1,358,500,649 204,789 $3,292,901,444 895,863 $549,884,391 113,925 $5,787,079,096 1,700,384 $13,523,486,149 3,202,171 $984,160,785 233,156 $660,731,979 156,958 $3,812,166,436 727,784 $5,168,511,470 1,104,813 $1,584,166,286 362,264 $4,193,175,197 776,638 $274,565,128 69,802 1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. Source: CMS, CMS-64 Report, FY 2002 and CMS-MSIS Report, FY 2002.

2-19

Average Per Eligible $4,766 $3,660 $5,649 $3,361 $3,681 $2,880 $5,296 $7,083 $4,307 $4,994 $3,668 $4,276 $3,782 $3,938 $4,243 $5,044 $7,179 $6,020 $4,888 $4,934 $4,128 $4,805 $6,695 $4,950 $6,486 $4,064 $4,880 $5,379 $5,030 $3,976 $8,796 $7,882 $3,839 $8,767 $4,839 $6,442 $5,505 $3,335 $4,036 $7,090 $6,634 $3,676 $4,827 $3,403 $4,223 $4,221 $4,210 $5,238 $4,678 $4,373 $5,399 $3,933

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Program Expenditures, 2003 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 Net Medical Assistance Expenditures

Administrative Expenditures

Total Program Expenditures

$259,895,896,495 $3,477,832,931 $563,428,717 $4,219,253,105 $2,329,593,600 $30,051,769,056 $2,552,159,860 $3,506,583,946 $718,470,271 $1,076,136,978 $10,946,214,986 $6,300,856,479 $766,109,972 $809,931,820 $9,253,097,164 $4,282,435,701 $2,136,386,901 $1,764,536,608 $3,697,230,708 $4,423,174,011 $1,747,306,187 $4,343,054,613 $7,680,882,159 $7,967,828,590 $3,604,575,049 $2,853,086,305 $5,541,604,705 $511,474,712 $1,325,133,485 $1,015,796,455 $916,422,038 $7,858,368,246 $2,006,492,205 $39,585,134,508 $7,050,804,888 $468,522,734 $10,177,517,569 $2,311,939,159 $2,678,357,318 $12,772,008,268 $1,436,618,006 $3,540,107,364 $536,195,894 $6,348,262,631 $15,420,026,696 $1,092,519,199 $705,028,688 $3,524,849,814 $5,006,473,801 $1,857,747,927 $4,799,267,070 $337,284,398

$13,046,737,079 $127,998,912 $46,999,870 $206,926,196 $111,158,811 $2,056,182,686 $111,002,758 $103,831,118 $46,279,569 $75,714,431 $548,942,130 $380,246,357 $69,711,658 $68,634,984 $695,015,816 $203,536,402 $82,657,277 $90,446,401 $106,527,424 $161,791,590 $79,401,252 $294,904,663 $365,645,374 $498,571,420 $211,870,042 $94,898,736 $253,735,879 $30,195,882 $71,664,220 $67,798,693 $62,874,759 $515,324,283 $67,963,008 $874,715,468 $301,214,843 $21,101,570 $360,355,327 $168,986,258 $241,943,386 $625,292,638 $80,854,110 $136,496,403 $17,468,705 $523,172,782 $749,960,111 $79,037,866 $63,031,099 $226,683,382 $459,002,964 $88,915,675 $94,223,622 $25,828,269

$272,942,633,574 $3,605,831,843 $610,428,587 $4,426,179,301 $2,440,752,411 $32,107,951,742 $2,663,162,618 $3,610,415,064 $764,749,840 $1,151,851,409 $11,495,157,116 $6,681,102,836 $835,821,630 $878,566,804 $9,948,112,980 $4,485,972,103 $2,219,044,178 $1,854,983,009 $3,803,758,132 $4,584,965,601 $1,826,707,439 $4,637,959,276 $8,046,527,533 $8,466,400,010 $3,816,445,091 $2,947,985,041 $5,795,340,584 $541,670,594 $1,396,797,705 $1,083,595,148 $979,296,797 $8,373,692,529 $2,074,455,213 $40,459,849,976 $7,352,019,731 $489,624,304 $10,537,872,896 $2,480,925,417 $2,920,300,704 $13,397,300,906 $1,517,472,116 $3,676,603,767 $553,664,599 $6,871,435,413 $16,169,986,807 $1,171,557,065 $768,059,787 $3,751,533,196 $5,465,476,765 $1,946,663,602 $4,893,490,692 $363,112,667

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

2-20

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total SCHIP Enrollment, 2003* 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

Medicaid SCHIP Enrollment 1,503,775 22,934 99,366 159 5,875 2,188 12,022 16,877 81,692 51,587 14,001 57,553 104,908 19,280 122,229 85,104 26,391 48 150,954 45,490 517 40,414 18,841 NR 1,773 207,854 91,914 22,893 90,764 9,529 30,616 68,641 -

Non-Medicaid SCHIP Enrollment 4,370,484 78,554 90,491 855,786 74,144 20,971 9,744 440,989 251,711 53,917 22,175 23,059 45,662 34,275 10,194 7,932 43,686 51,076 NR 75,010 13,084 47,183 9,376 78,858 795,111 150,444 3,180 44,752 160,015 1,612 2,759 726,428 37,766 6,467 53,100 9,571 35,320 5,241

Total SCHIP Enrollment 5,874,259 78,554 22,934 90,468 955,152 74,144 20,971 9,903 5,875 443,177 251,711 12,022 16,877 135,609 73,762 37,060 45,662 94,053 104,908 29,474 130,161 128,790 77,467 48 75,010 150,954 13,084 45,490 47,183 9,893 119,272 18,841 795,111 150,444 4,953 207,854 91,914 44,752 160,015 24,505 90,764 12,288 726,428 37,766 6,467 83,716 9,571 35,320 68,641 5,241

Adults Enrolled in SCHIP Demonstrations 483,728 98,431 1,423 70,773 41,317 123,716 2,129 22,044 123,895 -

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

2-21

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total SCHIP Expenditures, 2003 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

Medicaid SCHIP Expenditures $1,485,602,154 $150,501 $31,134,733 $0 $36,903,302 $53,141,395 $0 $48,883 $248,572 $7,499,314 $81,965,839 $0 $9,892,694 $14,386,996 $43,386,825 $63,114,262 $16,301,477 $0 $56,334,856 $92,640,822 $16,771,385 $190,811,878 $86,316,863 $25,992,200 $0 $16,595 $95,388,625 $0 $34,045,772 $0 $400,083 $44,419,989 $20,793,527 $82,448,115 $0 $3,016,734 $188,302,322 $47,612,740 $0 $0 $24,779,497 $52,274,653 $8,289,917 $0 $452,389 $0 $0 $21,674,120 $0 $0 $33,377,550 $0

Source: CMS, CMS-64 Report, 2003.

2-22

Non-Medicaid SCHIP Expenditures $4,553,214,312 $89,648,415 $2,712,687 $242,147,701 $3,450,290 $816,155,723 $62,458,057 $26,708,904 $6,834,859 $117,097 $420,667,742 $250,756,400 $280,288 $871,565 $47,932,135 $20,952,924 $27,868,966 $51,147,118 $31,383,334 $5,431,165 $10,828,951 $21,020,162 $24,583,525 $62,429,891 $98,837,468 $106,051,546 $2,840,651 $14,854,662 $871,781 $33,446,385 $6,070,794 $359,565,535 $1,362,438 $459,337,745 $177,136,298 $3,535,216 $6,305,620 $660,522 $27,505,941 $176,193,192 $31,490,573 $4,647,136 $3,785,231 $0 $563,044,186 $25,145,487 $4,042,623 $56,729,935 $24,851,674 $32,668,647 $100,484,536 $5,360,591

Total SCHIP Expenditures $6,038,816,466 $89,798,916 $33,847,420 $242,147,701 $40,353,592 $869,297,118 $62,458,057 $26,757,787 $7,083,431 $7,616,411 $502,633,581 $250,756,400 $10,172,982 $15,258,561 $91,318,960 $84,067,186 $44,170,443 $51,147,118 $87,718,190 $98,071,987 $27,600,336 $211,832,040 $110,900,388 $88,422,091 $98,837,468 $106,068,141 $98,229,276 $14,854,662 $34,917,553 $33,446,385 $6,470,877 $403,985,524 $22,155,965 $541,785,860 $177,136,298 $6,551,950 $194,607,942 $48,273,262 $27,505,941 $176,193,192 $56,270,070 $56,921,789 $12,075,148 $0 $563,496,575 $25,145,487 $4,042,623 $78,404,055 $24,851,674 $32,668,647 $133,862,086 $5,360,591

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 20021 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

All Eligibles 51,552,491 845,125 121,400 1,053,602 608,017 9,336,447 438,670 487,989 147,197 204,591 2,691,502 1,459,631 195,684 196,406 2,076,146 881,942 358,708 305,110 769,826 990,286 346,449 752,065 1,204,312 1,527,627 680,627 707,986 1,098,525 106,229 266,245 203,251 115,517 982,676 462,878 4,139,898 1,389,455 71,619 1,754,379 677,788 637,140 1,710,999 204,789 895,863 113,925 1,700,384 3,202,171 233,156 156,958 727,784 1,104,813 362,264 776,638 69,802

Not a Dual Eligible 40,008,697 627,146 99,842 891,673 421,744 7,523,677 336,155 376,168 118,672 173,783 2,072,192 1,163,783 156,830 171,732 1,581,719 706,225 257,128 227,750 549,992 787,181 242,436 612,534 887,127 1,217,506 504,862 523,298 899,710 78,459 215,554 150,778 90,356 715,363 408,518 2,963,226 1,004,720 51,954 1,450,281 495,758 476,725 1,294,399 158,661 756,869 88,716 1,322,117 2,471,405 194,965 120,711 524,983 936,178 286,111 565,889 55,136

QMB Only 461,055 24,763 5 918 18,403 7,008 6,320 6,209 3,935 87 21,989 50,127 107 2,809 10,717 8,787 4,533 4,191 24,944 24,420 2,524 13,750 184 552 1,705 603 9,149 394 0 7,223 1,838 0 10,191 2,007 720 724 29,749 22 4,571 520 221 0 2,370 36,052 57,996 1,084 159 32,289 8,113 12,924 1,686 1,463

1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid QMB/ Medicaid = QMBs With Full Medicaid SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid SLMB/Medicaid = SLMBs with full Medicaid QDWI = Qualified Disabled and Working Individuals QI 1 = Qualifying Individuals (1) QI 2 = Qualifying Individuals (2) Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2002.

2-23

QMB/ Medicaid 3,946,067 91,387 7,852 52,667 96,042 764,249 41,897 45,416 5,658 11,381 280,205 0 21,515 10,706 125,373 61,139 29,288 25,299 83,171 101,528 31,984 53,339 67,784 78,539 58,945 140,540 58,471 10,236 22,551 18,404 17,973 111,678 4,404 224,938 194,145 1,431 0 82,863 29,713 205,913 18,337 78,482 3,010 54,344 280,680 8,481 9,750 73,502 76,956 0 71,103 2,798

SLMB Only 319,072 22,661 119 114 2,907 3,122 3,476 3,443 3,242 860 19,242 46 1,262 0 2,311 5,842 3,574 2,366 10,805 12,220 5,013 5,475 14,098 12,687 6,072 1,512 4,953 603 2,305 5,670 0 20,333 0 0 27,374 598 0 8,308 8,937 18,831 1,138 17 1,171 21,870 30,912 492 361 13,000 6,089 0 2,979 662

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

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

SLMB/ Medicaid 284,793 9,952 0 0 0 113,100 3 6,160 0 0 37,316 0 0 0 17,643 14,933 6,464 210 4,315 446 1,899 0 0 0 10,521 0 8,260 1,698 0 0 0 0 0 0 5,547 337 0 4,688 4 13,066 0 0 934 0 8,073 0 5,266 0 1,923 0 8,477 3,558

QDWI 3,961 0 0 0 3,881 4 1 0 0 0 0 0 0 0 0 3 0 0 0 0 51 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14 0 0 1 0

QI(1) 136,263 2,897 0 31 0 1,714 1,556 4,116 23 261 22,385 0 0 0 10,360 3,235 1,817 852 3,979 6,214 1,464 1,833 2,915 5,506 2,243 0 290 0 0 0 0 8,334 0 0 12,133 270 0 0 4,871 11,249 653 6 514 0 15,658 223 12 4,644 2,700 0 969 336

1

Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid QMB/ Medicaid = QMBs With Full Medicaid SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid SLMB/Medicaid = SLMBs with full Medicaid QDWI = Qualified Disabled and Working Individuals QI 1 = Qualifying Individuals (1) QI 2 = Qualifying Individuals (2) Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2002.

2-24

QI(2) 45,553 62 0 43 0 1,532 767 0 0 237 0 0 0 0 0 3,278 1,019 34 1,225 4,267 693 1,192 3,267 5,628 0 2,840 533 0 0 0 0 0 0 0 0 77 0 0 4,647 4,496 564 2 152 0 5,381 146 0 3,218 0 0 135 118

Other 6,347,030 66,257 13,582 108,156 65,040 922,041 48,495 46,477 15,667 17,982 238,173 245,675 15,970 11,159 328,023 78,500 54,885 44,408 91,395 54,010 60,385 63,942 228,937 207,203 96,279 39,193 117,159 14,839 25,835 21,176 5,350 126,968 39,765 949,727 144,816 16,228 274,349 86,149 107,672 162,525 25,215 60,487 17,058 266,001 332,066 27,765 20,699 76,134 72,854 63,229 125,399 5,731

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 20021 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

All Eligibles $213,491,313,278 $3,204,063,602 $686,795,186 $2,881,870,077 $2,015,436,554 $23,636,239,505 $2,166,199,614 $3,245,142,644 $651,384,655

Not a Dual Eligible $106,490,928,726 $1,274,232,277 $453,075,715 $1,948,997,686 $883,682,774 $13,213,780,910 $1,025,390,092 $1,175,956,667 $376,621,212

QMB Only $1,030,874,920 $15,621,507 $2,393 $1,060,033 $33,136,737 $17,194,733 $2,726,907 $4,499,349 $5,282,458

QMB/ Medicaid $42,127,217,095 $776,780,560 $115,089,861 $434,460,779 $982,685,560 $5,372,345,733 $539,103,641 $1,158,720,879 $96,699,451

SLMB Only $380,179,278 $1,742,014 $42,590 $370,784 $876,861 $8,953,869 $378,910 $932,196 $710,727

$1,027,022,357 $9,827,003,688 $4,796,005,361 $695,279,178 $791,863,699 $9,121,713,188 $3,725,257,965 $1,855,817,441 $1,501,270,019 $3,459,365,581 $3,234,421,939 $1,716,581,955 $3,662,089,984 $6,387,100,271 $5,918,817,382 $4,439,493,794 $2,499,640,805 $4,071,544,403 $532,886,400 $1,255,039,718 $723,956,752

$628,363,371 $4,874,067,948 $2,604,578,450 $350,981,489 $574,360,327 $4,462,411,533 $1,828,126,131 $849,122,634 $641,032,282 $2,024,455,125 $1,818,732,605 $1,007,751,695 $2,174,249,468 $2,842,987,095 $2,383,042,311 $1,971,803,574 $1,244,615,576 $2,116,935,133 $267,585,800 $597,240,859 $393,365,477

$31,210 $70,370,898 $75,123,488 $98,371 $2,988,527 $8,884,937 $4,655,964 $4,851,165 $2,589,548 $30,181,481 $15,725,714 $2,241,357 $42,413,617 $1,119,363 $239,353 $1,834,826 $460,562 $13,187,461 $95,329 $0 $4,139,667

$145,262,877 $1,572,827,572 $0 $170,361,874 $155,399,823 $1,663,359,310 $965,283,909 $514,241,421 $442,607,105 $837,839,353 $1,129,348,514 $402,060,123 $561,303,632 $1,276,162,774 $324,807,789 $1,269,281,520 $1,115,192,344 $722,404,739 $121,091,801 $203,777,475 $205,892,296

$391,722 $1,914,956 $481,290 $438,832 $0 $150,684 $770,567 $1,118,401 $623,360 $5,423,430 $1,891,563 $4,571,138 $7,178,292 $13,833,824 $12,825,261 $1,576,820 $529,391 $1,793,555 $1,823 $830,507 $1,351,254

$745,754,084 $5,497,284,438 $1,796,901,383 $31,488,930,244

$322,552,211 $2,463,309,859 $270,634,581 $14,675,424,270

$5,726,610 $0 $2,669,257 $283,178

$393,680,976 $2,200,468,218 $26,751,670 $4,530,472,744

$0 $21,904,790 $0 $0

$6,041,011,008 $422,745,114 $9,186,330,669 $2,238,213,087 $2,136,400,869 $8,523,928,057 $1,251,440,036

$3,069,848,793 $141,026,852 $4,505,534,072 $1,000,843,567 $1,197,343,350 $4,394,947,388 $618,547,690

$476,113 $527,092 $53,754,743 $1,581 $2,454,895 $180,299 $29,133

$1,956,224,103 $11,637,757 $0 $866,098,451 $331,546,311 $2,006,722,671 $197,393,826

$11,998,085 $70,489 $0 $1,100,816 $104,945,182 $5,704,980 $650,916

$3,382,950,504 $503,947,234 $4,747,549,898 $11,121,020,040 $1,215,620,497 $607,249,969 $3,017,869,649 $4,373,171,467 $1,577,697,829 $3,605,541,906 $280,451,579

$1,596,815,267 $245,685,676 $2,989,461,147 $6,226,003,393 $597,811,407 $345,763,875 $1,491,183,939 $1,866,732,897 $809,141,082 $1,518,334,992 $136,436,202

$0 $2,324,910 $423,736,615 $13,230,318 $20,665,614 $326,101 $97,494,303 $11,597,264 $32,163,017 $1,330,865 $1,146,057

$633,188,504 $86,640,920 $193,006,651 $2,572,622,555 $148,327,002 $80,741,638 $840,368,767 $725,557,952 $0 $1,025,297,993 $26,025,571

$332 $486,079 $148,528,283 $2,739,277 $617,489 $810,752 $3,077,319 $4,353,706 $0 $1,423,172 $62,990

1

Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid QMB/ Medicaid = QMBs With Full Medicaid SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid SLMB/Medicaid = SLMBs with full Medicaid QDWI = Qualified Disabled and Working Individuals QI 1 = Qualifying Individuals (1) QI 2 = Qualifying Individuals (2) Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2002

2-25

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

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

SLMB/ Medicaid $3,559,380,313 $112,567,502 $0 $0 $0 $745,947,070 $142 $197,571,333 $0 $0 $123,645,804 $0 $0 $0 $296,069,746 $263,277,503 $115,732,538 $1,482,507 $105,575,625 $5,298,239 $26,664,799 $0 $0 $0 $228,125,144 $0 $109,503,184 $23,213,856 $0 $0 $0 $0 $0 $0 $145,924,080 $2,172,957 $0 $80,888,878 $20,304 $418,438,234 $0 $0 $22,512,693 $0 $150,439,855 $0 $129,875,293 $0 $9,357,997 $0 $150,448,240 $94,626,790

QDWI $735,149 $0 $0 $0 $672,119 $4,165 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $42,650 $0 $0 $9,474 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $6,741 $0 $0 $0 $0

1

QI (1) $178,350,688 $513,112 $0 $84,004 $0 $1,162,676 $146,264 $411,137 $333,000 $85,870 $20,102,739 $0 $0 $0 $63,709,153 $608,687 $615,501 $126,091 $1,404,720 $769,228 $1,479,128 $676,428 $708,782 $5,622,730 $651,618 $0 $164,581 $0 $0 $0 $0 $10,312,558 $0 $0 $4,503,365 $28,265 $0 $0 $57,550,344 $2,601,815 $121,993 $0 $482,607 $0 $971,338 $158,160 $33,049 $1,129,860 $879,661 $0 $193,214 $9,010

Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid QMB/ Medicaid = QMBs With Full Medicaid SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid SLMB/Medicaid = SLMBs with full Medicaid QDWI = Qualified Disabled and Working Individuals QI 1 = Qualifying Individuals (1) QI 2 = Qualifying Individuals (2) Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2002

2-26

QI (2) $74,882,766 $92,115 $0 $243,720 $0 $566,590 $68,737 $0 $0 $206,988 $0 $0 $0 $0 $0 $847,483 $498,436 $0 $323,582 $665,812 $829,750 $943,460 $592,059 $6,009,856 $0 $1,279,733 $159,402 $0 $0 $0 $0 $0 $0 $0 $0 $3,604 $0 $0 $58,249,186 $1,411,225 $246,581 $0 $95,771 $0 $0 $162,856 $0 $1,371,915 $0 $0 $7,787 $6,118

Other $59,648,764,343 $1,022,514,515 $118,584,627 $496,653,071 $114,382,503 $4,276,283,759 $598,384,921 $707,051,083 $171,737,807 $252,680,319 $3,164,073,771 $2,115,822,133 $173,398,612 $59,115,022 $2,627,127,825 $661,687,721 $369,637,345 $412,809,126 $454,162,265 $261,990,264 $270,941,315 $875,325,087 $2,251,696,374 $3,186,260,608 $966,220,292 $137,563,199 $1,107,396,348 $120,897,791 $453,190,877 $119,208,058 $23,794,287 $801,289,013 $1,496,845,875 $12,282,750,052 $852,036,469 $267,278,098 $4,627,041,854 $289,279,794 $384,291,297 $1,693,921,445 $434,449,897 $1,152,946,401 $145,718,578 $992,817,202 $2,155,013,304 $447,877,969 $49,699,261 $583,236,805 $1,754,691,990 $736,393,730 $908,505,643 $22,088,741

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MEDICAID MANAGED CARE ENROLLMENT Since 1981, when Congress authorized States to implement Section 1915(b) and Section 1115 Medicaid waivers to increase access to managed care and test innovative health care financing and delivery options, enrollment in Medicaid managed care has grown considerably, although the trend appears to be leveling off. Since 1993, managed care enrollment has increased from 14.4% to 60.7% of total Medicaid enrollment. In 2004, 60.7% of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30, 2004, all but three States (Alaska, Mississippi, New Hampshire and Wyoming) were enrolling Medicaid beneficiaries in some type of managed care plan. Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment 100% 80% 60%

85.6%

76.8%

70.6%

59.9%

46.4%

44.4%

44.2%

43.2%

42.4%

40.9%

39.3%

52.2%

53.6%

55.6%

55.8%

56.8%

57.6%

59.1%

60.7%

47.8%

19 9 7

19 9 8

19 9 9

2000

2001

2002

2003

2004

40% 20% 14.4%

23.2%

29.4%

40.1%

0% 19 9 3

19 9 4

19 9 5

19 9 6

Managed Care

Fee for Service

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

TYPES OF MEDICAID MANAGED CARE PLANS Medicaid managed care beneficiaries can be enrolled in one of five basic Medicaid managed care plans: • •

• •

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

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•

•

• •

Pharmaceutical Benefits 2004

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

The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.

Table 2-1: Medicaid Managed Care Plans

Health Insuring Organization (HIO) Commercial Managed Care Organization (COM-MCO) Medicaid-Only Managed Care Organization (Mcaid-MCO) Primary Care Case Management (PCCM) Prepaid Inpatient Health Plan (PIHP) Prepaid Ambulatory Health Plan (PAHP) Program of All-Inclusive Care for the Elderly (PACE) Other Total

Number of Plans 5 156 131 36 121 34 31 9 523

Number of Enrollees 513,255 9,680,307 7,841,591 5,891,174 7,961,643 3,799,313 9,999 213,113 35,910,395*

*This table provides duplicated figures by plan type. The total number of enrollees includes 8,996,825 individuals who were enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.

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

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Medicaid Managed Care Enrollment, As of June 30, 2004

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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Medicaid Enrollment 44,355,955 800,569 96,630 904,658 594,264 6,471,239 378,416 402,286 135,224 138,637 2,207,375 1,323,036 190,381 166,088 1,740,488 803,786 284,918 269,032 678,529 919,079 258,686 696,097 947,297 1,409,832 568,761 637,910 974,310 86,452 206,701 169,334 96,188 798,132 420,935 4,022,544 1,112,341 52,458 1,645,454 518,926 426,905 1,599,570 873,211 180,528 845,870 97,774 1,345,131 2,692,012 188,839 130,782 10,900 607,493 1,080,738 298,093 792,177 58,939

Medicaid Managed Care Enrollment 26,913,570 439,832 0 806,193 386,395 3,258,787 369,270 303,404 99,598 88,452 1,450,117 1,273,133 145,580 131,693 158,869 509,732 262,487 153,395 625,807 723,837 154,785 469,998 581,520 1,255,067 361,381 73,445 432,339 58,030 149,405 89,846 0 541,820 273,018 2,341,733 788,943 33,065 507,337 354,110 345,410 1,265,891 842,827 124,921 69,791 95,577 1,345,131 1,150,773 167,338 86,263 0 398,871 834,883 156,468 374,003 0

Percent in Managed Care 60.68% 54.94% 0.00% 89.12% 65.02% 50.36% 97.58% 75.42% 73.65% 63.80% 65.69% 96.23% 78.04% 79.29% 9.13% 63.42% 92.13% 57.02% 92.23% 78.76% 59.84% 67.52% 61.39% 89.02% 63.54% 11.51% 44.37% 67.12% 72.28% 53.06% 0.00% 67.89% 64.86% 58.22% 70.93% 63.03% 30.83% 68.24% 80.91% 79.14% 96.52% 69.20% 8.25% 97.75% 100.00% 42.75% 88.61% 65.96% 0.00% 65.66% 77.25% 52.49% 47.21% 0.00%

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

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.

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Pharmaceutical Benefits Under Managed Care Plans

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

Where do managed care recipients receive pharmacy benefits? (State, Managed Care Plan, Both) N/A State Both Managed Care Plan Managed Care Plan State Managed Care Plan Managed Care Plan N/A Managed Care Plan (Except dental claims) N/A Managed Care Plan Managed Care Plan State Both Both N/A State Both Both Managed Care Plan Managed Care Plan State Managed Care Plan State State Managed Care Plan State Both Managed Care Plan State State State Managed Care Plan State Managed Care Plan Managed Care Plan Managed Care Plan Managed Care Plan N/A Managed Care Plan State State State Managed Care Plan Both State Managed Care Plan -

Special requirements for pharmacy benefits in managed care? N/A None Statutes, regulations, guidelines, contractual Statutes, regulations, contractual Statutes, regulations, contractual N/A Contractual Statutes N/A Guidelines N/A Contractual Statutes None Guidelines, contractual Contractual N/A N/A Regulations Contractual Contractual Contractual Guidelines, contractual None None None None Contractual Regulations, contractual N/A None None Statutes Contractual Statutes, regulations, contractual Regulations Contractual N/A Statutes N/A Regulations None Regulations, contractual Contractual N/A Statutes, regulations, guidelines, contractual -

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. “-” indicates Not Applicable, “N/A” indicates “No Answer” was received on the Survey. Sources: As reported by State drug program administrators in the 2004 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 2000-2004 State 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

2000 18,786,137 325,059 0 442,254 222,261 2,525,406 254,232 229,995 75,535 78,864 1,016,641 806,009 121,581 32,338 137,622 376,066 182,251 108,093 464,191 48,802 57,151 385,687 583,324 1,063,557 291,365 218,431 304,499 42,312 140,199 37,945 4,432 371,641 199,297 691,422 598,852 23,962 239,460 279,205 312,064 975,211 828,021 104,041 32,149 67,835 1,323,319 606,238 119,200 55,605 0 280,978 800,481 90,631 210,423 0

2001 20,773,813 350,485 0 527,674 257,662 2,870,514 247,181 239,829 83,422 79,673 1,184,506 878,140 127,779 37,913 136,497 433,014 206,751 118,209 489,711 56,542 96,051 421,355 616,241 1,023,264 322,640 297,916 378,771 46,995 150,840 47,518 6,200 459,087 212,456 728,709 674,133 25,540 277,617 299,272 360,926 1,037,374 898,171 111,624 41,716 79,641 1,426,622 753,613 128,898 78,181 0 291,767 766,366 122,230 266,577 0

2002 23,117,668 405,090 0 697,171 336,111 3,191,168 278,095 280,106 87,465 80,300 1,267,998 1,043,154 132,787 58,284 130,988 484,116 227,495 130,162 500,987 206,992 110,922 451,307 628,832 1,208,803 368,186 0 413,361 52,209 163,772 60,823 9,206 523,904 243,069 1,099,900 722,089 30,808 378,476 338,819 378,739 1,140,211 865,285 117,024 64,272 85,868 1,430,966 839,798 154,784 82,261 0 323,863 829,625 144,911 317,106 0

2003 25,262,873 404,797 0 808,506 374,067 3,258,787 262,263 294,331 86,709 85,370 1,354,025 1,212,639 141,399 101,257 137,682 502,401 243,954 141,119 611,878 505,434 148,151 466,688 572,835 1,314,810 362,349 0 425,161 55,372 142,377 74,923 13,407 525,864 261,015 1,914,794 749,152 35,515 436,146 338,859 330,874 1,192,031 857,310 119,257 71,195 90,733 1,304,794 1,065,945 162,364 85,751 0 262,961 854,861 151,515 349,246 0

2004 26,913,570 439,832 0 806,193 386,395 3,258,787 369,270 303,404 99,598 88,452 1,450,117 1,273,133 145,580 131,693 158,869 509,732 262,487 153,395 625,807 723,837 154,785 469,998 581,520 1,255,067 361,381 73,445 432,339 58,030 149,405 89,846 0 541,820 273,018 2,341,733 788,943 33,065 507,337 354,110 345,410 1,265,891 842,827 124,921 69,791 95,577 1,345,131 1,150,773 167,338 86,263 0 398,871 834,883 156,468 374,003 0

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2000; 2001; 2002; 2003and. DHHS, CMS, Center for Medicaid & State Operations.

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Medicaid Managed Care Plan Type, As of June 30, 2004 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

HIO 5 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 -

Commercial Medicaid-only MCO MCO 156 131 0 0 0 26 0 0 23 0 0 2 2 2 0 1 0 4 10 1 0 0 2 1 0 0 3 2 0 3 3 0 0 1 0 1 0 0 0 0 0 7 2 2 7 11 6 3 0 0 3 4 0 0 1 0 2 0 2 3 3 0 14 22 1 0 1 0 4 2 0 0 2 11 2 10 5 0 3 0 0 1 0 0 4 3 9 2 0 0 0 0 6 1 5 2 3 0 28 3 -

PCCM 36 0 0 1 0 1 0 0 0 1 1 0 1 0 3 1 1 1 1 1 0 1 0 0 0 0 1 1 0 0 0 6 2 1 0 1 1 1 0 0 0 1 0 2 1 1 1 1 1 0 -

PIHP 121 1 1 0 0 9 0 0 1 2 1 2 0 0 0 1 0 0 0 0 0 1 18 0 0 0 0 0 0 0 0 12 0 0 0 0 10 28 2 0 0 0 2 1 12 0 0 14 0 3 -

PAHP 34 0 0 1 11 0 0 0 0 4 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 8 0 0 0 1 1 0 0 1 0 0 2 0 0 -

PACE 31 0 0 0 4 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 6 0 0 0 1 0 0 0 0 1 4 0 0 2 0 1 2 0 0 1 0 1 2 0 0 0 1 0 1 -

Other 9 1 0 0 1 0 0 1 0 2 0 1 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 -

HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only Managed Care Organization; PCCM=Primary Care Case Management; PIHP=Prepaid Inpatient Health Plan; PAHP=Prepaid Ambulatory Health Plans; PACE=Program for All-Inclusive Care for the Elderly. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.

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Medicaid Managed Care Enrollment by Plan Type, As of June 30, 2004 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

HIO 513,255 531,255 -

Commercial MCO 9,680,307 2,650,685 223,366 512,210 100,121 80,187 54,253 98,639 417,394 336,417 116,997 31,204 89,846 186,407 272,783 756,800 13,153 794 157,281 24,563 233,871 842,827 124,921 887,027 472,762 230,959 427,612 92,993 244,235 -

MedicaidPCCM only MCO 7,841,591 5,891,174 806,193 332,473 56,351 57,561 80,038 85,598 88,452 195,046 688,109 840,002 48,459 131,693 78,682 294,014 326,484 102,434 63,997 89,287 132,813 339,003 723,837 154,785 469,849 178,735 304,146 470,643 25,144 315,342 58,030 37,636 355,413 1,538,431 20,335 775,790 32,271 350,056 5,572 233,567 11,414 897,047 140,668 52,944 74,264 458,104 320,182 357,097 44,898 86,263 78,352 89,560 48,217 4,087 63,475 119,922 -

PIHP 7,961,643 423,112 75,548 381,312 3,198 95,287 2,235 673 262,487 325,344 1,255,067 9,849 291,480 1,030,653 842,827 1,345,131 292,623 238,152 1,077,312 9,353 -

PAHP 3,799,313 386,395 297,180 88,698 1,273,133 625,807 73,445 0 6,725 348,538 303,495 16,480 95,577 154,730 129,110 -

PACE 9,999 1,665 830 55 111 149 1,310 176 235 1,967 458 530 437 367 269 732 215 493 -

* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operations.

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Other 213,113 16,720 2,652 13,565 17,810 1,409 926 149,405 10,626 -

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Medicaid Managed Care Enrollment by Payment Arrangement, As of June 30, 2004 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 Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Fee-for-Service (FFS) 6,058,012

332,473 57,561 13,565 705,895 840,002

Capitated 29,707,004 423,112 881,741 386,395 3,465,437 438,493 303,404 85,598 91,650 802,598 1,275,368 150,662

Other 145,379 16,720

88,722

131,693 326,484 102,434 89,287 339,003 723,837 154,785 304,146 926

58,030 187,041

5,491 775,790 32,271 5,572 11,414 140,668

74,264 357,097 44,898 86,263 89,560 4,087 63,475

158,869 294,014 316,740 64,108 758,620

469,998 604,028 2,143,104 361,561 73,445 432,515 31,204 89,846 541,820 273,018 2,339,242 13,153 794 507,795 348,538 853,635 2,162,008 1,685,654 124,921 69,791 95,577 2,690,531 1,086,299 352,945

39,937

309,311 1,682,466 92,993 374,003

Individual State totals may not sum to total managed care enrollment (page 2-29) because State totals include individuals enrolled in more than one plan type including dental, mental, and long-term care. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2004. DHHS, CMS, Center for Medicaid & State Operation

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

SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide access to care, and comparability requirements under Section 1902 of the Social Security Act. With a 1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e., cost must be less than the Medicaid program would cost without the waiver). Section 1915(b) waivers are typically limited to a targeted geographical area or population, are approved for an initial period of two years, and can be renewed on an ongoing basis if the State reapplies. Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section 1915(b); • Paragraph (b)(1) - Case Management: States are allowed to implement case management systems which can be as simple as requiring each beneficiary to choose a primary care provider or as comprehensive as mandating enrollment in a prepaid health plan. The Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries into managed care via a State Plan Amendment. • Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in assisting Medicaid eligibles in selecting among competing health care plans, if such a restriction does not substantially impair access to medically necessary services of adequate quality. • Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of additional services) cost savings (resulting from use by the recipient of more costeffective medical care) with recipients of medical assistance under the State Plan. • Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain services. These waivers are sometimes referred to as selective contracting waivers and are gaining in popularity. For example, some approved 1915(b)(4) waivers include programs to restrict the number of providers of transportation services, organ transplants, and inpatient obstetrical care. Refer to the table on page 2-38 for a listing of 1915(b) waivers. Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan Eligibility or change their benefits package. In order to expand their Medicaid programs even further than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.

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

PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY Section 1115 demonstration authority may be used to extend pharmacy coverage to certain lowincome elderly and disabled individuals who are not otherwise eligible for Medicaid. This type of Section 1115 waiver program is commonly referred to as “Pharmacy Plus.” Its purpose is to provide a subsidized pharmacy benefit that is intended to assist individuals in maintaining their healthy status and avoid spending down to Medicaid income and asset eligibility levels. The waivers will test how provision of a pharmacy benefit to a non-Medicaid covered population will affect Medicaid costs, utilization and future eligibility trends. Pharmacy Plus demonstrations 1) cover an individual’s cost of drugs; 2) cover the individual’s cost sharing obligation for private prescription programs; and 3) provide wrap-around coverage to bring private sources of drug coverage up to the level of the Pharmacy Plus benefit. States may construct their Pharmacy Plus programs to provide eligibility for individuals who are not eligible for full Medicaid benefits and who have incomes below 200 percent of the Federal Poverty Level. Under a Pharmacy Plus waiver, States may elect to provide a prescription and over-the-counter drug benefit that is similar to, or different from, the benefits provided in the Medicaid State Plan. States may choose to deliver the services via fee-for-service or capitation. Last, States may choose whether to perform assets tests and income adjustments, and may also choose to enact an enrollment ceiling on the number of individuals who participate in the demonstration. Like all 1115 demonstrations, Pharmacy Plus waivers must be budget neutral to the Federal government. Under the terms and conditions of an approved plan, which is usually granted for a 5year period, a ceiling cap is placed on Federal financial payments for services included in the budget neutrality agreement. States are encouraged to involve the private sector in implementing these programs and are encouraged to explore the use of pharmacy benefit managers (PBM). Premiums, cost sharing (deductibles, co-payments and coinsurance), and benefit limitations are all available tools for providing incentives and cost containment.

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As of September 16, 2004, four States had received Pharmacy Plus demonstration approval: Florida, Illinois, South Carolina and Wisconsin. Another 8 states had applications pending and one state withdrew its request. Refer to the table on page 2-41 for a complete status of the Pharmacy Plus Demonstrations Program.

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

State

1915) Statutes Utilized Implemented

Program(s) Approved st

Expiration

Alabama

Patient 1

Alaska

None

--

--

--

Arizona

None

--

--

--

1, 4

3/1/98

11/21/05

Arkansas

1, 3, 4

Non-Emergency Transportation Primary Care Physician

2/18/04

1

11/1/96

12/17/04

Caloptima

1, 4

10/1/95

7/10/05

Central Coast Alliance for Health

1, 4

1/1/96

7/10/05

Health Plan of San Mateo

1, 4

11/30/87

8/26/04

4

4/24/92

10/14/03

1, 2, 4

3/1/97

6/30/03

Hudman Managed Care Network

California

01/1/97

Medi-Cal Mental Health Care Field Test (San Mateo Co.)

4

4/1/95

7/25/05

Medi-Cal Specialty Mental Health Services Consolidation

4

3/15/95

4/27/05

1, 4

5/1/94

2/10/05

Partnership Health Plan of California Primary Care Case Management Program

1, 4

8/1/84

8/13/03

Sacramento Geographic Managed Care

1, 2, 4

4/1/94

10/8/04

San Diego Geographic Managed Care

1, 2, 4

10/17/98

10/10/03

1, 4

9/1/83

1/11/05

Santa Barbara Health Initiative Selective Provider Contracting Program

4

9/21/82

12/31/04

Two-Plan Model Program

1, 2, 4

1/23/96

11/8/03

Colorado

Mental Health Capitation Program

Connecticut

HUSKY A

1, 3, 4 1, 4

7/1/95 10/1/95

5/4/05 5/30/04

Delaware District of Columbia

None

--

--

--

DC Medicaid Managed Care Program Managed Health Care

Florida

Georgia Hawaii

Prepaid Mental Health Plan

1, 2, 4

4/1/94

6/30/04

1, 2, 3, 4

10/1/92

9/26/04

1, 4

3/1/96

11/12/03

Statewide Inpatient Psychiatric Program

4

4/1/99

12/31/03

Non-Emergency Transportation Broker Program Preadmission Screening and Annual Resident Review (PASARR) None

4

10/1/97

1/10/04

1, 4

11/1/94

10/5/05

--

--

--

Idaho

Healthy Connections

1, 2

10/1/93

9/21/04

Illinois

None

--

--

--

Indiana

Hoosier Healthwise

1

7/1/94

9/22/05

Indiana Medicaid Select

1

1/1/03

7/22/05

1, 3, 4

1/1/99

6/30/05

--

--

--

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

6/1/98 6/1/92 ---7/1/97 1/1/88 -9/1/95

6/12/05 2/28/04 ---4/21/05 3/23/03 -3/14/04

Iowa

Iowa Plan for Behavioral Health

Kansas

None

Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri

Human Service Transportation Community Care None None None Comprehensive Health Care Consolidated Chemical Dependency Treatment Fund None MC+ Managed Care/1915(b)

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State

Program(s) Approved

1915) Statutes Utilized Implemented

Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York

Passport to Health Nebraska Health Connection Combined Waiver Program None

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

1/1/94 7/1/95 --

4/24/04 6/30/05 --

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

-10/1/00 7/1/97 7/1/96 7/1/98 4/1/91 7/1/96 -7/1/01 -9/1/94 2/1/94 2/1/97 ---

-12/29/04 6/30/04 11/14/04 8/5/03 8/5/03 8/5/03 -6/30/05 -7/25/03 10/26/03 6/16/04 ---

---4

---9/1/94

---9/3/04

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

3/10/95 11/1/99 8/1/93

3/4/04 11/5/03 8/31/03

None

Puerto Rico Rhode Island

New Jersey Care 2000+ 1915(b) SALUD! Non-Emergency Transportation ACCESS II/III 1915(b) Carolina Access 1915(b) Health Care Connection 1915(b) None PremierCare None Transportation Program Family Care Network HealthChoices None None

South Carolina

None

South Dakota Tennessee

None None Lonestar Select I

North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania

Texas

Lonestar Select II NorthSTAR STAR Choice of Health Care Delivery

Utah Vermont Virginia Washington West Virginia

Expiration

1, 2, 4

7/1/82

7/23/03

Non-Emergency Transportation

1, 4

7/1/01

10/21/05

Prepaid Mental Health Program

4

7/1/91

12/26/05

None Medallion Medallion II Healthy Options

--

--

--

1, 2

3/1/92

3/24/04

1, 2, 4

1/1/96

12/25/04

1, 4

10/1/93

7/1/03

The Integrated Mental Health Services

1, 4

7/1/93

3/4/04

Mountain Health Trust

1, 4

9/1/96

3/22/04

Physician Assured Access System

1,2

6/1/92

4/27/04

Wisconsin

None

--

--

--

Wyoming

None

--

--

--

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

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Section 1115 Research and Demonstration Waivers As of June 30, 2003 State

Program

Implemented

Expiration

Arizona

Arizona Health Care Cost Containment System (AHCCCS)

10/1/82

9/30/06

4/1/95

11/24/03

11/1/83

11/24/03

Senior Care Action Network

1/1/85

12/31/03

Sutter Senior Care

5/1/94

11/24/03

Delaware

Diamond State Health Plan

1/1/96

3/15/04

Hawaii

Hawaii QUEST

8/1/94

3/31/05

Kentucky

Kentucky Health Care Partnership Program

11/1/97

11/1/05

Maryland

HealthChoice

6/2/97

5/31/05

Massachusetts

Mass Health

7/1/97

6/30/05

MinnesotaCare Program for Families and Children

7/1/95

6/30/05

Prepaid Medical Assistance Program

7/1/85

6/30/05

MC+ Managed Care/1115

9/1/98

3/1/07

Partnership Plan – Family Health Plus

9/04/01

3/31/06

Partnership Plan Medicaid Managed Care Program

10/1/97

3/31/06

Centers For Elders Independence On Lok Senior Health Services California

Minnesota Missouri New York Oklahoma

SoonerCare

1/1/96

12/31/03

Oregon

Oregon Health Plan

2/1/94

1/31/05

Rhode Island

Rite Care

8/1/94

7/31/05

Tennessee

TennCare

1/1/94

6/30/07

Utah

Primary Care Network (PCN)

7/1/02

7/31/07

Vermont

Vermont Health Access

1/1/96

12/31/03

7/01/99

3/31/04

1/1/96

12/31/03

BadgerCare [SCHIP] Wisconsin Wisconsin Partnership Program

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

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Pharmacy Plus Demonstrations Program Status Pharmacy Waivers Under 1115 Authority STATE

PROGRAM NAME

STATUS

Arkansas

Arkansas RX Senior Care

Pending

Connecticut

ConnPACE Program Rx

Pending

Delaware

Delaware Pharmacy Assistance Program

Disapproved

Florida

Ron Silver Senior Rx Program

Approved

Hawaii

Prescription Plus

Disapproved

Illinois

Prescription Drug Benefit for Illinois’ Low Income

Approved

Indiana Hoosier Rx

Pending

Indiana

Pending

Maine

Maine Health Prescription Drug Demonstration

Massachusetts

Pharmacy Waiver

Withdrawn

Michigan

EPIC Ex

Pending

New Jersey

Pharmaceutical Assistance for the Aged and Disabled

Pending

North Carolina

North Carolina Senior Care

Pending

Rhode Island

Rhode Island RX+

South Carolina

Prescription Drug Benefit for South Carolina’s Low Income Seniors

Approved

Wisconsin

WI Senior Care

Approved

Pending

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

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Section 3: State Characteristics

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Pharmaceutical Benefits 2004

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Pharmaceutical Benefits 2004

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

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

Because of the unevenness with which the various government agencies and other organizations have released updated information, we have carefully reviewed all possible information sources and made judgments on which data to present. In the final analysis, we have included those data that, in our opinion, best reflect the factors and characteristics on which we have reported. However, certain limitations in the different sources have resulted in some inconsistencies among the tables. The following examples illustrate this problem. The table showing the age distribution of the population is derived from the 2003 American Community Survey conducted by the U.S. Bureau of the Census. Unfortunately, the approximately 5 million individuals residing in “group quarters” were not included. Hence, the total population figure (and the corresponding figures for each State) presented in this table is lower than the population total in the table showing insurance status. The data on insurance status was compiled from the Current Population Survey, 2004 Annual Social and Economic Supplement, a collaborative effort by the Census Bureau and BLS. Hence, the estimates on the number of Medicare and Medicaid beneficiaries differ slightly from those published by CMS. In addition, more detailed data on poverty, also compiled from 2004 Annual Social and Economic Supplement to the Current Population Survey, have been included in this year’s Compilation. HRSA’s Bureau of Health Professions, National Center for Health Workforce Analysis is responsible for compiling the Area Resource File (ARF), an important annual data file for researchers, planners, policymakers, and others seeking information on the health professions workforce, health care facilities, health care utilization and expenditures, etc. at a variety of geographic levels. The ARF has been our primary source of information on physicians and, for the past several years, registered nurses. Unfortunately, 2002 physician data provided by the American Medical Association (AMA) that HRSA had hoped to include in the 2004 ARF were not able to be included. Instead, HRSA carried over 2001 physician data from the 2003 ARF. Therefore, since no update information was available, we decided not to acquire the 2004 ARF and have repeated the 2001 physician data that appeared in last year’s Compilation (see page 316).

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Pharmaceutical Benefits 2004

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

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Age Demographics, 2003* 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 Population 282,909,885 4,385,446 629,832 5,470,843 2,650,062 34,650,690 4,447,892 3,371,241 792,494 528,759 16,618,145 8,438,203 1,221,885 1,333,165 12,328,721 6,017,445 2,839,868 2,641,747 4,003,036 4,361,271 1,270,602 5,372,472 6,218,773 9,825,840 4,919,584 2,785,493 5,534,753 892,497 1,687,661 2,207,574 1,251,572 8,444,076 1,838,277 18,600,527 8,146,508 609,236 11,134,722 3,396,794 3,482,337 11,922,023 1,037,196 4,008,553 735,349 5,689,261 21,547,821 2,309,555 598,352 7,151,960 5,990,020 1,766,196 5,316,215 487,341

Percent Ages 19 and under 28.1% 27.8% 33.3% 30.1% 27.9% 29.6% 28.2% 26.8% 27.0% 20.8% 25.8% 29.4% 26.6% 30.7% 28.5% 28.8% 26.5% 28.5% 27.1% 29.5% 24.8% 27.9% 25.9% 28.2% 27.8% 29.6% 27.7% 26.8% 28.3% 28.6% 26.5% 27.3% 30.0% 26.4% 27.6% 26.4% 27.6% 28.3% 26.5% 25.7% 25.3% 27.6% 28.9% 26.7% 31.5% 35.1% 25.0% 27.4% 27.4% 24.2% 27.2% 27.4%

Percent Ages 20-44 35.9% 34.6% 35.1% 35.4% 34.5% 37.6% 38.5% 34.4% 35.7% 43.5% 33.2% 38.8% 34.3% 34.7% 36.5% 35.5% 34.5% 35.6% 35.9% 35.4% 33.4% 35.9% 36.5% 35.0% 36.5% 35.3% 35.1% 32.5% 35.0% 36.7% 35.2% 35.4% 33.9% 36.4% 36.8% 34.6% 34.6% 34.6% 35.6% 33.7% 36.1% 35.2% 33.8% 35.9% 37.1% 38.3% 33.8% 36.4% 36.6% 33.4% 35.5% 33.4%

Percent Ages 45-64 24.0% 24.8% 25.3% 21.8% 24.0% 22.5% 23.9% 26.0% 24.3% 23.7% 24.3% 22.6% 25.7% 23.6% 23.6% 23.9% 25.0% 23.6% 24.9% 23.7% 27.9% 25.2% 24.8% 24.8% 24.2% 23.2% 24.5% 27.6% 24.0% 23.5% 26.9% 24.8% 24.1% 24.6% 24.0% 25.0% 25.0% 24.4% 25.5% 25.8% 25.0% 25.0% 23.7% 25.3% 21.8% 18.1% 28.5% 25.2% 25.0% 27.5% 24.8% 27.6%

Percent Ages 65+ 12.0% 12.8% 6.3% 12.7% 13.6% 10.3% 9.5% 12.8% 12.9% 12.0% 16.7% 9.2% 13.4% 11.1% 11.4% 11.9% 14.0% 12.3% 12.1% 11.3% 13.9% 11.1% 12.8% 12.0% 11.4% 11.8% 12.7% 13.1% 12.6% 11.1% 11.4% 12.6% 12.0% 12.6% 11.7% 14.1% 12.8% 12.6% 12.4% 14.8% 13.6% 12.2% 13.6% 12.0% 9.6% 8.5% 12.7% 11.0% 11.0% 14.9% 12.5% 11.6%

This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by the Bureau of the Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2003. *Sum of percentages may not equal 100 percent due to rounding. Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

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Pharmaceutical Benefits 2004

Race Demographics, 2003*

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 Population % White % Black % Asian 282,909,885 76.2% 12.1% 4.2% 4,385,446 71.1% 26.2% 0.7% 629,832 69.6% 3.5% 4.1% 5,470,843 76.8% 3.0% 2.1% 2,650,062 79.3% 15.5% 1.0% 34,650,690 66.2% 6.2% 11.9% 4,447,892 83.8% 4.1% 2.7% 3,371,241 81.5% 9.1% 3.1% 792,494 75.5% 19.0% 2.5% 528,759 30.5% 58.9% 3.2% 16,618,145 77.1% 15.2% 2.0% 8,438,203 66.2% 27.6% 2.5% 1,221,885 24.3% 2.1% 42.3% 1,333,165 92.4% 0.6% 1.5% 12,328,721 74.5% 14.7% 3.9% 6,017,445 87.2% 7.9% 1.2% 2,839,868 93.7% 1.9% 1.5% 2,641,747 86.5% 5.7% 2.7% 4,003,036 89.9% 7.3% 0.8% 4,361,271 64.0% 32.1% 1.5% 1,270,602 97.0% 0.4% 0.7% 5,372,472 64.2% 27.6% 4.7% 6,218,773 84.4% 6.0% 4.4% 9,825,840 80.3% 13.9% 2.2% 4,919,584 88.6% 3.8% 3.5% 2,785,493 61.0% 36.6% 0.7% 5,534,753 85.0% 11.3% 1.4% 892,497 90.1% 0.2% 0.6% 1,687,661 89.0% 4.0% 1.7% 2,207,574 77.2% 6.4% 5.0% 1,251,572 95.5% 0.9% 1.7% 8,444,076 72.3% 13.4% 6.7% 1,838,277 70.2% 1.8% 1.4% 18,600,527 68.8% 15.8% 6.5% 8,146,508 71.9% 21.2% 1.6% 609,236 92.2% 0.8% 0.9% 11,134,722 84.9% 11.5% 1.4% 3,396,794 76.1% 7.6% 1.6% 3,482,337 87.8% 1.7% 3.2% 11,922,023 85.1% 9.8% 2.0% 1,037,196 85.2% 5.2% 2.7% 4,008,553 66.9% 29.8% 1.0% 735,349 94.5% 0.7% 0.6% 5,689,261 79.9% 16.4% 1.2% 21,547,821 73.0% 11.0% 3.1% 2,309,555 90.3% 1.1% 1.8% 598,352 96.5% 0.4% 0.9% 7,151,960 72.7% 19.3% 4.4% 5,990,020 81.3% 3.3% 6.4% 1,766,196 95.1% 3.1% 0.5% 5,316,215 88.3% 5.7% 1.8% 487,341 92.6% 0.7% 0.5%

% Native % American Hawaiian and Indian and Other Pacific Islander Alaska Native 0.8% 0.1% 0.3% 0.0% 14.7% 0.6% 4.8% 0.2% 0.6% 0.0% 0.8% 0.3% 0.7% 0.0% 0.4% 0.0% 0.3% 0.0% 0.5% 0.1% 0.4% 0.1% 0.2% 0.1% 0.1% 9.0% 1.8% 0.0% 0.2% 0.0% 0.3% 0.0% 0.3% 0.0% 0.8% 0.0% 0.3% 0.0% 0.6% 0.1% 0.7% 0.0% 0.3% 0.0% 0.2% 0.0% 0.5% 0.0% 0.9% 0.0% 0.3% 0.0% 0.4% 0.0% 6.4% 0.1% 0.8% 0.0% 1.3% 0.3% 0.2% 0.0% 0.1% 0.0% 9.1% 0.3% 0.3% 0.0% 1.1% 0.1% 4.6% 0.2% 0.2% 0.0% 8.0% 0.1% 1.1% 0.3% 0.1% 0.0% 0.5% 0.6% 0.2% 0.0% 2.3% 0.0% 0.3% 0.1% 0.4% 0.1% 0.7% 0.8% 0.4% 0.0% 0.3% 0.0% 1.2% 0.4% 0.1% 0.0% 0.6% 0.0% 2.0% 0.0%

% Some other race 4.8% 0.5% 1.5% 11.1% 2.0% 11.6% 6.7% 4.6% 1.4% 5.3% 3.6% 2.5% 1.1% 2.8% 5.2% 1.9% 1.1% 1.8% 0.6% 0.6% 0.1% 1.7% 3.5% 1.4% 1.5% 0.6% 0.6% 0.6% 2.9% 5.9% 1.0% 6.0% 14.6% 6.6% 2.6% 0.6% 0.7% 2.3% 2.8% 1.9% 4.6% 0.8% 0.5% 1.3% 11.0% 3.5% 0.4% 1.6% 3.6% 0.2% 2.0% 1.9%

% Indicated 2 or More Races 1.9% 1.3% 6.1% 2.0% 1.6% 2.9% 2.1% 1.4% 1.4% 1.5% 1.7% 1.0% 21.1% 1.0% 1.4% 1.5% 1.4% 2.5% 1.1% 1.1% 1.0% 1.5% 1.4% 1.7% 1.7% 0.8% 1.3% 2.1% 1.6% 3.8% 0.7% 1.5% 2.7% 2.0% 1.5% 0.8% 1.3% 4.3% 3.1% 1.0% 1.2% 1.2% 1.3% 0.9% 1.5% 1.8% 1.4% 1.7% 3.8% 1.0% 1.6% 2.3%

This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2002. *Sum of percentages may not equal 100 percent due to rounding. Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

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Pharmaceutical Benefits 2004

Hispanic Demographics, 2003 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 Population 282,909,885 4,385,446 629,832 5,470,843 2,650,062 34,650,690 4,447,892 3,371,241 792,494 528,759 16,618,145 8,438,203 1,221,885 1,333,165 12,328,721 6,017,445 2,839,868 2,641,747 4,003,036 4,361,271 1,270,602 5,372,472 6,218,773 9,825,840 4,919,584 2,785,493 5,534,753 892,497 1,687,661 2,207,574 1,251,572 8,444,076 1,838,277 18,600,527 8,146,508 609,236 11,134,722 3,396,794 3,482,337 11,922,023 1,037,196 4,008,553 735,349 5,689,261 21,547,821 2,309,555 598,352 7,151,960 5,990,020 1,766,196 5,316,215 487,341

Hispanic Population 39,194,837 84,021 28,011 1,525,366 98,628 11,980,884 831,314 337,911 42,514 51,900 3,108,578 530,896 92,014 110,604 1,694,185 237,800 88,869 178,727 60,593 108,563 9,946 259,160 463,452 341,722 155,015 38,226 125,406 17,646 105,122 487,022 22,649 1,234,632 797,141 3,034,125 456,334 8,762 227,059 191,993 320,243 405,083 100,242 93,580 9,931 135,669 7,614,414 229,386 4,339 379,423 478,824 12,322 211,352 33,239

Percent Hispanic 13.9% 1.9% 4.4% 27.9% 3.7% 34.6% 18.7% 10.0% 5.4% 9.8% 18.7% 6.3% 7.5% 8.3% 13.7% 4.0% 3.1% 6.8% 1.5% 2.5% 0.8% 4.8% 7.5% 3.5% 3.2% 1.4% 2.3% 2.0% 6.2% 22.1% 1.8% 14.6% 43.4% 16.3% 5.6% 1.4% 2.0% 5.7% 9.2% 3.4% 9.7% 2.3% 1.4% 2.4% 35.3% 9.9% 0.7% 5.3% 8.0% 0.7% 4.0% 6.8%

This information was taken from the 2003 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2003. Source: U.S. Department of Commerce, Bureau of the Census, 2003 American Community Survey.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Insurance Status - Populations, 2003* Privately Not Total Medicaid Medicare Military Insured Insured Population Population Population Insurance State 288,280,000 35,647,000 39,456,000 9,979,000 197,869,000 44,961,000 National Total Alabama 4,427,000 584,000 685,000 182,000 2,997,000 629,000 Alaska 645,000 97,000 55,000 90,000 396,000 122,000 Arizona 5,576,000 739,000 757,000 354,000 3,568,000 951,000 Arkansas 2,671,000 428,000 455,000 188,000 1,621,000 465,000 California 35,394,000 5,340,000 4,132,000 964,000 22,591,000 6,499,000 Colorado 4,480,000 406,000 446,000 250,000 3,125,000 772,000 Connecticut 3,421,000 365,000 525,000 73,000 2,594,000 357,000 Delaware 820,000 92,000 110,000 32,000 620,000 91,000 District of Columbia 554,000 101,000 69,000 12,000 358,000 79,000 Florida 16,921,000 1,900,000 3,116,000 791,000 10,950,000 3,071,000 Georgia 8,571,000 965,000 994,000 280,000 5,954,000 1,409,000 Hawaii 1,253,000 133,000 176,000 104,000 927,000 127,000 Idaho 1,360,000 167,000 167,000 40,000 912,000 253,000 Illinois 12,628,000 1,194,000 1,706,000 216,000 9,238,000 1,818,000 Indiana 6,149,000 566,000 842,000 92,000 4,529,000 853,000 Iowa 2,921,000 233,000 465,000 78,000 2,317,000 329,000 Kansas 2,683,000 237,000 346,000 205,000 2,024,000 294,000 Kentucky 4,110,000 551,000 662,000 248,000 2,813,000 574,000 Louisiana 4,429,000 606,000 605,000 194,000 2,716,000 912,000 Maine 1,283,000 231,000 222,000 54,000 877,000 133,000 Maryland 5,493,000 441,000 673,000 186,000 4,129,000 762,000 Massachusetts 6,367,000 756,000 892,000 112,000 4,740,000 682,000 Michigan 9,918,000 1,258,000 1,394,000 135,000 7,555,000 1,080,000 Minnesota 5,076,000 484,000 572,000 106,000 4,110,000 444,000 Mississippi 2,854,000 537,000 421,000 188,000 1,696,000 511,000 Missouri 5,623,000 680,000 912,000 190,000 4,210,000 620,000 Montana 917,000 114,000 135,000 68,000 589,000 177,000 Nebraska 1,727,000 152,000 216,000 83,000 1,316,000 195,000 Nevada 2,250,000 188,000 278,000 90,000 1,518,000 426,000 New Hampshire 1,264,000 87,000 159,000 30,000 1,003,000 131,000 New Jersey 8,579,000 712,000 1,085,000 124,000 6,368,000 1,201,000 New Mexico 1,871,000 362,000 281,000 91,000 1,033,000 414,000 New York 18,970,000 3,125,000 2,754,000 234,000 12,594,000 2,866,000 North Carolina 8,253,000 1,057,000 1,213,000 438,000 5,277,000 1,424,000 North Dakota 631,000 55,000 88,000 43,000 480,000 69,000 Ohio 11,247,000 1,207,000 1,471,000 230,000 8,413,000 1,362,000 Oklahoma 3,438,000 397,000 555,000 224,000 2,136,000 701,000 Oregon 3,569,000 415,000 475,000 122,000 2,437,000 613,000 Pennsylvania 12,155,000 1,271,000 2,077,000 253,000 9,208,000 1,384,000 Rhode Island 1,053,000 160,000 163,000 27,000 766,000 108,000 South Carolina 4,064,000 553,000 663,000 221,000 2,777,000 584,000 South Dakota 751,000 81,000 119,000 34,000 560,000 91,000 Tennessee 5,909,000 964,000 856,000 258,000 3,935,000 778,000 Texas 21,858,000 2,916,000 2,320,000 686,000 12,663,000 5,374,000 Utah 2,352,000 199,000 208,000 85,000 1,831,000 298,000 Vermont 611,000 113,000 94,000 20,000 435,000 58,000 Virginia 7,386,000 574,000 986,000 750,000 5,301,000 962,000 Washington 6,091,000 842,000 688,000 314,000 4,160,000 944,000 West Virginia 1,787,000 298,000 355,000 65,000 1,089,000 296,000 Wisconsin 5,429,000 654,000 754,000 89,000 4,081,000 593,000 Wyoming 488,000 60,000 64,000 38,000 333,000 78,000 *The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one category. Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and Economic Supplement.

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Pharmaceutical Benefits 2004

Insurance Status - Percentages, 2003* % Covered by % Covered by Private Military Total % Covered by % Covered by Insurance % Not Insured Insurance Population Medicaid Medicare State 288,280,000 12.4% 13.7% 3.5% 68.6% 15.6% National Total Alabama 4,427,000 13.2% 15.5% 4.1% 67.7% 14.2% Alaska 645,000 15.1% 8.5% 14.0% 61.5% 18.9% Arizona 5,576,000 13.3% 13.6% 6.3% 64.0% 17.0% Arkansas 2,671,000 16.0% 17.0% 7.0% 60.7% 17.4% California 35,394,000 15.1% 11.7% 2.7% 63.8% 18.4% Colorado 4,480,000 9.1% 9.9% 5.6% 69.8% 17.2% Connecticut 3,421,000 10.7% 15.4% 2.1% 75.8% 10.4% Delaware 820,000 11.2% 13.4% 3.9% 75.7% 11.1% District of Columbia 554,000 18.2% 12.5% 2.1% 64.6% 14.3% Florida 16,921,000 11.2% 18.4% 4.7% 64.7% 18.2% Georgia 8,571,000 11.3% 11.6% 3.3% 69.5% 16.4% Hawaii 1,253,000 10.6% 14.1% 8.3% 74.0% 10.1% Idaho 1,360,000 12.3% 12.3% 3.0% 67.1% 18.6% Illinois 12,628,000 9.5% 13.5% 1.7% 73.2% 14.4% Indiana 6,149,000 9.2% 13.7% 1.5% 73.7% 13.9% Iowa 2,921,000 8.0% 15.9% 2.7% 79.3% 11.3% Kansas 2,683,000 8.8% 12.9% 7.6% 75.4% 11.0% Kentucky 4,110,000 13.4% 16.1% 6.0% 68.4% 14.0% Louisiana 4,429,000 13.7% 13.7% 4.4% 61.3% 20.6% Maine 1,283,000 18.0% 17.3% 4.2% 68.4% 10.4% Maryland 5,493,000 8.0% 12.3% 3.4% 75.2% 13.9% Massachusetts 6,367,000 11.9% 14.0% 1.8% 74.4% 10.7% Michigan 9,918,000 12.7% 14.1% 1.4% 76.2% 10.9% Minnesota 5,076,000 9.5% 11.3% 2.1% 81.0% 8.7% Mississippi 2,854,000 18.8% 14.8% 6.6% 59.4% 17.9% Missouri 5,623,000 12.1% 16.2% 3.4% 74.9% 11.0% Montana 917,000 12.5% 14.7% 7.4% 64.2% 19.4% Nebraska 1,727,000 8.8% 12.5% 4.8% 76.2% 11.3% Nevada 2,250,000 8.3% 12.4% 4.0% 67.5% 18.9% New Hampshire 1,264,000 6.9% 12.6% 2.4% 79.3% 10.3% New Jersey 8,579,000 8.3% 12.6% 1.4% 74.2% 14.0% New Mexico 1,871,000 19.3% 15.0% 4.8% 55.2% 22.1% New York 18,970,000 16.5% 14.5% 1.2% 66.4% 15.1% North Carolina 8,253,000 12.8% 14.7% 5.3% 63.9% 17.3% North Dakota 631,000 8.7% 13.9% 6.8% 76.0% 10.9% Ohio 11,247,000 10.7% 13.1% 2.0% 74.8% 12.1% Oklahoma 3,438,000 11.5% 16.1% 6.5% 62.1% 20.4% Oregon 3,569,000 11.6% 13.3% 3.4% 68.3% 17.2% Pennsylvania 12,155,000 10.5% 17.1% 2.1% 75.8% 11.4% Rhode Island 1,053,000 15.2% 15.5% 2.5% 72.7% 10.2% South Carolina 4,064,000 13.6% 16.3% 5.4% 68.3% 14.4% South Dakota 751,000 10.8% 15.8% 4.6% 74.6% 12.2% Tennessee 5,909,000 16.3% 14.5% 4.4% 66.6% 13.2% Texas 21,858,000 13.3% 10.6% 3.1% 57.9% 24.6% Utah 2,352,000 8.5% 8.8% 3.6% 77.8% 12.7% Vermont 611,000 18.4% 15.4% 3.3% 71.1% 9.5% Virginia 7,386,000 7.8% 13.4% 10.2% 71.8% 13.0% Washington 6,091,000 13.8% 11.3% 5.2% 68.3% 15.5% West Virginia 1,787,000 16.6% 19.9% 3.6% 60.9% 16.6% Wisconsin 5,429,000 12.1% 13.9% 1.6% 75.2% 10.9% Wyoming 488,000 12.3% 13.1% 7.8% 68.2% 15.9% *The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one category. Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2004 Annual Social and Economic Supplement.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Poverty Status - Populations, 2003

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 *FPL- Federal Poverty Level

Total Population 287,699,000 4,417,000 643,000 5,558,000 2,670,000 35,309,000 4,478,000 3,417,000 818,000 550,000 16,884,000 8,559,000 1,250,000 1,356,000 12,616,000 6,130,000 2,916,000 2,676,000 4,100,000 4,422,000 1,279,000 5,485,000 6,357,000 9,893,000 5,075,000 2,851,000 5,606,000 915,000 1,725,000 2,242,000 1,263,000 8,574,000 1,867,000 18,922,000 8,223,000 631,000 11,227,000 3,430,000 3,560,000 12,135,000 1,051,000 4,060,000 749,000 5,901,000 21,827,000 2,346,000 610,000 7,367,000 6,078,000 1,785,000 5,412,000 487,000

Population Below 100% FPL* 35,861,000 663,000 62,000 749,000 474,000 4,634,000 436,000 278,000 60,000 92,000 2,148,000 1,014,000 117,000 138,000 1,592,000 610,000 260,000 288,000 589,000 750,000 149,000 472,000 652,000 1,125,000 376,000 456,000 602,000 139,000 168,000 244,000 73,000 741,000 338,000 2,707,000 1,289,000 61,000 1,226,000 440,000 446,000 1,279,000 121,000 516,000 95,000 829,000 3,705,000 213,000 52,000 740,000 766,000 310,000 528,000 48,000

Population Below 135% FPL* 54,460,000 945,000 99,000 1,225,000 665,000 7,310,000 682,000 420,000 100,000 120,000 3,266,000 1,544,000 184,000 220,000 2,282,000 1,062,000 418,000 443,000 952,000 1,129,000 246,000 705,000 1,010,000 1,676,000 570,000 681,000 929,000 231,000 273,000 408,000 119,000 1,138,000 510,000 3,879,000 1,912,000 103,000 1,771,000 720,000 646,000 1,894,000 176,000 843,000 139,000 1,331,000 5,592,000 349,000 93,000 1,024,000 1,041,000 458,000 851,000 77,000

Population Below 150% FPL* 62,553,000 1,067,000 120,000 1,446,000 761,000 8,467,000 789,000 496,000 120,000 135,000 3,714,000 1,722,000 205,000 263,000 2,672,000 1,205,000 495,000 508,000 1,113,000 1,239,000 280,000 863,000 1,172,000 1,910,000 677,000 811,000 1,084,000 262,000 314,000 488,000 141,000 1,304,000 589,000 4,354,000 2,202,000 120,000 2,053,000 820,000 758,000 2,237,000 201,000 960,000 159,000 1,515,000 6,256,000 390,000 107,000 1,186,000 1,230,000 517,000 964,000 93,000

Population Below 200% FPL* 287,699,000 4,417,000 643,000 5,558,000 2,670,000 35,309,000 4,478,000 3,417,000 818,000 550,000 16,884,000 8,559,000 1,250,000 1,356,000 12,616,000 6,130,000 2,916,000 2,676,000 4,100,000 4,422,000 1,279,000 5,485,000 6,357,000 9,893,000 5,075,000 2,851,000 5,606,000 915,000 1,725,000 2,242,000 1,263,000 8,574,000 1,867,000 18,922,000 8,223,000 631,000 11,227,000 3,430,000 3,560,000 12,135,000 1,051,000 4,060,000 749,000 5,901,000 21,827,000 2,346,000 610,000 7,367,000 6,078,000 1,785,000 5,412,000 487,000

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Poverty Status - Percentages, 2003

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 *FPL- Federal Poverty Level

Total Population 287,699,000 4,417,000 643,000 5,558,000 2,670,000 35,309,000 4,478,000 3,417,000 818,000 550,000 16,884,000 8,559,000 1,250,000 1,356,000 12,616,000 6,130,000 2,916,000 2,676,000 4,100,000 4,422,000 1,279,000 5,485,000 6,357,000 9,893,000 5,075,000 2,851,000 5,606,000 915,000 1,725,000 2,242,000 1,263,000 8,574,000 1,867,000 18,922,000 8,223,000 631,000 11,227,000 3,430,000 3,560,000 12,135,000 1,051,000 4,060,000 749,000 5,901,000 21,827,000 2,346,000 610,000 7,367,000 6,078,000 1,785,000 5,412,000 487,000

Percent Below 100% FPL* 12.5% 15.0% 9.6% 13.5% 17.8% 13.1% 9.7% 8.1% 7.3% 16.8% 12.7% 11.9% 9.3% 10.2% 12.6% 9.9% 8.9% 10.8% 14.4% 17.0% 11.6% 8.6% 10.3% 11.4% 7.4% 16.0% 10.7% 15.1% 9.8% 10.9% 5.8% 8.6% 18.1% 14.3% 15.7% 9.7% 10.9% 12.8% 12.5% 10.5% 11.5% 12.7% 12.7% 14.0% 17.0% 9.1% 8.5% 10.0% 12.6% 17.4% 9.8% 9.8%

Percent Below 135% FPL* 18.9% 21.4% 15.4% 22.0% 24.9% 20.7% 15.2% 12.3% 12.2% 21.8% 19.3% 18.0% 14.7% 16.2% 18.1% 17.3% 14.3% 16.5% 23.2% 25.5% 19.3% 12.9% 15.9% 16.9% 11.2% 23.9% 16.6% 25.2% 15.9% 18.2% 9.4% 13.3% 27.3% 20.5% 23.2% 16.3% 15.8% 21.0% 18.1% 15.6% 16.7% 20.8% 18.6% 22.6% 25.6% 14.9% 15.2% 13.9% 17.1% 25.7% 15.7% 15.8%

Percent Below 150% FPL* 21.7% 24.1% 18.6% 26.0% 28.5% 24.0% 17.6% 14.5% 14.7% 24.6% 22.0% 20.1% 16.4% 19.4% 21.2% 19.7% 17.0% 19.0% 27.1% 28.0% 21.9% 15.7% 18.4% 19.3% 13.3% 28.5% 19.3% 28.6% 18.2% 21.8% 11.1% 15.2% 31.5% 23.0% 26.8% 19.0% 18.3% 23.9% 21.3% 18.4% 19.1% 23.6% 21.2% 25.7% 28.7% 16.6% 17.6% 16.1% 20.2% 29.0% 17.8% 19.1%

Percent Below 200% FPL* 31.1% 34.4% 27.5% 36.7% 40.5% 32.9% 26.2% 22.0% 24.1% 32.5% 32.6% 28.4% 25.1% 34.7% 29.6% 28.2% 25.9% 28.9% 35.3% 39.9% 32.5% 24.2% 25.2% 28.9% 21.6% 39.7% 27.9% 38.5% 26.0% 30.9% 18.6% 23.1% 43.6% 31.6% 37.2% 29.0% 27.7% 35.4% 30.2% 27.7% 28.4% 33.7% 31.2% 35.3% 39.5% 28.6% 26.2% 23.0% 28.8% 40.3% 26.5% 29.2%

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid/Medicare Certified Facilities, 2004 Skilled Nursing ICF-MR State Hospitals Facilities Facilities National Total* 6,0482 14,982 6,521 Alabama 126 226 6 Alaska 24 14 0 Arizona 91 132 13 Arkansas 105 203 41 California 432 1,228 1,117 Colorado 87 195 3 Connecticut 45 246 118 Delaware 10 37 2 District of Columbia 14 19 128 Florida 237 686 108 Georgia 178 332 12 Hawaii 27 41 20 Idaho 48 77 66 Illinois 220 683 308 Indiana 156 483 520 Iowa 120 403 133 Kansas 152 264 31 Kentucky 119 295 13 Louisiana 221 297 486 Maine 42 117 20 Maryland 65 231 4 Massachusetts 112 463 6 Michigan 175 395 1 Minnesota 147 396 221 Mississippi 111 168 13 Missouri 138 482 19 Montana 66 100 1 Nebraska 96 185 4 Nevada 43 41 19 New Hampshire 32 72 1 New Jersey 108 357 9 New Mexico 51 73 43 New York 245 659 678 North Carolina 138 420 332 North Dakota 50 83 68 Ohio 216 941 421 Oklahoma 152 273 72 Oregon 59 120 1 Pennsylvania 247 710 192 Rhode Island 15 95 15 South Carolina 77 177 121 South Dakota 66 90 1 Tennessee 153 304 83 Texas 517 1,030 894 Utah 48 82 15 Vermont 16 41 2 Virginia 109 252 27 Washington 101 240 14 West Virginia 68 122 61 Wisconsin 143 369 36 Wyoming 30 33 2 *National total does not include certified facilities in Puerto Rico and U.S. territories.

Home Health Agencies 7,617 141 16 67 173 621 130 84 15 18 538 98 14 49 329 185 181 136 105 225 30 48 118 244 213 59 156 40 68 50 35 52 62 192 169 26 386 195 60 292 22 69 46 139 1,220 49 12 164 61 63 122 30

Rural Health Clinics 3,545 66 6 12 71 241 37 0 16 0 154 93 1 46 209 53 131 177 118 62 46 0 1 158 73 141 284 42 99 6 17 0 12 9 103 62 17 40 53 41 1 95 55 41 327 14 19 56 111 68 58 19

Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, January 18, 2005.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Licensed Pharmacies (As of June 30, 2004)* Out-of-State or Independent Hospital/ Non-Resident Community Chain Pharmacies Institutional Total Pharmacies Pharmacies (Four or More) Pharmacies State Pharmacies 80,858 7,934 15,443 15,651 13,280 National Total Alabama 1,350 163 724 636 404 Alaska 130 (G) 25 (H) 257 Arizona 1,362 85 98 787 295 Arkansas 739 164 404 335 208 California 6,122 497 198 Colorado 1,232 353 Connecticut 617 (D) 50 (D) 162 (D) 455 (D) 312 (D) Delaware 245 18 63 182 517 District of Columbia 123 13 27 61 0 Florida 6,841 (F) 1,945 (V) (V) 419 Georgia 3,689 205 (P) (P) Hawaii 209 184 Idaho 639 275 (A, E) 273 Illinois 2,451 342 2,183 (A) (A) 296 Indiana 1,354 371 Iowa 1,247 130(F) 798 (A, F) (A) 302 Kansas 818 175 348 264 372 Kentucky 1,495 (X) 174 633 493 189 Louisiana 1,760 181 633 555 339 Maine 290 42 187 Maryland 2,168 (I) 65 126 700 331 Massachusetts 1,048 (J) 158 250 740 0 Michigan 2,547 150 Minnesota 1,502 134 478 552 334 Mississippi 962 130 220 Missouri 1,561 (K) 115 224 473 290 Montana 312 93 255 Nebraska 500 N/A 204 (L) Nevada 794 268 New Hampshire 275 32 43 180 276 New Jersey 1,981 New Mexico 499 52 68 (A) 274 New York 4,644 470 (Q) 1,990 2,072 91 North Carolina 2,123 (F) 166 572 990 286 North Dakota 584 47 156 30 289 Ohio 2,984 (N) 227 573 1,544 374 Oklahoma 1,430 154 (D) 871 (A) (A) 383 Oregon 1,147 123 366 543 469 Pennsylvania 3,172 284 0 Rhode Island 206 21 38 5 363 South Carolina 1,169 403 South Dakota 546 45 123 87 291 Tennessee 1,918 444 525 844 105 Texas 5,981 (B) 583 1,737 2,354 332 Utah 898 106 473 (A) (A) 300 Vermont 158 17 141 89 Virginia 1,549 462 Washington 1,633 230 (C) 341 769 293 West Virginia 549 (J) 331 Wisconsin 3,165 0 Wyoming 140 (F) 29 341 *Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to total. Total includes other pharmacies not specified in the four practice settings. Blanks indicate that information was not available. Source: 2005 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

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Pharmaceutical Benefits 2004

Physicians, 2001 Physicians Office Based Percent Primary Care Percent State Physicians Per 1,000 Pop. Physicians Office Based Physicians* Primary Care National Total 820,869 3.0 507,015 61.8% 313,078 38.1% Alabama 10,009 2.3 6,743 67.4% 4,208 42.0% Alaska 1,414 2.3 991 70.1% 756 53.5% Arizona 12,660 2.4 7,872 62.2% 4,511 35.6% Arkansas 5,856 2.2 3,889 66.4% 2,883 49.2% California 99,547 3.0 62,387 62.7% 36,298 36.5% Colorado 12,095 2.8 7,906 65.4% 4,893 40.5% Connecticut 13,657 4.1 8,016 58.7% 4,227 31.0% Delaware 2,152 2.8 1,387 64.5% 824 38.3% District of Columbia 4,490 8.4 2,082 46.4% 1,180 26.3% Florida 47,299 3.0 30,148 63.7% 15,311 32.4% Georgia 19,837 2.4 13,015 65.6% 7,448 37.5% Hawaii 4,044 3.4 2,606 64.4% 1,420 35.1% Idaho 2,448 1.9 1,812 74.0% 1,181 48.2% Illinois 36,361 3.0 21,875 60.2% 14,576 40.1% Indiana 13,887 2.3 9,378 67.5% 6,356 45.8% Iowa 6,041 2.1 3,727 61.7% 2,891 47.9% Kansas 6,533 2.5 4,147 63.5% 2,965 45.4% Kentucky 9,678 2.4 6,641 68.6% 4,076 42.1% Louisiana 12,439 2.9 7,956 64.0% 4,466 35.9% Maine 3,708 3.0 2,423 65.3% 1,653 44.6% Maryland 23,857 4.6 13,018 54.6% 7,092 29.7% Massachusetts 29,336 4.8 15,944 54.3% 8,752 29.8% Michigan 25,710 2.6 15,280 59.4% 9,913 38.6% Minnesota 14,752 3.1 9,283 62.9% 7,352 49.8% Mississippi 5,544 2.0 3,741 67.5% 2,221 40.1% Missouri 14,350 2.6 8,799 61.3% 5,209 36.3% Montana 2,292 2.6 1,642 71.6% 1,013 44.2% Nebraska 4,399 2.6 2,829 64.3% 2,286 52.0% Nevada 4,280 2.1 3,050 71.3% 1,599 37.4% New Hampshire 3,609 2.9 2,310 64.0% 1,423 39.4% New Jersey 28,179 3.4 17,727 62.9% 9,672 34.3% New Mexico 4,678 2.6 2,815 60.2% 1,996 42.7% New York 79,541 4.3 42,839 53.9% 25,738 32.4% North Carolina 21,899 2.8 13,922 63.6% 8,668 39.6% North Dakota 1,602 2.6 1,094 68.3% 879 54.9% Ohio 30,880 2.8 19,072 61.8% 12,208 39.5% Oklahoma 6,572 2.0 4,278 65.1% 2,794 42.5% Oregon 9,748 2.9 6,347 65.1% 3,861 39.6% Pennsylvania 40,063 3.4 23,701 59.2% 14,387 35.9% Rhode Island 3,942 3.9 2,254 57.2% 1,365 34.6% South Carolina 9,939 2.5 6,600 66.4% 4,253 42.8% South Dakota 1,755 2.4 1,220 69.5% 886 50.5% Tennessee 15,695 2.8 10,437 66.5% 6,179 39.4% Texas 48,339 2.3 31,647 65.5% 18,647 38.6% Utah 5,165 2.3 3,337 64.6% 2,036 39.4% Vermont 2,403 4.1 1,399 58.2% 1,029 42.8% Virginia 20,880 3.0 13,050 62.5% 8,082 38.7% Washington 17,404 3.0 11,170 64.2% 7,527 43.2% West Virginia 4,498 2.6 2,812 62.5% 1,956 43.5% Wisconsin 14,374 2.7 9,667 67.3% 6,666 46.4% Wyoming 1,029 2.1 730 70.9% 557 54.1% *Primary care physicians include General Practice, General Family Practice, General Internal Medicine, and General Pediatrics. Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File, February 2003.

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Other Providers, 2001/2004 # FTE Registered Nurses* State National Total 962,195 Alabama 17,143 Alaska 2,339 Arizona 13,058 Arkansas 9,898 California 85,878 Colorado 12,034 Connecticut 9,930 Delaware 2,971 District of Columbia 5,011 Florida 56,078 Georgia 28,447 Hawaii 3,470 Idaho 3,599 Illinois 45,501 Indiana 21,436 Iowa 12,404 Kansas 9,102 Kentucky 16,213 Louisiana 17,274 Maine 5,265 Maryland 16,623 Massachusetts 24,133 Michigan 35,094 Minnesota 16,122 Mississippi 12,356 Missouri 23,650 Montana 3,205 Nebraska 7,249 Nevada 5,084 New Hampshire 4,206 New Jersey 28,082 New Mexico 5,258 New York 72,057 North Carolina 32,695 North Dakota 3,175 Ohio 43,869 Oklahoma 10,827 Oregon 11,674 Pennsylvania 48,786 Rhode Island 2,850 South Carolina 14,942 South Dakota 3,829 Tennessee 20,777 Texas 65,056 Utah 5,446 Vermont 1,656 Virginia 23,152 Washington 15,440 West Virginia 9,307 Wisconsin 16,878 Wyoming 1,666 *FTE- Full-time equivalent employees as of 2001 **As of June 30, 2004

# FTE Registered Nurses* per 1,000 population 3.4 3.8 3.7 2.5 3.7 2.5 2.7 2.9 3.7 8.7 3.4 3.4 2.8 2.7 3.6 3.5 4.2 3.4 4.0 3.9 4.1 3.1 3.8 3.5 3.2 4.3 4.2 3.5 4.2 2.4 3.3 3.3 2.9 3.8 4.0 5.0 3.9 3.1 3.4 4.0 2.7 3.7 5.1 3.6 3.0 2.4 2.7 3.2 2.6 5.2 3.1 3.4

Pharmacists** Pharmacists** (Licensed by State) per 1,000 population 352,869 1.2 6,026 1.3 616 0.9 6,884 1.2 3,649 1.3 29,676 0.8 5,445 1.2 4,486 1.3 1,385 1.7 1,564 2.8 21,540 1.2 10,474 1.2 1,574 1.2 1,623 1.2 13,151 1.0 8,696 1.4 5,001 1.7 3,652 1.3 5,383 1.3 5,970 1.3 1,267 1.0 7,391 1.3 9,940 1.5 11,322 1.1 6,052 1.2 3,483 1.2 7,123 1.2 1,556 1.7 2,722 1.6 8,386 3.6 1,963 1.5 13,100 1.5 2,325 1.2 19,136 1.0 9,864 1.2 2,155 3.4 14,703 1.3 4,785 1.4 4,189 1.2 17,991 1.5 1,810 1.7 5,256 1.3 1,443 1.9 7,498 1.3 21,795 1.0 2,266 0.9 840 1.4 8,754 1.2 7,146 1.2 2,970 1.6 5,836 1.1 1,007 2.0

Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File, February 2003. 2005 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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Section 4: Pharmacy Program Characteristics

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Pharmaceutical Benefits 2004

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

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR 28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR 2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program; (3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take advantage of savings in the marketplace for multiple-source drugs. To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs, based on application of a specific formula. The upper limit for other drugs is similar, in that it retains the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet. However, this standard is applied on an aggregate basis rather than on a prescription-specific basis. State agencies are therefore encouraged to exercise maximum flexibility in establishing their own payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).

Multiple-Source Drugs A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two or more different proprietary names or under a proprietary name and without such a name. A specific upper limit for a multiple-source drug may be established if the following requirements are met: •

All of the formulations of the drug approved by the Food and Drug Administration (FDA) have been evaluated as therapeutically equivalent in the current edition of the publication, Approved Drug Products with Therapeutically Equivalent Evaluations; and

•

At least three suppliers list the drug (which is classified by the FDA as Category A in its publication) in the current editions of published compendia of cost information for drugs available for sale nationally.

The upper limit for a multi-source drug for which a specific limit has been established does not apply if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for a particular recipient. The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary” must appear on the face of the prescription. The rule specifically states that a check-off box on a prescription form is not acceptable, but it does not address the use of two-line prescription forms.

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

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

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

•

The provider’s usual and customary charges to the general public.

States may continue to use their existing EAC program, or adopt another method, as long as their aggregate expenditures do not exceed what would have been paid under EAC principles.

Other Requirements The rule requires States to submit a State plan that describes their payment methods for prescribed drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate spending in each category is equal to or below the upper limit requirements. States are also required to submit assurances to CMS that the requirements are met. The rule does not prescribe a preferred payment method for the States, but gives States the flexibility to determine how they will pay for prescription drugs under Medicaid. As long as the State’s aggregate spending is at or below the amount derived from the formula, the State is free to maintain its current payment program or adopt other methods. States can alter payment rates for individual drugs, balancing payment increases for certain products with payment decreases for other drugs so that, in the aggregate, the program does not exceed the established limit. With the establishment of upper limit payment maximums, some States may alter their current payment methods to comply with the established limits. State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs cover the same drugs listed by CMS. States with established MAC programs may be unaffected if their MAC rates are already low, or they may have to make certain adjustments in their MAC levels to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new payment method to increase the use of lower cost generic drug products in order to stay within the upper payment limits, or may simply adopt CMS’ formula for listed drug products.

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

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Pharmaceutical Benefits 2004

Drug Expenditures 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

2002 $29,339,050,970 $452,269,953 $70,708,412 $3,725,371 $273,257,660 $3,591,537,830 $189,717,036 $357,919,257 $97,750,161 $66,129,208 $1,717,652,527 $873,703,133 $88,256,904 $119,177,013 $1,293,435,797 $631,637,846 $285,467,642 $213,778,616 $652,904,065 $714,107,841 $220,420,714 $297,291,733 $958,972,520 $674,222,281 $310,174,144 $567,313,801 $790,853,387 $83,587,410 $207,782,737 $86,929,536 $99,682,997 $694,669,924 $73,877,785 $3,660,427,024 $1,100,822,176 $52,495,878 $1,333,992,298 $285,068,869 $279,029,096 $718,210,352 $125,187,888 $451,846,044 $62,382,937 $905,405,421 $1,591,064,713 $140,275,267 $114,157,870 $458,953,342 $541,963,790 $277,039,990 $442,718,195 $39,094,579

*Rebates have not been subtracted from these figures. Source: CMS, CMS-64 Report, FY 2002 and FY 2003.

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2003 $33,794,520,738 $536,222,703 $69,512,220 $4,744,244 $310,709,182 $4,219,504,969 $225,297,507 $403,802,170 $109,844,743 $81,762,504 $2,018,037,106 $1,073,715,230 $97,386,406 $132,143,091 $1,469,190,682 $627,575,345 $331,222,324 $228,920,787 $685,229,661 $827,713,132 $268,547,563 $429,589,193 $946,210,618 $758,266,989 $276,731,202 $568,007,104 $941,522,305 $79,771,831 $210,199,726 $106,821,075 $112,948,647 $766,995,569 $86,408,362 $4,218,811,815 $1,291,263,155 $56,960,417 $1,520,147,470 $301,294,000 $262,335,388 $791,053,653 $140,686,626 $558,129,364 $71,223,108 $1,280,129,986 $1,920,865,985 $163,217,885 $127,763,857 $506,414,352 $592,437,155 $345,831,214 $592,295,000 $49,106,118

% Change 2002-2003 15.2% 18.6% -1.7% 27.3% 13.7% 17.5% 18.8% 12.8% 12.4% 23.6% 17.5% 22.9% 10.3% 10.9% 13.6% -0.6% 16.0% 7.1% 5.0% 15.9% 21.8% 44.5% -1.3% 12.5% -10.8% 0.1% 19.1% -4.6% 1.2% 22.9% 13.3% 10.4% 17.0% 15.3% 17.3% 8.5% 14.0% 5.7% -6.0% 10.1% 12.4% 23.5% 14.2% 41.4% 20.7% 16.4% 11.9% 10.3% 9.3% 24.8% 33.8% 25.6%

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Ranking Based on Drug Expenditures*

State

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

2003 Payments

2003 Ranking

% of 2003 National Medicaid Drug Expenditures

2002 Payments

2002 Ranking

$33,794,520,738 $4,219,504,969 $4,218,811,815 $2,018,037,106 $1,920,865,985 $1,520,147,470 $1,469,190,682 $1,291,263,155 $1,280,129,986 $1,073,715,230 $946,210,618 $941,522,305 $827,713,132 $791,053,653 $766,995,569 $758,266,989 $685,229,661 $627,575,345 $592,437,155 $592,295,000 $568,007,104 $558,129,364 $536,222,703 $506,414,352 $429,589,193 $403,802,170 $345,831,214 $331,222,324 $310,709,182 $301,294,000 $276,731,202 $268,547,563 $262,335,388 $228,920,787 $225,297,507 $210,199,726 $163,217,885 $140,686,626 $132,143,091 $127,763,857 $112,948,647 $109,844,743 $106,821,075 $97,386,406 $86,408,362 $81,762,504 $79,771,831 $71,223,108 $69,512,220 $56,960,417 $49,106,118 $4,744,244

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 51

12.5% 12.5% 6.0% 5.7% 4.5% 4.3% 3.8% 3.8% 3.2% 2.8% 2.8% 2.4% 2.3% 2.3% 2.2% 2.0% 1.9% 1.8% 1.8% 1.7% 1.7% 1.6% 1.5% 1.3% 1.2% 1.0% 1.0% 0.9% 0.9% 0.8% 0.8% 0.8% 0.7% 0.7% 0.6% 0.5% 0.4% 0.4% 0.4% 0.3% 0.3% 0.3% 0.3% 0.3% 0.2% 0.2% 0.2% 0.2% 0.2% 0.1% 0.0%

$29,339,050,970 $3,591,537,830 $3,660,427,024 $1,717,652,527 $1,591,064,713 $1,333,992,298 $1,293,435,797 $1,100,822,176 $905,405,421 $873,703,133 $958,972,520 $790,853,387 $714,107,841 $718,210,352 $694,669,924 $674,222,281 $652,904,065 $631,637,846 $541,963,790 $442,718,195 $567,313,801 $451,846,044 $452,269,953 $458,953,342 $297,291,733 $357,919,257 $277,039,990 $285,467,642 $273,257,660 $285,068,869 $310,174,144 $220,420,714 $279,029,096 $213,778,616 $189,717,036 $207,782,737 $140,275,267 $125,187,888 $119,177,013 $114,157,870 $99,682,997 $97,750,161 $86,929,536 $88,256,904 $73,877,785 $66,129,208 $83,587,410 $62,382,937 $70,708,412 $52,495,878 $39,094,579 $3,725,371

2 1 3 4 5 6 7 9 10 8 11 13 12 14 15 16 17 19 23 18 22 21 20 26 24 30 27 31 28 25 32 29 33 35 34 36 37 38 39 40 41 43 42 45 47 44 48 46 49 50 51

*Rebates have not been subtracted from these figures. Source: CMS, HCFA-64 Report, FY 2002 and FY 2003.

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Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Net Expenditures, 2003

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 Medicaid Net Medical Assistance Expenditures

Total Drug Expenditures*

% of Total Net Expenditures

$259,895,896,495 $3,477,832,931 $563,428,717 $4,219,253,105 $2,329,593,600 $30,051,769,056 $2,552,159,860 $3,506,583,946 $718,470,271 $1,076,136,978 $10,946,214,986 $6,300,856,479 $766,109,972 $809,931,820 $9,253,097,164 $4,282,435,701 $2,136,386,901 $1,764,536,608 $3,697,230,708 $4,423,174,011 $1,747,306,187 $4,343,054,613 $7,680,882,159 $7,967,828,590 $3,604,575,049 $2,853,086,305 $5,541,604,705 $511,474,712 $1,325,133,485 $1,015,796,455 $916,422,038 $7,858,368,246 $2,006,492,205 $39,585,134,508 $7,050,804,888 $468,522,734 $10,177,517,569 $2,311,939,159 $2,678,357,318 $12,772,008,268 $1,436,618,006 $3,540,107,364 $536,195,894 $6,348,265,631 $15,420,026,696 $1,092,519,199 $705,028,688 $3,524,849,814 $5,006,473,801 $1,857,747,927 $4,799,267,070 $337,284,398

$33,794,520,738 $536,222,703 $69,512,220 $4,744,244 $310,709,182 $4,219,504,969 $225,297,507 $403,802,170 $109,844,743 $81,762,504 $2,018,037,106 $1,073,715,230 $97,386,406 $132,143,091 $1,469,190,682 $627,575,345 $331,222,324 $228,920,787 $685,229,661 $827,713,132 $268,547,563 $429,589,193 $946,210,618 $758,266,989 $276,731,202 $568,007,104 $941,522,305 $79,771,831 $210,199,726 $106,821,075 $112,948,647 $766,995,569 $86,408,362 $4,218,811,815 $1,291,263,155 $56,960,417 $1,520,147,470 $301,294,000 $262,335,388 $791,053,653 $140,686,626 $558,129,364 $71,223,108 $1,280,129,986 $1,920,865,985 $163,217,885 $127,763,857 $506,414,352 $592,437,155 $345,831,214 $592,295,000 $49,106,118

13.0% 15.4% 12.3% 0.1% 13.3% 14.0% 8.8% 11.5% 15.3% 7.6% 18.4% 17.0% 12.7% 16.3% 15.9% 14.7% 15.5% 13.0% 18.5% 18.7% 15.4% 9.9% 12.3% 9.5% 7.7% 19.9% 17.0% 15.6% 15.9% 10.5% 12.3% 9.8% 4.3% 10.7% 18.3% 12.2% 14.9% 13.0% 9.8% 6.2% 9.8% 15.8% 13.3% 20.2% 12.5% 14.9% 18.1% 14.4% 11.8% 18.6% 12.3% 14.6%

*Rebates have not been subtracted from these figures. Source: CMS, CMS-64 Report, FY 2003.

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

2001 11.4% 13.5% 9.7% 0.1% 13.0% 12.5% 7.7% 9.5% 13.7% 6.5% 17.2% 14.6% 11.8% 14.9% 11.4% 14.0% 14.1% 11.0% 17.9% 13.9% 14.6% 7.5% 12.1% 8.1% 6.9% 20.2% 14.2% 15.0% 14.4% 9.1% 10.5% 9.1% 4.0% 9.5% 16.0% 10.8% 13.0% 8.5% 8.6% 6.3% 8.6% 14.5% 11.1% 12.4% 11.4% 14.1% 17.3% 13.8% 10.6% 16.8% 9.6% 12.9%

2002 11.9% 14.6% 10.3% 0.1% 12.2% 13.4% 8.2% 10.4% 15.4% 6.5% 17.4% 14.0% 11.9% 15.4% 14.7% 14.2% 11.1% 11.6% 17.3% 14.6% 15.4% 8.2% 11.9% 8.9% 7.0% 19.7% 14.8% 14.6% 15.5% 10.8% 9.8% 9.0% 4.2% 10.1% 16.4% 11.4% 13.8% 12.6% 10.9% 5.9% 9.2% 13.7% 11.3% 15.6% 11.8% 14.3% 17.3% 12.0% 10.5% 17.5% 10.6% 14.2%

*Percentages are based on figures that have not had rebates subtracted from them. Source: CMS, HCFA-64 Report, FY 2001 - FY 2003.

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2003 13.0% 15.4% 12.3% 0.1% 13.3% 14.0% 8.8% 11.5% 15.3% 7.6% 18.4% 17.0% 12.7% 16.3% 15.9% 14.7% 15.5% 13.0% 18.5% 18.7% 15.4% 9.9% 12.3% 9.5% 7.7% 19.9% 17.0% 15.6% 15.9% 10.5% 12.3% 9.8% 4.3% 10.7% 18.3% 12.2% 14.9% 13.0% 9.8% 6.2% 9.8% 15.8% 13.3% 20.2% 12.5% 14.9% 18.1% 14.4% 11.8% 18.6% 12.3% 14.6%

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Share of Drug Expenditures by Category, 2003

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

Central Nervous System Drugs

Cardiovascular Drugs

$12,363,631,847 $190,945,957 $40,923,331 $124,140,938 $1,289,548,645 $103,640,073 $175,996,061 $35,648,536 $22,639,645 $693,597,564 $352,660,702 $38,608,056 $60,904,208 $495,470,501 $285,453,451 $157,180,331 $108,704,011 $259,250,343 $243,290,866 $117,977,151 $204,973,562 $426,324,589 $361,027,746 $181,317,127 $177,433,416 $405,814,288 $40,552,154 $90,518,087 $47,839,070 $55,511,397 $282,889,997 $33,805,242 $1,289,421,527 $448,996,966 $25,861,471 $652,799,378 $119,561,069 $141,970,988 $307,075,831 $62,768,301 $207,810,670 $31,103,276 $519,390,119 $649,950,752 $76,262,627 $12,190,259 $191,563,725 $264,734,853 $132,548,914 $106,988,776 $18,045,300

$3,801,947,569 $66,659,877 $7,768,953 $31,785,881 $559,177,157 $22,017,120 $43,649,610 $9,932,451 $11,118,033 $226,902,557 $106,114,919 $16,570,061 $9,756,419 $216,632,381 $56,722,913 $29,475,299 $20,129,864 $77,499,804 $80,234,506 $25,767,867 $52,518,379 $92,542,559 $76,602,148 $22,612,381 $84,476,651 $102,560,092 $6,856,348 $18,113,336 $11,322,593 $8,670,264 $100,795,953 $10,254,314 $466,736,184 $150,623,341 $4,787,469 $157,137,204 $30,104,381 $14,073,890 $86,090,827 $18,136,380 $89,756,227 $5,211,572 $161,820,197 $197,853,618 $10,588,695 $4,029,933 $64,498,544 $57,092,141 $41,425,874 $34,076,588 $2,663,814

Anti-Infective Gastrointestinal Agents Drugs

Hormones and Synthetic Substitutes

$2,450,238,097 $27,223,794 $9,310,870 $15,032,482 $332,606,715 $14,468,064 $33,724,817 $6,274,352 $2,311,674 $166,461,633 $46,097,696 $4,368,883 $4,941,868 $120,206,662 $38,769,474 $20,589,271 $19,155,941 $38,423,330 $54,704,705 $25,943,479 $30,695,978 $65,955,409 $46,655,710 $26,666,517 $32,146,980 $42,501,845 $7,054,158 $9,825,208 $4,793,034 $7,987,351 $66,022,618 $9,600,179 $298,153,780 $137,251,191 $3,635,205 $126,543,046 $17,356,536 $9,146,150 $76,369,314 $12,448,121 $28,189,939 $6,629,496 $114,371,425 $119,278,242 $12,287,375 $1,274,253 $55,067,690 $50,205,897 $22,586,370 $26,031,579 $2,891,791

$3,122,393,794 $60,041,745 $7,442,275 $34,833,265 $446,647,443 $20,563,418 $28,069,637 $9,960,540 $5,808,770 $169,619,538 $101,979,157 $10,537,125 $12,181,215 $147,429,047 $61,546,793 $31,129,735 $20,852,659 $71,239,832 $72,578,920 $26,564,709 $30,165,832 $76,059,993 $59,556,708 $26,618,045 $57,169,431 $91,382,260 $7,814,615 $19,259,675 $9,231,504 $9,272,731 $59,052,329 $11,525,477 $377,655,759 $121,245,082 $4,990,743 $143,667,021 $27,406,868 $15,944,333 $66,108,211 $11,563,648 $67,604,062 $6,748,303 $102,886,876 $196,523,211 $13,644,567 $3,432,229 $43,083,321 $54,915,790 $36,930,892 $27,907,393 $4,001,062

$3,524,213,631 $60,716,138 $8,847,721 $36,048,688 $328,595,843 $18,531,371 $33,252,384 $15,575,193 $20,050,510 $327,894,156 $146,354,001 $8,256,539 $10,628,384 $158,093,371 $50,052,280 $29,648,480 $17,339,561 $65,552,414 $109,817,991 $18,778,785 $37,778,689 $91,559,817 $41,181,543 $21,521,170 $66,031,112 $85,327,587 $5,988,940 $17,825,594 $12,500,368 $6,145,697 $86,862,944 $7,189,377 $660,900,621 $133,935,843 $3,856,941 $135,588,872 $28,607,550 $12,508,942 $51,191,071 $10,787,026 $70,178,436 $7,244,215 $77,633,377 $227,126,956 $13,338,853 $2,955,483 $41,046,594 $43,927,432 $31,511,034 $23,531,062 $4,396,675

* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2003.

4-9

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

State National Average 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

Unclassified Therapeutic Agents $1,055,465,025 $16,933,831 $3,017,515 $11,391,635 $124,486,965 $8,369,762 $10,845,172 $3,080,673 $1,528,819 $66,881,733 $32,931,912 $4,528,069 $4,314,264 $47,769,159 $23,254,776 $9,787,979 $7,119,076 $26,072,218 $23,611,873 $8,040,234 $10,075,261 $25,289,436 $24,190,573 $10,553,097 $16,796,656 $27,673,946 $3,539,485 $6,717,962 $3,571,056 $2,992,898 $25,517,275 $3,806,974 $141,742,052 $42,606,450 $1,697,267 $45,200,120 $11,119,046 $5,192,257 $24,675,241 $3,880,507 $19,236,343 $2,361,480 $32,266,211 $68,447,771 $4,199,480 $1,171,684 $15,844,703 $18,662,019 $11,707,954 $9,066,980 $1,697,176

Autonomic Blood Formation Drugs and Coagulation $1,444,434,327 $29,117,413 $4,143,870 $16,290,279 $109,440,799 $12,209,376 $15,529,027 $4,797,072 $1,881,191 $92,245,297 $58,770,316 $4,022,621 $5,635,849 $63,945,423 $31,028,392 $16,730,776 $12,062,663 $45,278,547 $38,485,281 $12,176,814 $12,388,585 $32,901,099 $28,593,928 $14,662,898 $27,954,253 $51,284,406 $4,642,139 $9,742,260 $5,639,042 $5,631,726 $33,348,479 $4,222,012 $155,076,486 $56,952,033 $2,510,695 $85,106,203 $14,623,169 $8,586,132 $44,691,804 $5,800,930 $28,235,443 $3,460,577 $51,570,846 $95,780,057 $6,240,065 $1,460,581 $25,131,271 $24,374,739 $16,987,581 $10,992,631 $2,051,251

$1,631,603,922 $24,798,577 $6,586,137 $20,346,625 $277,059,101 $8,772,382 $15,588,038 $4,129,047 $4,304,599 $114,802,172 $47,089,914 $6,637,325 $2,919,820 $85,924,830 $42,923,482 $9,418,099 $6,580,327 $30,533,575 $36,873,442 $10,185,925 $21,864,657 $38,923,231 $37,571,523 $13,349,968 $26,440,052 $44,879,042 $2,668,099 $6,302,498 $6,116,918 $2,482,312 $52,697,474 $3,924,480 $197,337,654 $60,109,134 $1,645,740 $57,239,140 $14,922,093 $7,653,099 $48,107,836 $4,609,417 $24,643,479 $2,942,659 $37,631,333 $88,073,590 $2,186,777 $1,529,437 $27,136,311 $20,421,210 $9,383,374 $11,481,805 $1,856,163

* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2003.

4-10

Other

Total

$4,342,078,576 $88,291,181 $10,045,292 $43,386,184 $392,418,402 $28,741,953 $42,629,307 $14,564,793 $11,053,831 $273,547,974 $172,266,157 $12,070,039 $13,229,104 $197,901,702 $102,732,283 $39,127,637 $28,274,280 $94,528,334 $139,158,070 $25,153,673 $39,448,955 $105,231,780 $85,771,522 $38,123,425 $76,114,896 $128,694,744 $10,979,885 $26,583,522 $13,564,994 $12,988,214 $104,790,316 $13,564,380 $555,046,144 $193,389,654 $6,675,757 $213,194,584 $32,159,087 $16,824,128 $101,012,127 $15,825,524 $92,173,886 $10,135,666 $119,158,930 $351,910,677 $19,419,642 $4,942,610 $71,109,483 $64,322,622 $43,432,138 $40,318,584 $6,050,504

$33,736,006,788 $564,728,513 $98,085,964 $333,255,977 $3,859,981,070 $237,313,519 $399,284,053 $103,962,657 $80,697,072 $2,131,952,624 $1,064,264,774 $105,598,718 $124,511,131 $1,533,373,076 $692,483,844 $343,087,607 $240,218,382 $708,378,397 $798,755,654 $270,588,637 $439,909,898 $954,787,913 $761,151,401 $355,424,628 $564,563,447 $980,118,210 $90,095,823 $204,888,142 $114,578,579 $111,682,590 $811,977,385 $97,892,435 $4,142,070,207 $1,345,109,694 $55,661,288 $1,616,475,568 $295,859,799 $231,899,919 $805,322,262 $145,819,854 $627,828,485 $75,837,244 $1,216,729,314 $1,994,944,874 $158,168,081 $32,986,469 $534,481,642 $598,656,703 $346,514,131 $290,395,398 $43,653,736

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Share of Prescriptions Processed, 2003

State National Average 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

Central Nervous System Drugs

Cardiovascular Drugs

171,087,805 3,171,638 548,257 1,731,110 14,259,438 1,583,124 2,072,006 487,968 268,419 9,307,006 5,424,867 490,672 763,814 8,266,131 4,206,893 2,232,976 1,429,685 4,209,055 3,653,912 1,909,114 2,485,651 5,852,176 5,348,834 2,088,156 2,572,856 5,202,372 563,101 1,289,900 599,049 783,744 3,444,576 595,916 16,319,688 6,235,662 357,380 9,926,750 1,395,693 2,004,987 4,198,755 813,442 2,928,723 399,558 8,340,084 9,092,238 1,109,740 166,600 2,838,758 3,872,043 2,215,492 1,788,091 241,705

80,839,088 1,567,963 203,519 797,550 7,954,722 593,377 915,787 184,937 225,749 5,172,090 2,495,750 324,763 214,445 5,540,656 1,419,140 746,404 544,022 1,901,993 1,731,401 708,202 1,120,167 2,326,321 2,085,945 559,625 1,769,873 2,282,561 171,791 447,252 256,638 217,582 1,981,577 281,797 9,021,907 3,386,484 143,776 3,864,726 581,302 453,103 2,036,284 308,215 2,021,657 147,440 3,670,322 3,169,705 241,808 74,664 1,428,824 1,467,594 928,170 1,087,096 62,412

Anti-Infective Gastrointestinal Agents Drugs 48,001,985 1,138,879 122,476 759,124 3,977,118 413,553 259,671 162,745 84,515 2,831,244 2,494,567 92,049 196,731 2,496,296 992,144 578,027 345,553 1,308,853 1,710,847 356,938 313,685 1,039,851 746,226 311,226 1,137,394 1,195,140 129,643 390,739 151,055 131,413 628,802 134,825 5,175,402 2,032,839 91,286 2,349,075 512,325 222,004 837,861 116,847 1,047,783 158,080 1,286,313 4,802,083 297,363 41,811 603,632 701,236 664,115 333,075 97,526

*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2003.

4-11

34,302,085 553,609 103,357 263,680 3,317,303 244,334 362,472 76,266 33,064 1,902,380 898,164 136,203 82,277 2,101,959 932,118 304,342 244,418 1,002,805 586,044 323,601 353,731 891,682 801,119 451,235 451,414 814,529 96,744 310,048 81,940 158,724 714,276 143,222 4,049,862 1,332,424 50,922 2,407,992 232,606 224,644 948,649 159,760 475,084 71,747 1,496,149 1,600,010 166,672 22,874 774,924 823,549 359,356 329,368 38,433

Hormones and Synthetic Substitutes 55,890,837 1,127,896 149,034 648,832 5,721,487 520,571 545,336 169,529 98,035 3,047,416 1,998,544 177,740 238,825 3,234,926 1,112,689 638,478 448,490 1,352,565 1,301,839 580,394 609,632 1,614,601 1,280,656 485,462 1,012,463 1,643,419 172,580 385,045 183,761 181,359 1,021,018 286,371 5,817,384 2,364,568 120,832 2,899,276 454,827 397,877 1,335,172 192,723 1,339,858 138,279 2,213,225 2,757,927 294,969 57,384 853,123 1,224,420 691,640 675,631 72,729

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Share of Prescriptions Processed, 2003 (Con't)

State National Average 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

Unclassified Therapeutic Agents 11,853,860 212,576 28,043 121,607 1,119,181 96,895 125,679 33,085 21,565 835,642 392,437 63,617 44,790 656,985 230,548 114,630 81,549 313,874 281,821 97,307 130,618 275,688 275,857 90,260 208,689 287,390 34,681 77,885 39,978 32,045 294,180 41,959 1,610,186 524,687 22,156 561,787 96,291 52,451 274,742 49,480 225,238 27,068 396,317 617,164 45,455 10,812 205,807 189,025 143,269 125,280 15,584

Autonomic Blood Formation Drugs and Coagulation 30,838,002 658,280 87,848 322,711 2,220,821 298,800 292,253 107,860 44,891 1,831,715 1,305,010 82,552 120,381 1,573,171 698,234 354,809 245,679 870,152 863,458 303,890 299,880 813,956 652,859 280,272 476,308 973,232 99,230 230,919 123,670 114,142 575,191 101,590 3,409,929 1,193,010 52,161 1,914,814 266,844 196,722 754,046 120,909 569,221 70,636 1,173,744 2,146,746 158,015 29,345 486,953 608,244 377,868 238,879 46,152

13,382,215 265,307 30,535 129,844 1,370,538 100,463 156,958 26,206 24,297 861,701 428,075 45,988 33,901 928,489 310,000 140,862 90,475 342,808 341,589 83,761 189,155 301,360 409,452 95,056 285,945 386,707 25,941 84,325 40,868 35,577 332,324 49,449 1,192,203 454,082 25,011 739,909 81,798 73,708 579,899 51,961 268,378 29,357 503,537 626,793 42,323 9,374 245,099 213,822 125,592 157,435 13,978

*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2003.

4-12

Other

Total

115,859,862 2,704,930 233,712 1,262,522 9,121,332 850,026 939,638 328,206 218,812 6,044,048 4,639,338 330,097 347,382 6,946,150 2,781,211 1,107,657 771,341 3,154,670 3,512,998 675,526 1,013,935 2,415,517 2,342,925 941,083 2,158,653 3,028,715 275,126 951,883 325,257 398,917 2,355,693 459,079 13,543,607 4,694,793 206,338 6,915,185 746,371 579,612 2,602,161 387,406 2,314,061 270,255 3,793,613 10,040,023 539,754 96,604 2,043,981 1,954,869 1,222,582 1,112,614 159,654

562,055,739 11,401,078 1,506,781 6,036,980 49,061,940 4,701,143 5,669,800 1,576,802 1,019,347 31,833,242 20,076,752 1,743,681 2,042,546 31,744,763 12,682,977 6,218,185 4,201,212 14,456,775 13,983,909 5,038,733 6,516,454 15,531,152 13,943,873 5,302,375 10,073,595 15,814,065 1,568,837 4,167,996 1,802,216 2,053,503 11,347,637 2,094,208 60,140,168 22,218,549 1,069,862 31,579,514 4,368,057 4,205,108 13,567,569 2,200,743 11,190,003 1,312,420 22,873,304 34,852,689 2,896,099 509,468 9,481,101 11,054,802 6,728,084 5,847,469 748,173

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Average Cost Per Prescription, 2003* State National Average 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 Payments

Prescriptions Processed

Average Prescription Cost

$33,736,006,788 $564,728,513 $98,085,964 $333,255,977 $3,859,981,070 $237,313,519 $399,284,053 $103,962,657 $80,697,072 $2,131,952,624 $1,064,264,774 $105,598,718 $124,511,131 $1,533,373,076 $692,483,844 $343,087,607 $240,218,382 $708,378,397 $798,755,654 $270,588,637 $439,909,898 $954,787,913 $761,151,401 $355,424,628 $564,563,447 $980,118,210 $90,095,823 $204,888,142 $114,578,579 $111,682,590 $811,977,385 $97,892,435 $4,142,070,207 $1,345,109,694 $55,661,288 $1,616,475,568 $295,859,799 $231,899,919 $805,322,262 $145,819,854 $627,828,485 $75,837,244 $1,216,729,314 $1,994,944,874 $158,168,081 $32,986,469 $534,481,642 $598,656,703 $346,514,131 $290,395,398 $43,653,736

562,055,739 11,401,078 1,506,781 6,036,980 49,061,940 4,701,143 5,669,800 1,576,802 1,019,347 31,833,242 20,076,752 1,743,681 2,042,546 31,744,763 12,682,977 6,218,185 4,201,212 14,456,775 13,983,909 5,038,733 6,516,454 15,531,152 13,943,873 5,302,375 10,073,595 15,814,065 1,568,837 4,167,996 1,802,216 2,053,503 11,347,637 2,094,208 60,140,168 22,218,549 1,069,862 31,579,514 4,368,057 4,205,108 13,567,569 2,200,743 11,190,003 1,312,420 22,873,304 34,852,689 2,896,099 509,468 9,481,101 11,054,802 6,728,084 5,847,469 748,173

$60.02 $49.53 $65.10 $55.20 $78.68 $50.48 $70.42 $65.93 $79.17 $66.97 $53.01 $60.56 $60.96 $48.30 $54.60 $55.17 $57.18 $49.00 $57.12 $53.70 $67.51 $61.48 $54.59 $67.03 $56.04 $61.98 $57.43 $49.16 $63.58 $54.39 $71.55 $46.74 $68.87 $60.54 $52.03 $51.19 $67.73 $55.15 $59.36 $66.26 $56.11 $57.78 $53.19 $57.24 $54.61 $64.75 $56.37 $54.15 $51.50 $49.66 $58.35

*Rebates have not been subtracted from these figures. **Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2003.

4-13

National Pharmaceutical Council

Pharmaceutical Benefits 2004

4-14

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MEDICAID DRUG REBATES In 1990, Congress considered a number of proposals designed to reduce and control Federal and State expenditures for prescription drug products provided to Medicaid patients (S.2605, the Pharmaceutical Access and Prudent Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug Act, sponsored by Senator David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access and Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A vigorous Congressional debate ensued over which of these approaches to pursue. Several pharmaceutical manufacturers voluntarily offered rebates to the States in exchange for open access for their products, while the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for open formularies. Numerous public interest groups offered opinions on the proposals and in some cases proposals of their own. The Congressional debate ended in both the House and Senate offering somewhat similar proposals. During the ensuing Conference between the House and Senate, the Office of Management and Budget (OMB) argued for the inclusion of several proposals into the provisions in budget bill, the Omnibus Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-508, enacted November 5, 1990, required a drug manufacturer to enter into and have in effect a national rebate agreement with the Secretary of DHHS for States to receive Federal funding for outpatient drugs dispensed to Medicaid patients. (For a detailed account of the debate and genesis of various provisions see Robert Betz’s analysis of the Medicaid Best Price Law and its effect on pharmaceutical manufacturers’ pricing policies.∗) The requirement for rebate agreements does not apply to the dispensing of a single-source or innovator multiple-source drug if the State has determined that the drug is essential, rated 1-A by the FDA, and prior authorization is obtained for the exception. Existing rebate agreements qualify under the law if the State agrees to report all rebates to DHHS and the agreement provides for a minimum aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products. OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug manufacturer to enter into discount pricing agreements with the Department of Veterans Affairs and with covered entities funded by the Public Health Service in order to have its drugs covered by Medicaid. The Medicaid rebate law, as amended, is included as Appendix C. The drug rebate program is administered by CMS’ Center for Medicaid and State Operations (CMSO). Currently, the rebate for covered outpatient drugs is as follows: •

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

•

For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of each product’s AMP.

∗

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

4-15

National Pharmaceutical Council

Pharmaceutical Benefits 2004

4-16

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Drug Rebates, 2003 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

Allocation of Drug Rebate Monies1 Medicaid Drug Budget General Fund Medicaid Drug Budget Medicaid Drug Budget Medicaid General General Fund Medicaid General Medicaid Drug Budget Medicaid Drug Budget General Fund General Fund General Fund Drug Rebate Fund General Fund Medicaid Drug Budget General Fund General Fund Medicaid Drug Budget Medicaid Drug Budget Medicaid General Medicaid General General Fund Medicaid General Medicaid General Medicaid Drug Budget General Fund Medicaid Drug Budget General Fund General Fund Medicaid Drug Budget General Fund General Fund Medicaid General Medicaid Drug Budget Medicaid General Medicaid General General Fund Outpatient Appropriation General Fund Medicaid Drug Budget Medicaid Drug Budget Medicaid General Medicaid Drug Budget General Fund Health Access Trust Fund Medicaid General General Fund Medicaid General Medicaid General Medicaid Drug Budget

Total Rebates2 $7,008,382,303 $102,784,110 $15,060,446 $58,097,761 $1,207,800,866 $32,446,928 $81,550,711 $28,352,506 $15,120,780 $464,880,949 $219,238,104 $19,212,047 $31,430,642 $292,630,625 $131,850,261 $62,173,583 $59,849,370 $124,919,867 $165,904,174 $68,331,107 $77,934,401 $208,146,240 $179,774,542 $54,081,115 $114,233,479 $178,620,625 $17,172,113 $42,766,762 $21,078,909 $27,628,562 $149,040,244 $19,585,223 $598,407,083 $260,487,290 $11,369,358 $325,329,459 $59,205,487 $65,706,778 $149,563,463 $30,477,726 $119,101,600 $14,808,661 $224,072,761 $392,292,711 $25,931,043 $28,595,852 $112,854,618 $123,683,508 $69,568,029 $118,267,026 $6,962,798

Federal Share2 $4,145,168,732 $74,244,635 $8,946,379 $44,058,096 $635,884,565 $16,743,775 $42,156,720 $14,871,627 $10,813,162 $281,544,767 $133,880,256 $11,571,434 $22,834,044 $150,740,652 $83,862,599 $40,568,073 $36,912,589 $89,772,191 $121,064,068 $46,664,469 $40,509,917 $108,049,289 $103,731,878 $27,643,562 $89,163,417 $112,813,582 $12,822,675 $26,291,497 $11,402,018 $14,223,879 $76,924,905 $14,894,385 $305,702,916 $168,077,481 $8,067,828 $196,899,815 $42,776,373 $40,630,979 $84,158,389 $17,361,117 $85,684,428 $10,010,329 $148,367,141 $242,560,725 $19,597,473 $18,448,953 $59,506,765 $64,563,377 $53,266,225 $69,458,066 $4,425,247

*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply. Sources: 1As reported by State drug program administrators in the 2004 NPC Survey. 2 CMS, CMS-64 Report, FY 2003, includes reported state supplemental rebates for CA, FL, IL, LA, MI, VT, and WV.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Drug Rebate Trends, 1999-2003 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

1999

2000

2001

2002**

$3,338,497,983 $49,785,076 $7,050,981 $37,931,853 $539,928,783 $25,151,080 $38,656,394 $9,787,444 $8,379,982 $195,512,719 $95,237,778 $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 $32,311,299 $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 $90,472,488 $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 $15,145,126 $10,579,999 $67,715,512 $54,331,249 $35,941,495 $51,869,264 $4,364,795

$3,980,646,518 $60,984,826 $8,594,014 $40,814,931 $600,895,711 $28,832,989 $49,164,014 $13,780,359 $9,215,651 $248,637,014 $91,886,605 $10,947,632 $13,984,004 $143,590,170 $84,453,135 $36,040,216 $31,022,023 $93,688,165 $84,800,897 $31,598,262 $42,081,781 $146,225,538 $75,687,945 $43,228,324 $61,260,326 $110,025,619 $10,985,923 $31,004,940 $4,863,879 $15,073,211 $105,535,091 $8,901,456 $470,317,992 $140,047,825 $6,503,601 $171,685,793 $37,135,809 $32,056,386 $118,989,849 $19,223,034 $73,052,676 $7,198,848 $41,302,450 $222,314,531 $21,889,639 $17,869,053 $75,630,717 $69,782,396 $46,762,149 $66,358,433 $4,720,686

$4,948,222,331 $76,624,463 $11,337,883

$5,917,504,760 $84,994,286 $14,347,654 $56,688,398 $946,651,118 $39,054,140 $62,627,160 $16,990,455 $11,445,790 $353,649,807 $205,469,531 $15,267,796 $22,939,130 $190,316,986 $126,512,101 $50,092,788 $29,755,595 $133,330,557 $113,729,749 $47,395,300 $54,261,949 $191,118,385 $172,522,597 $62,655,474 $115,221,421 $147,281,505 $15,955,235 $47,855,128 $13,547,604 $20,888,707 $127,373,014 $13,274,387 $663,973,100 $207,064,443 $11,651,682 $263,267,258 $51,471,649 $54,474,938 $154,338,235 $26,213,636 $98,272,773 $12,056,925 $180,613,885 $305,110,523 $36,756,960 $24,488,863 $76,776,155 $100,874,789 $48,976,536 $89,226,751 $8,681,912

$45,744,406 $786,113,991 $34,264,574 $61,916,192 $17,042,045 $10,446,499 $297,362,792 $110,087,285 $14,363,603 $18,841,154 $170,733,612 $103,148,144 $42,602,101 $39,731,568 $104,759,238 $115,254,842 $41,847,632 $34,263,429 $180,517,139 $111,716,756 $54,548,714 $88,481,567 $133,927,028 $13,359,968 $30,219,685 $16,330,579 $13,934,765 $124,127,231 $12,110,896 $543,984,948 $207,551,841 $8,780,182 $217,702,350 $40,177,945 $34,991,037 $129,265,110 $21,467,002 $95,438,155 $9,405,933 $102,644,077 $268,557,241 $21,949,963 $22,045,277 $79,484,868 $91,250,830 $52,402,218 $79,554,207 $5,809,366

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

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2003** $7,008,382,303 $102,784,110 $15,060,446 $58,097,761 $1,207,800,866 $32,446,928 $81,550,711 $28,352,506 $15,120,780 $464,880,949 $219,238,104 $19,212,047 $31,430,642 $292,630,625 $131,850,261 $62,173,583 $59,849,370 $124,919,867 $165,904,174 $68,331,107 $77,934,401 $208,146,240 $179,774,542 $54,081,115 $114,233,479 $178,620,625 $17,172,113 $42,766,762 $21,078,909 $27,628,562 $149,040,244 $19,585,223 $598,407,083 $260,487,290 $11,369,358 $325,329,459 $59,205,487 $65,706,778 $149,563,463 $30,477,726 $119,101,600 $14,808,661 $224,072,761 $392,292,711 $25,931,043 $28,595,852 $112,854,618 $123,683,508 $69,568,029 $118,267,026 $6,962,798

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Drug Rebate Trends Annual Percent Change, 1998-2003 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

% Change 98-99 35.2% 36.3% 40.3% 68.4% 48.8% 23.1% 20.3% 37.9% 18.0% 29.7% 48.1% 39.8% 38.2% 20.6% 23.6% 28.1% 35.4% 27.3% 15.4% 52.8% 29.2% 57.4% 4.3% 20.4% 23.4% 27.3% 25.9% 30.6% 50.2% 33.9% 27.4% -25.3% 41.7% 37.1% 19.3% 34.4% 37.1% 48.0% 24.7% 30.8% 42.9% 17.8% 27.5% 51.6% 19.3% 32.6% 38.6% 34.3% 27.2% 44.3%

% Change 99-00 19.2% 22.5% 21.9% 7.6% 11.3% 14.6% 27.2% 40.8% 10.0% 27.2% -3.5% 30.7% 17.5% 18.1% 34.7% 11.3% 15.4% 28.9% 11.4% 5.2% 30.2% 4.4% 0.0% 15.6% 24.2% 30.0% 18.2% 43.5% -37.1% 16.3% 16.6% 11.7% 32.1% 25.8% 9.2% 15.6% 16.1% 50.1% -0.3% 33.1% 30.5% 20.6% 84.1% 19.7% 44.5% 68.9% 11.7% 28.4% 30.1% 27.9% 8.2%

% Change 00-01 24.3% 25.6% 31.9%

% Change 01-02 19.6% 10.9% 26.5%

% Change 02-03 18.4% 20.9% 5.0%

12.1% 30.8% 18.8% 25.9% 23.7% 13.4% 19.6% 19.8% 31.2% 34.7% 18.9% 22.1% 18.2% 28.1% 11.8% 35.9% 32.4% -18.6% 23.5% 47.6% 26.2% 44.4% 21.7% 21.6% -2.5% 235.8% -7.6% 17.6% 36.1% 15.7% 48.2% 35.0% 26.8% 8.2% 9.2% 8.6% 11.7% 30.6% 30.7% 148.5% 20.8% 0.3% 23.4% 5.1% 30.8% 12.1% 19.9% 23.1%

23.9% 20.4% 14.0% 1.1% -0.3% 9.6% 18.9% 86.6% 6.3% 21.8% 11.5% 22.7% 17.6% -25.1% 27.3% -1.3% 13.3% 58.4% 5.9% 54.4% 14.9% 30.2% 10.0% 19.4% 58.4% -17.0% 49.9% 2.6% 9.6% 22.1% -0.2% 32.7% 20.9% 28.1% 55.7% 19.4% 22.1% 3.0% 28.2% 76.0% 13.6% 67.5% 11.1% -3.4% 10.5% -6.5% 12.2% 49.4%

2.5% 27.6% -16.9% 30.2% 66.9% 32.1% 31.5% 6.7% 25.8% 37.0% 53.8% 4.2% 24.1% 101.1% -6.3% 45.9% 44.2% 43.6% 8.9% 4.2% -13.7% -0.9% 21.3% 7.6% -10.6% 55.6% 32.3% 17.0% 47.5% -9.9% 25.8% -2.4% 23.6% 15.0% 20.6% -3.1% 16.3% 21.2% 22.8% 24.1% 28.6% -29.5% 16.8% 47.0% 22.6% 42.0% 32.5% -19.8%

*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply. **Tennessee did not report data for 1998. Source: CMS, CMS-64 Report, FY 1998 – FY 2003.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Rebates as a Percent of Drug Expenditures, 2003 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

Drug Expenditures

Rebates**

Rebates as % Drug Expenditure

$33,794,520,738 $536,222,703 $69,512,220 $4,744,244 $310,709,182 $4,219,504,969 $225,297,507 $403,802,170 $109,844,743 $81,762,504 $2,018,037,106 $1,073,715,230 $97,386,406 $132,143,091 $1,469,190,682 $627,575,345 $331,222,324 $228,920,787 $685,229,661 $827,713,132 $268,547,563 $429,589,193 $946,210,618 $758,266,989 $276,731,202 $568,007,104 $941,522,305 $79,771,831 $210,199,726 $106,821,075 $112,948,647 $766,995,569 $86,408,362 $4,218,811,815 $1,291,263,155 $56,960,417 $1,520,147,470 $301,294,000 $262,335,388 $791,053,653 $140,686,626 $558,129,364 $71,223,108 $1,280,129,986 $1,920,865,985 $163,217,885 $127,763,857 $506,414,352 $592,437,155 $345,831,214 $592,295,000 $49,106,118

$7,008,382,303 $102,784,110 $15,060,446 $58,097,761 $1,207,800,866 $32,446,928 $81,550,711 $28,352,506 $15,120,780 $464,880,949 $219,238,104 $19,212,047 $31,430,642 $292,630,625 $131,850,261 $62,173,583 $59,849,370 $124,919,867 $165,904,174 $68,331,107 $77,934,401 $208,146,240 $179,774,542 $54,081,115 $114,233,479 $178,620,625 $17,172,113 $42,766,762 $21,078,909 $27,628,562 $149,040,244 $19,585,223 $598,407,083 $260,487,290 $11,369,358 $325,329,459 $59,205,487 $65,706,778 $149,563,463 $30,477,726 $119,101,600 $14,808,661 $224,072,761 $392,292,711 $25,931,043 $28,595,852 $112,854,618 $123,683,508 $69,568,029 $118,267,026 $6,962,798

20.7% 19.2% 21.7% 18.7% 28.6% 14.4% 20.2% 25.8% 18.5% 23.0% 20.4% 19.7% 23.8% 19.9% 21.0% 18.8% 26.1% 18.2% 20.0% 25.4% 18.1% 22.0% 23.7% 19.5% 20.1% 19.0% 21.5% 20.3% 19.7% 24.5% 19.4% 22.7% 14.2% 20.2% 20.0% 21.4% 19.7% 25.0% 18.9% 21.7% 21.3% 20.8% 17.5% 20.4% 15.9% 22.4% 22.3% 20.9% 20.1% 20.0% 14.2%

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

MEDICAID DRUG COVERAGE In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior approval before dispensing of any drug product and may design and implement a formulary intended to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet specific requirements established in Medicaid law. A State Medicaid program can restrict coverage for a drug product through a formulary, if based on official labeling or information in designated official medical compendia, “the excluded drug does not have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or clinical outcome of such treatment” over other drug products, and there is a written explanation (available to the public) of the basis for the exclusion. However, drug products excluded from the formulary under these conditions, nevertheless, must be available through prior authorization. Drugs in certain specific classes may be restricted or excluded from coverage without regard to the formulary conditions and need not be available through prior authorization. These classes include: •

Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic relief of cough or colds, or for cessation of smoking.

•

Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or non-prescription drugs.

•

Drugs that require tests or monitoring services to be purchased exclusively from the manufacturer or his designee.

•

Barbiturates or benzodiazepines.

PRIOR AUTHORIZATION Whether or not a drug product is on a formulary, States may require physicians to request and receive official permission before a particular product can be dispensed. This procedure is called Prior Authorization or Prior Approval. States may not operate prior authorization plans unless the State provides for a response within 24 hours of a request and provides for a 72-hour emergency supply of the medication. The Congressional intent for the prior authorization provision was not to encourage the use of such programs, but rather to make them available to the States for the purpose of controlling utilization of products that have very narrow indications or high abuse potential. The majority of States report the establishment of prior authorization programs and have plans to apply prior authorization to a select number of drugs. Some States will do so only after their Drug Utilization Review (DUR) program has identified areas of therapeutic concern. DRUG UTILIZATION REVIEW DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse medical results. A DUR Program consists of prospective and retrospective components as well as components to educate physicians and pharmacists on common drug therapy problems.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Specifically, the program educates physicians and pharmacists how to identify and reduce fraud, abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drugallergy interactions, and clinical abuse or misuse. The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR programs is whether or not the systems currently in place (or envisioned) meet the two objectives outlined above. Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in the exercise of the pharmacist’s professional judgment are deemed significant, including the following: •

Name and description of the medication;

•

The route of administration, dosage form, dosage, and duration of therapy;

•

Special directions and precautions for preparation, administration and use by the patient;

•

Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur;

•

Techniques for self-monitoring prescription therapy;

•

Proper storage;

•

Prescription refill information; and

•

Action to be taken in the event of a missed dose.

State law must also require pharmacists to make a reasonable effort to obtain, record, and maintain at least the following information for each Medicaid recipient: •

Name, address, telephone number, date of birth (or age) and gender;

•

Individual history where significant, including a disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices; and

•

Pharmacist comments relevant to the individual’s pharmaceutical therapy.

Retrospective DUR. This activity continuously assesses data on drug use against established standards, preferably using automated claims processing and information retrieval techniques to monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary, introduce remedial strategies in order to improve the quality of care and to conserve program funds or personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and recipients, or with respect to specific drugs or groups of drugs. State Drug Use Review Board. Each State must provide for the establishment of a DUR board of health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help implement the DUR program. Each State must require its DUR board to make annual reports to DHHS on its activities and on cost savings resulting from the DUR program. 4-22

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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 None Medi-Cal Contract Drug Advisory Committee Medical Advisory Council DUR Board and P & T Committee advise DUR Board DUR Board None None DUR Board advises Medical Care Advisory Committee None DUR Board DUR Board DUR Board Pharmacy & Therapeutic Advisory Committee Pharmacy Advisory Committee DUR Committee None DUR Board Pharmacy & Therapeutics Committee Drug Formulary Committee None Pharmacy Advisory Group DUR Board None DUR Board None None None Pharmacy Advisory Committee NC Physician Advisory Group None Pharmacy & Therapeutic Committee DUR Board DUR Board Medical Assistance Advisory Committee None None Pharmacy & Therapeutics Committee TennCare Pharmacy Advisory Committee None DUR Board DUR Committee Pharmacy Liaison Committee Drug Evaluation Matrix Team Medical Services Fund Advisory Council None DUR Board

Quarterly Ad Hoc Quarterly Bi-Monthly Monthly Quarterly Quarterly Monthly 8 per year Bi-Monthly Bi-Monthly Semiannually Monthly Quarterly Quarterly Quarterly Quarterly Monthly Quarterly Quarterly Quarterly Quarterly Monthly Quarterly Monthly Annually Quarterly Monthly Monthly Quarterly Weekly Quarterly Bi-Monthly

Introductory letter Introductory letter Inform health plans directly Introductory letter Petition with specific content requirements Introductory letter Introductory letter Introductory letter Introductory letter Introductory letter Intro. letter to Express Scripts & Medicaid Formulary kit Introductory letter Contact First DataBank Electronic form Introductory letter Introductory letter Introductory letter, Package insert Introductory letter Introductory letter Introductory letter Introductory letter State form, Introductory letter Introductory letter Introductory letter AMPC format dossier Electronic submission Introductory letter Introductory letter Introductory letter, Information packet Introductory letter Contact First DataBank Introductory letter E-mail Contact First DataBank Introductory letter E-mail to [email protected] Introductory letter Introductory letter to State agency Introductory letter Formulary packet Product profile information Introductory letter State form Introductory letter, FDA information Introductory letter Introductory letter AMCP format dossier Introductory letter Notification Introductory letter

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage State

Cosmetics

Fertility Drugs

Experimental Drugs

Alabama 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

Not Covered Covered with Restrictions 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 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not 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 Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered

Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not 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 2004 NPC Survey.

4-24

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage (Con’t) State

Prescribed Insulin

Disposable Needles for Insulin Use

Syringe Combinations Blood Glucose Test 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 with Restrictions Covered Covered with Restrictions Covered Covered Covered Covered Covered Covered Covered with Restrictions Covered Covered Covered with Restrictions Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered, PA Required Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered Covered

Covered Covered as DME Covered with Restrictions Covered DME Covered Covered Covered Covered with Restrictions Covered Covered as DME Covered Covered with Restrictions Covered Not Covered Covered as DME Not Covered Covered Covered Covered Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Not Covered Covered as DME Covered Covered Covered Covered Covered Not Covered Covered Covered as DME Covered as DME Covered as DME Covered Covered Covered Covered Covered Covered Covered as DME Covered Covered Covered Covered Covered Covered

Covered Covered as DME Covered with Restrictions Covered DME Covered Covered Covered Covered with Restrictions Covered Covered as DME Covered Covered with Restrictions Covered Not Covered Covered Covered Covered Covered with Restrictions Covered Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Covered Covered, PA Required Covered Covered Covered Covered Covered Not Covered Covered Covered as DME Covered as DME Covered as DME Covered Covered Covered Covered Covered Covered Covered with Restrictions Covered Covered Covered Covered Covered Covered

Covered as DME Covered as DME Not Covered Covered DME Covered Covered Covered Covered with Restrictions Covered with Restrictions Covered as DME Covered as DME Covered with Restrictions Covered Not Covered Covered as DME Not Covered Covered Covered Covered as DME Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Not Covered Covered as DME Covered Covered Covered Covered Covered Not Covered Covered Covered as DME Covered as DME Covered as DME Covered Covered as DME Covered as DME Covered Covered Not Covered Covered Covered Covered Covered Covered Covered Covered

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy Benefit Design - Coverage (Con’t) 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

Covered as DME Covered as DME Not Covered Covered Covered as DME Covered Covered Covered Covered with Restrictions Covered with Restrictions Covered as DME Covered as DME Covered Covered Not Covered Covered as DME Not Covered Covered Covered Covered as DME Covered with Restrictions Covered

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 Not Covered Covered Not Covered Covered as DME Covered Covered Covered Covered Covered Not Covered Not Covered Covered as DME Covered as DME Covered as DME Covered Covered Covered as DME Covered Covered Not Covered Not Covered Not Covered Covered Covered Covered Covered Covered

Covered, PA Required Covered Not Covered Covered, PA Required Covered Not Covered Covered Not Covered Covered Covered with Restrictions Covered, PA Required Covered as DME Covered Covered Covered Covered as DME Covered, PA Required Covered as DME Not Covered Covered Covered with Restrictions Covered with Restrictions, PA required Covered Covered Covered Covered, PA Required Covered as DME Covered as DME Covered Covered Covered Covered Not Covered Covered Covered as DME, PA Required Covered with Restrictions Covered, PA Required Covered Covered as DME, PA Required Covered as DME Covered, PA Required Covered Not Covered Covered as DME Covered as DME Covered Covered Not Covered Covered Covered as DME

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

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Physicians Office

Home Health Care

Extended Care Facility

Alabama 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

PP PP PP PP PP PP PP and PDP PP PP PP PDP PP PDP and PP PDP and PP PDP and PP PP PDP and PP PDP and PP PDP PDP and PP PDP and PP PP PP PP PDP PP PP PP PP PDP and PP PDP and PP PP PP PDP and PP PP PP PP PDP PDP PP PDP and PP PP PP PP PP PP PP PP PDP and PP PP

PDP PDP PDP PDP PDP PP PDP PDP PDP PDP PP PDP PDP and PP PDP and PP PDP PDP PDP PDP PDP PDP PDP PDP PDP PP PDP PDP PDP PDP and PP PDP and PP PDP PDP PDP PDP PDP and PP PP PDP PDP PDP PDP and PP PDP PDP PDP PP PDP PDP PDP PDP PP

PDP PDP PDP PDP PDP PP PDP PDP PDP PDP PDP PP PDP PDP and PP PDP and PP PDP PDP PDP PDP PDP PDP PDP PDP PDP PP PDP PDP PDP PDP and PP PDP and PP Included in facility rate PDP PDP PDP PDP and PP PP PDP PDP PDP PDP and PP PDP PDP PDP PP PDP PDP PDP PDP PP

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

4-27

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Coverage of Vaccines and Unit Dose State

Method for Vaccine Reimbursement ^

Reimbursement for Unit Dose

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

VCP EPSDT, CHIP, VCP EPSDT, CHIP, VCP VCP EPSDT CHIP CHIP, VCP EPSDT, VCP VCP EPSDT, CHIP, VCP EPSDT, CHIP, VCP EPSDT, CHIP, VCP, State Vaccine Program EPSDT, VCP EPSDT, CHIP, VCP VCP VCP EPSDT, CHIP, VCP, Pharmacy Program EPSDT, VCP EPSDT, CHIP, VCP VCP EPSDT, Department of Public Health EPSDT, CHIP, VCP VCP VCP VCP EPSDT, CHIP, VCP EPSDT, CHIP, VCP EPSDT EPSDT, CHIP, VCP VCP EPSDT, CHIP, VCP, Dept. of Health EPSDT, CHIP, VCP EPSDT, VCP EPSDT VCP EPSDT, VCP VCP EPSDT, CHIP, VCP, Pharmacy Services VCP VCP EPSDT, CHIP, VCP EPSDT, VCP EPSDT, CHIP, VCP VCP Health Dept. provides vaccines to physician offices VCP EPSDT CHIP, VCP VCP EPSDT, CHIP, VCP

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

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

4-28

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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 Not Covered Limited Coverage Limited Coverage Covered Covered Covered Not Covered Not Covered Limited Coverage Covered Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Covered Covered with Restrictions Limited Coverage Limited Coverage Covered Limited Coverage Limited Coverage Covered with Restrictions Covered with Restrictions Covered Covered Covered with Restrictions Covered Covered Limited Coverage Covered with Restrictions Selective Coverage Covered with Restrictions Covered Covered with Restrictions Covered Covered with Restrictions Limited Coverage Covered Covered Limited Coverage Covered with Restrictions Covered Limited Coverage Limited Coverage Covered with Restrictions Covered

Covered Not Covered Limited Coverage Limited Coverage Covered Not Covered Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered Not Covered Covered Covered with Restrictions Covered with Restrictions Covered Covered with Restrictions Not Covered Covered Limited Coverage Limited Coverage Limited Coverage Covered Limited Coverage Limited Coverage Not Covered Covered with Restrictions Covered Covered Covered with Restrictions Covered Covered Not Covered Covered Selective Coverage Not Covered Covered Covered Covered Covered with Restrictions Not Covered Covered Covered Not Covered Covered with Restrictions Covered Limited Coverage Limited Coverage Covered Covered

Covered Not Covered Limited Coverage Limited Coverage Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Covered with Restrictions Limited Coverage Not Covered Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Not Covered Not Covered Limited Coverage Not Covered Covered Limited Coverage Limited Coverage Not Covered Covered with Restrictions Covered Covered Covered with Restrictions Covered Covered Not Covered Not Covered Selective Coverage Not Covered Covered Covered with Restrictions Covered Covered with Restrictions Not Covered Not Covered Covered Limited Coverage Covered with Restrictions Covered Limited Coverage Limited Coverage Covered with Restrictions Covered

Not Covered Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Not Covered Covered with Restrictions Not Covered Not Covered Limited Coverage Covered Limited Coverage Not Covered PA Required Not Covered Covered Covered Covered Covered Limited Coverage Not Covered Covered with Restrictions Selective Coverage Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Not Covered Not Covered Covered Not Covered Covered with Restrictions Covered Not 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 2004 NPC Survey.

4-29

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Digestive Products (non- 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 Not Covered Limited Coverage Covered with Restrictions Covered Covered with Restrictions Covered Not Covered Covered with Restrictions Not Covered Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Covered Covered with Restrictions Not Covered Covered Not Covered Limited Coverage Limited Coverage Covered Limited Coverage Limited Coverage Not Covered Covered with Restrictions Covered Covered Not Covered Covered Covered Covered Covered Selective Coverage Covered with Restrictions Covered Covered Not Covered Covered with Restrictions Limited Coverage Covered Covered Not Covered Covered with Restrictions Covered Limited Coverage Limited Coverage Covered with Restrictions Covered with Restrictions

Covered Not Covered Covered Covered with Restrictions Covered Covered with Restrictions Covered Not Covered Not Covered Not Covered Limited Coverage Not Covered Not Covered Covered with Restrictions Not Covered Covered Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions Limited Coverage Limited Coverage Covered Not Covered Not Covered Covered Covered with Restrictions Covered Covered Not Covered Covered Covered Limited Coverage Covered Selective Coverage Not Covered Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered Covered Covered Covered with Restrictions Covered Limited Coverage Not Covered Covered Covered

Not Covered Limited Coverage Limited Coverage Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions Not Covered Covered with Restrictions Not Covered N/A Not Covered Not Covered Covered with Restrictions Not Covered Covered Covered with Restrictions Not Covered Covered Not Covered Limited Coverage Limited Coverage Covered Limited Coverage Not Covered Not Covered Covered with Restrictions Not Covered Covered Not Covered Not Covered Covered Not Covered Not Covered Selective Coverage Not Covered Covered Covered Covered Covered with Restrictions Not Covered Not Covered Not Covered Not Covered Covered with Restrictions Covered Limited Coverage Limited Coverage Covered Covered with Restrictions

Covered with Restrictions Limited Coverage Limited Coverage Covered with Restrictions Covered with Restrictions Covered Covered Not Covered Not Covered Covered with Restrictions Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered Covered with Restrictions Not Covered Covered Not Covered Limited Coverage Limited Coverage Covered Limited Coverage Limited Coverage Not Covered Covered with Restrictions Covered with Restrictions Covered Covered with Restrictions Covered with Restrictions Covered Not Covered Covered with Restrictions Selective Coverage Not Covered Covered with Restrictions Covered Covered Covered with Restrictions Not Covered Covered Covered Not Covered Covered with Restrictions Covered Limited Coverage Limited Coverage Covered with Restrictions Covered

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures State

PA Procedure Prior Authorization Committee

Members

Meetings

Alabama Alaska Arizona* Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Pharmacy and Therapeutics Committee No DUR Board No No Pharmaceutical and Therapeutics Committee No No No No No Pharmacy and Therapeutics Committee

10 9 14 12

Illinois

Yes

Drugs and Therapeutics Committee

12

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 No Yes Yes Yes Yes Yes Yes Yes Yes Yes

No DUR Board DUR Board Pharmacy and Therapeutics Advisory Committee Pharmaceutical and Therapeutics Committee No No No No Drug Formulary Committee Pharmacy and Therapeutics Committee Prior Authorization Committee DUR Board No No Pharmacy and Therapeutics Advisory Committee No No Pharmacy and Therapeutics Committee NC Physician Advisory Group DUR Board No No DUR Board No DUR Board No No No Pharmaceutical and Therapeutics Committee No No No DUR Team and Drug Eval. Matrix Team P and T Committee and DUR Board Pharmacy Prior Authorization Advisory Comm. DUR Board

9 9 14 21 9 12 9 10 13 11 9 15 12 7 11 8 11 9 12

Quarterly Quarterly Quarterly Bi-monthly At least quarterly 8 per year Bi-monthly Bi-monthly Semi-annually Quarterly Bi-monthly Quarterly Monthly Quarterly Quarterly Monthly Quarterly Quarterly Quarterly Quarterly Daily, weekly Semi-annually As needed Bi-monthly

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

4-31

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures (Con’t) State

Initiated By:

Alabama Alaska Arizona* Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii

M.D., R.Ph. M.D., R.Ph. M.D. M.D., R.Ph. M.D., M.D.’s Agent M.D., R.Ph. M.D., R.Ph. R.Ph., Pharm. Tech. M.D. M.D., R.Ph. M.D., R.Ph., Pharm. Tech. M.D., R.Ph., Pharm. Tech., SmartPA System M.D., R.Ph. M.D., Other Providers M.D. M.D., R.Ph. M.D., R.Ph. M.D. M.D. M.D., R.Ph. M.D. M.D. M.D., R.Ph. M.D. M.D., R.Ph., Other Authorized Prescriber M.D., R.Ph., Pharm. Tech. M.D., R.Ph. M.D. M.D. M.D., R.Ph. M.D. M.D./Ordering Provider M.D. M.D., R.Ph., Pharm. Tech. M.D. R.Ph. M.D. M.D., Other Licensed Prescriber M.D. M.D. M.D., R.Ph. M.D. M.D. M.D. M.D., Prescribing Agent M.D. R.Ph., Pharm. Tech. M.D., R.Ph. M.D., R.Ph. M.D., R.Ph., Pharm. Tech.

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

Annual Requests

% Approved

N/A 4,600 195,000 2,900,000 30,000 99,000 34,000 9,000 440,000 99,000 N/A 177,000

N/A 98% 80% 82% 75% 98% 92% 77% 78% 90% 99% 76%

400,000 N/A 60,000 N/A 285,000 171,000 65,000 68,000 137,000 120,000 36,000 200,000 87,000 27,000 26,000 N/A 11,700 715,000 1,300 630,000 57,000 2,000 240,000 210,500 30,000 N/A N/A 37,700 28 180,000 1,500 N/A 43,000 N/A N/A 132,000 182,000 4,500

75% N/A 95% N/A 58% 95% 82% >99% 67% 95% 90% 90% 58% 80% 27% N/A 79% 95% N/A 100% 86% 60% Most 53% 73% N/A N/A 60% 100% 74% 95% N/A 92% N/A N/A 53% 97% 75%

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

4-32

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization Process and Procedures (Con’t) State

Reviewer

Review Time

Response Vehicle

Alabama Alaska Arizona* Arkansas California Colorado Connecticut Delaware District of Columbia Florida

R.Ph., Pharm. Tech. R.Ph., Pharm. Tech. Voice response system R.Ph. Pharm. Tech. R.Ph., Pharm. Tech. M.D., R.Ph., R.N, Pharm. Tech. R.N., R.Ph. R.Ph., Pharm. Tech., AHCA Analyst PBM R.Ph., Pharm. Tech. M.D., R.Ph., Pharm. Tech., Smart PA System M.D., R.Ph. Medicaid Director or designee R.Ph. R.N., R.Ph. R.N., R.Ph. R.Ph. M.D. M.D., R.Ph., Pharm. Tech. R.Ph. M.D., R.Ph., Pharm. Tech. R.N. R.N., R.Ph., Pharm. Tech. M.D., R.Ph., R.N., Medicaid Tech. R.Ph., Pharm. Tech. M.D., R.Ph., Pharm, Tech. R.Ph., Pharm. Tech. R.Ph., Pharm. Tech. R.N., R.Ph. R.Ph. Voice interactive system R.Ph., Pharm. Tech. R.Ph. R.Ph., Pharm. Tech. R.Ph., Pharm. Tech, Pharm. Intern R.Ph., Pharm. Tech. R.N., M.D. Contractor R.Ph., First Health R.Ph. R.Ph. R.Ph. Nurse R.Ph., Pharm. Tech, Medical Director M.D., R.Ph. R.Ph. R.Ph. R.Ph., Done electronically R.Ph., Pharm. Tech.

24 hours or less 24 hours 1-3 minutes One business day 24 hours 2 hours < 1 working day 20 minutes 24 hours

Phone, fax Phone, fax Voice response system Phone, fax Phone, fax Phone, fax, mail Phone, mail, e-mail Phone, mail Phone, fax, mail

10 minutes 24 hours 24 hours

Phone, fax, mail Phone, fax, mail Phone, fax, mail

24 hours or less 10 days 4 hours 24 hours or less 4-24 hours 3-5 minutes 4 hours 24 hours or less 24 hours 24 hours or less Within minutes 6 hours < 5 minutes 1-2 minutes varies 24 hours 24 hours 3 minutes 24 hours Processed during call 24 hours or less 4 hours Immediate 24 hours 24 hours or less Immediately to 24 hours Immediately to 24 hours Per OBRA ‘90 guidelines 24 hours Same day 15 minutes 1 working day 24 hours

Phone Phone, letter Fax Phone, mail Phone, fax Phone, fax Mail Phone, fax Phone, mail Phone, fax Phone, fax, mail, e-mail Phone, fax, mail Phone, fax Phone, fax, mail Phone, fax Phone Phone, fax with written follow-up of denials Phone, fax, mail Phone, fax PA issued to prescriber by phone Phone, fax, e-mail Fax, mail Phone, fax Mail Phone, fax Phone, mail Phone Phone, fax Phone, fax, mail, e-mail Fax Phone, e-mail Phone, fax, mail, e-mail Phone, fax

Less than 3 minutes <24 hours 24 hours Immediate 24 hours

Mail, e-mail Phone, fax; denial through mail Phone, fax Online, phone, fax, mail Phone, fax, mail, e-mail

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

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

4-33

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

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

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

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

4-34

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization (Con’t) State

Antihistamines

Anxiolytics, Sedatives, and Hypnotics

Prescribed Cold Medications

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

4-35

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization (Con’t) State

Growth Hormones

Miscellaneous GI Products

Prescribed Smoking Deterrents

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

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Drug Utilization Review State

State Contact

Telephone

In-House or Contracted

PRODUR Implemented

Alabama Alaska Arizona* Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho

Louise Jones Dave Campana, R.Ph. Pamela Ford, P.D. Ellis Ellis, Pharm.D. Catherine Traugott James Zakszewski, R.Ph. Cynthia R. Denemark, R.Ph. Christopher Keeys Linda Barnes Patricia Z. Jeter, R.Ph., M.P.A. Kathleen Kang-Kaulupali Tamara Eide, P.D., B.C.P.S., FASHP Pamela Bunch DUR Board Secretary Julie Kuhle, R.Ph. Vicki Schmidt Debra Bahr, R.Ph. Mary J. Terrebonne, Pharm.D. Bruce McClenahan Jeffrey Gruel Paul L. Jeffrey Debera Eggleston, M.D. Mary Beth Reinke, Pharm.D., M.S.A. Judith P. Clark, R.Ph. Tisha A. Pomering Mark Eichler, R.Ph., FASCP Beth Wilson, R.Ph. Dionne Coston, R.N. Robert Coppola Kaye S. Morrow Neal Solomon, M.P.H., R.Ph. Lydia Kosinski, R.Ph. Melissa Weeks, Pharm.D Brendan K. Joyce, Pharm.D., R. Ph. Jeff Corzine Ronald Graham, D.Ph. Kathy L. Ketchum, R.Ph., M.P.A Terri Cathers Paula Avarista, R.Ph., M.B.A. Caroline Sojourner, R.Ph. Teddi Martell Jeffrey G. Stockard, D.Ph. Barbara Dean, R.Ph. Duane Parke Felicia Montineri Rachel E. Cain Nicole Nguyen, Pharm.D. Vicki M. Cunningham, R.Ph. Michael Mergener, R.Ph., Ph.D. Debra Devereuax, R.Ph.

334-242-5039 907-334-2425 501-683-4120 916-552-9500 303-866-2468 860-424-5150 302-453-8453 301-617-0555 850-487-4441 404-657-9181 808-692-8065 208-364-1821

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

Jul-96 Jun-95 Mar-97 Aug-95 Dec-98 Sep-96 Feb-94 Sep-96 Jul-93 Oct-00 1997 Jan-98

217-524-7478 317-232-4307 515-725-1226 785-274-4287 502-564-7940 225-342-9768 886-796-2463 410-767-1455 617-210-5319 517-335-5181 651-215-1239

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

Jan-93 Mar-96 Jul-97 Nov-96 1987 Apr-66 Dec-95 Jan-93 Oct-95 Jul-00 Feb-96

601-359-5253 573-751-6961 406-457-5818 402-420-1500 702-684-3775 603-220-2083 609-631-2396 505-827-3174 518-474-6866 919-855-4300 701-328-4023 614-466-9689 405-271-6614 503-494-1589 717-772-6195 401-4642-6390 803-898-2876 605-773-3653 615-532-3107 512-491-1101 801-538-6452 802-879-5900 804-225-2873 360-725-1757 304-588-6541 608-258-3348 307-766-6750

Contracted In-House Contracted Contracted Contracted Contracted In-House In-House In-House Contracted In-House Both Contracted Contracted Contracted Contracted Contracted In-House Contracted In-House In-House Contracted Contracted In-House Contracted Contracted Contracted

Oct-93 Feb-93 Sep-94 Apr-95 2004 Jul-95 Oct-96 Oct-93 Mar-95 Oct-96 Jul-96 Feb-00 2000 Mar-94 Jun-93 Dec-94 Nov-00 1996 Jul-01 Feb-95 1994 Nov-93 Jul-94 Mar-96 Mar-95 2001 Oct-95

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

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

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Prescribing/Dispensing Limits State

Limits on Rx 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

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

5 refills per Rx, 34 day supply per Rx, 4 brand limit per month 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months 6 Rx per month, maximum 100 day supply for most medications 30 day quantity supply per Rx; reasonable amts. for maint. meds. Other limits may apply 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives 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 4 brand name Rxs per month (with exceptions) 34 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override)

Yes Yes Yes No Yes Yes Yes Yes

Maine

Yes

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

30 day supply or 100 unit doses per Rx, maximum quantities for some drugs 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills Medically appropriate monthly quantity Maximum 30 day supply except select maintenance drugs (90 days) 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications 30 day supply, max. 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 mos., max. 8 scripts per recipient per month 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription, 5 brand scripts per month 34 day supply per Rx; maximum 11 refills per Rx, refills may not exceed 360 day supply 30 day supply, maximum 11 refills per prescription 100 day supply, quantity limits for selected drugs (e.g., sedative hypnotics) 34 day supply 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 11 refills maximum 34 day supply 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles 34 day supply per Rx; 100 day supply for maintenance medications. 5 refills within 6 months. 30 day supply, 90 day supply on maintenance medications 34 day supply or 100 unit doses per Rx, 5 refills within 6 months 34 day supply, except contraceptives (100 days) and maintenance drugs (90 days) 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override) 34 day supply per Rx, with exceptions; 6 Rx per month 34 day supply per Rx, max 5 refills per script, limits on refills by Class 34 day supply; 102 day supply for maintenance medications; 5 refills per Rx 6 Rx (incl. 5 brands) per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx 34 day supply (15 day supply for initial Rx for chronic conditions), duration limits on selected drugs 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month 30 day supply per Rx (non-maintenance); 5 refills per Rx 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override) Varies by drug 31 day supply, 1 year for non-controlled medications 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills or 6 months 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs 60 day supply for maintenance medications, 5 refills per Rx 34 day supply per Rx 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs 34 day supply; 11 refills per Rx with quantity limits on some drugs 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period Quantity limits on some medications as deemed clinically appropriate.

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

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PHARMACY PAYMENT AND PATIENT COST SHARING Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs. These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as determined under the federal formula; they indicate the actual method for paying for prescription drugs. Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed care organization, payment is made to the MCO in accordance with its contract with the State Medicaid agency to the extent the contract covers outpatient prescribed drugs. Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple-source drugs” must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing fee, or (2) providers’ charges to the general public.

PATIENT COST SHARING States are permitted to require certain recipients to share some of the costs of Medicaid by imposing on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the regulations specify the standards and conditions under which States may impose cost-sharing, set forth minimum amounts and the methods for determining maximum amounts, and describe limitations on availability that relate to cost-sharing requirements. With the passage of the Social Security Amendments of 1972, States were empowered to impose “nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act, States may impose a nominal deductible, coinsurance, copayment, or similar charge on both categorically needy and medically needy persons for any service offered under the State Plan. Public Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing on the following: •

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

•

Pregnancy-related services (or, at State option, any service provided to pregnant women);

•

Services provided to certain institutionalized individuals, who are required to spend all of their income for medical care except for a personal needs allowance;

•

Emergency services;

•

Family planning services and supplies;

•

Services furnished to categorically needy HMO enrollees (or, at State option, services provided to both categorically needy and medically needy HMO enrollees).

In addition, the law prohibits imposing more than one type of charge on any service. While emergency services are excluded from cost sharing, States may apply for waivers of nominal amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows States to impose a copayment amount up to twice the current maximum for such services. Approval 4-39

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

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Pharmacy Payment and Patient Cost Sharing State Alabama Alaska Arizona* Arkansas California Colorado

Dispensing Fee

Ingredient Reimbursement Basis

$5.40 $3.45 minimum $5.51 ($7.51 non-MAC generics) $7.25 ($8.00 for LTC) $4.00; $1.89 for Institutions

Connecticut Delaware DC Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas

$3.15 $3.65 $4.50 $4.23 $4.33-$4.63 + $0.50 (for generics) $4.67 $4.94 ($5.54 for unit dose) G: $4.60, B: $3.40 $4.90 $4.26 $3.40

Kentucky Louisiana Maine Maryland

$4.51 $4.45 (avg.) to $5.77 $3.35 - $12.50 $2.69-$4.69

AWP- 10%; WAC+9.2% AWP-5% B: AWP-14%, G: AWP-20% AWP-17% AWP-13.5% or WAC+18%, whichever is lowest; AWP-35% (for generics) AWP-12% AWP-14% AWP-16% (LTC) AWP-10% AWP-15.4%; WAC+5.75% AWP-11% AWP-10.5% AWP-12% B: AWP-12% B: AWP-13.5%, G: AWP-20% AWP-12% B: AWP-13%, G: AWP-27%, IV AWP-50%, blood AWP-30% AWP-12% AWP-13.5% (AWP-15% for chains) AWP-15% Lowest of :WAC+8%, direct+8%, AWP-12%

Massachusetts Michigan Minnesota Mississippi Missouri

$3.50 - $5.00 $2.50 ($2.75 – LTC) $3.65 $3.91 $4.09 - $8.19

WAC+5% AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) AWP-11.5% AWP-12% AWP-10.43%, WAC+10%

Montana Nebraska Nevada New Hampshire New Jersey New Mexico

$2.00 - $4.70 $3.27 - $5.00 $4.76 $1.75 $3.70 - $4.07 $3.65

AWP-15% AWP-11% AWP-15% AWP-16% AWP-12.75%, WAC+30%, AAC for injectables AWP-14%

New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee*

B: $3.50, G: $4.50 B: $4.00, G: $5.60 B: $4.60, G: $5.60 $3.70 $4.15 Retail: $3.50, Inst./NF: $3.80 $4.00 ($5.00 for compounds) OP: $3.40, LTC: $2.85 $4.05 $4.75 ($5.55 for unit dose) $2.50

B: AWP-12. 75%;, G: AWP-16.50% AWP-10% AWP-10% WAC + 9% AWP-12.0% AWP-15% (retail), AWP-11% (institutional) AWP-10% WAC+5% AWP-10% AWP-10.5% AWP-13%

Texas Utah Vermont Virginia Washington West Virginia Wisconsin

(EAC+$5.14)/0.98 & delivery fee $3.90 (urban), $4.40 (rural) $4.25 $3.75 $4.20-$5.20 (based on annual # of Rx) $3.90 (+ extra $1.00 for compounding) $4.88 (to a maximum $40.11)

AWP-15% or WAC+12%, whichever is lowest AWP-15% AWP-11.9% AWP-10.25% AWP-14% AWP-12% AWP-13%

Wyoming

$5.00 (legend), 50% AWP OTC

AWP-11%

Copayment $0.50 - $3.00 $2.00 $0.50 - $5.00 $1.00 B: $3.00, G: $1.00 None $0.50 - $3.00 $1.00 None G/P: $0.50, B/NP: $0.50 - $3.00 None None B: $3.00 $3.00 $0.50-$3.00 $3.00 $1.00 $0.50 - $3.00 $2.50, Max $25/rec/pharm/mo $2.00 Brand not on PDL, $1.00 Brand on PDL & generics B: $3.00, G: $1.00 B: $3.00, G: $1.00, ABW: $1.00 B: $3.00, G: $1.00 $1.00 - $3.00 $0.50 - $2.00, $5.00 for some 1115 waiver pop. $1.00 - $5.00 $2.00 None B: $2.00, G: $1.00 None None (except $5.00 for CHIP and working disabled) G: $0.50, B: $2.00 G: $1.00, B: $3.00 $3.00 (Brand) $3.00 (PA drugs only) $1.00 - $2.00 B: $3.00, G: $2.00 $1.00 ($2.00 for General Assist.) None $3.00 $2.00 Medicaid: None; Other: $5/$10 based on income None $3.00 $1.00 - $3.00 dep. on Rx Cost B: $3.00, G: $1.00 None $0.50 - $3.00 $1.00-$3.00, max $12/rec/pharm/mo $1.00 - $3.00

WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost; G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred; PDL= Preferred Drug List *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by State drug program administrators in the 2004 NPC Survey.

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Maximum Allowable Cost (MAC) Programs State

Federal State-Specific Upper Limits Upper Limits MAC Override Provisions

Alabama Alaska Arizona* Arkansas

Yes Yes Yes

Yes No Yes

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

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

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

Utah Vermont

Yes Yes

Yes Yes

Virginia Washington West Virginia Wisconsin Wyoming

Yes Yes Yes No Yes

Yes Yes No Yes Yes

Brand medically necessary Medically necessary and reason for medical necessity Brand medically necessary MedWatch indicating why generics cannot be dispensed Medically necessary and product unavailable at MAC rate Medically necessary with documentation No physician MAC override MedWatch form for prior authorization MedWatch form and prior authorization request Prior authorization (Brand medically necessary and MedWatch form) Prior authorization Prior authorization for brand names Prior authorization request by M.D. justifying need for brand Brand medically necessary, prior authorization Brand medically necessary Prior authorization and MedWatch form Brand necessary, brand medically necessary, plus PA on some drugs Brand necessary, brand medically necessary Prior authorization Brand medically necessary and MedWatch form Dispense as written, brand medically necessary, prior authorization Brand medically necessary and prior authorization Dispense as written, brand medically necessary, plus prior authorization Brand medically necessary or prior authorization for brand multi-source Brand medically necessary, prior authorization and MedWatch form Brand necessary or brand required Brand medically necessary Brand medically necessary Brand medically necessary Dispense as written, medically necessary Brand necessary, brand medically necessary Prior authorization Brand medically necessary in writing on prescription Dispense as written Prior authorization Brand medically necessary plus prior authorization Brand medically necessary and documentation of generic intolerance Brand necessary, brand medically necessary, plus prior authorization Brand medically necessary w/cert. by prescriber and prior authorization Brand necessary, brand medically necessary Dispense as written Dispense as written, medically necessary, brand necessary, brand medically necessary Brand medically necessary plus prior approval Dispense as written, medically necessary, brand necessary, brand medically necessary or DAW 8 (generic not available) Medically necessary Brand medically necessary Dispense as written, brand medically necessary Brand medically necessary plus prior authorization Brand medically necessary

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

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Mandatory Substitution State

Incentive Fee for Generic Substitution

Dispensing of Generic Multi-Source Required

Dispensing of Lowest Cost Multi-Source 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 $2.00 No No No No No No $0.50 No No No No No No No No No $1.00 No No Yes No No No No No No No No $1.00 $1.60 No No No No No No No No No No No No No No No No No

Yes Yes Yes No Yes Yes Yes Yes Yes Yes (brand PA required) Yes Yes No Yes Yes No Yes No Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Yes Yes No Yes No Yes Yes Yes Yes Yes Yes Yes

Yes No Yes Yes No No No No No Yes No No No Yes Yes No Yes No No Yes No No Yes No Yes No No No No No No No Yes No No No No No No No No Yes No Yes Yes No Yes 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 2004 NPC Survey.

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Counseling Requirements and Payment for Cognitive Services State

Patient Counseling Required1

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

All All All All All Medicaid Only Medicaid Only All Medicaid Only, New Prescriptions All All Medicaid Only All All All All All All All All Medicaid Only, New Prescriptions All All All All All

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

All All All All All All All All All All All All All All Medicaid Only All All All All All All All

West Virginia Wisconsin Wyoming

All All All

Medicaid Payment for Cognitive Services2 No No No No No No No No No No No No No No Yes (pharm. Case management) No No No No No No No No Yes (diabetes, asthma, coagulation, and lipids) Yes (diabetes, asthma, heart failure, and depression education) No No No No No No No No No No No No No No No No No No No No No Yes (emergency contraceptive counseling, clozaril case management) No Yes No

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

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Prescription Price Updating State

Contact

Telephone

Updated

Alabama 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

Allyn Williford Dave Campana First DataBank EDS Federal Corp. Martha Warner Ellen Arce, R.Ph. Cynthia R. Denemark, R.Ph. Christine Quinn First DataBank Express Scripts ACS State Healthcare Katie Ayad First DataBank First DataBank Patrick Danlan Mary H. Obley Unisys Provider Services Maggie Vick, Unisys Corp. Bruce McClanahan First DataBank First DataBank First Health Service Corp. First DataBank Terri R. Kirby, R.Ph. First DataBank First DataBank Dyke Anderson, R.Ph. First DataBank First Health Services Corp. First DataBank First DataBank Carl Cioppa, Pharm.D. Tom D’Andrea, R.Ph., M.B.A. Brendan K. Joyce, Pharm.D., R.Ph. First DataBank First DataBank First Health Service Corp. First DataBank Paula Avarista, R.Ph., M.B.A. First DataBank Mark Petersen, R.Ph. First DataBank Martha McNeill, R.Ph. RaeDell Ashley, R.Ph. Cathy England Keith T. Hayashi Tom Zuchlewski Heather Bodiford First DataBank First DataBank

334-242-5034 907-334-2425 650-588-5454 916-636-1000 303-866-3176 860-832-5885 302-453-8453 202-906-8304 650-588-5454 770-552-3793 800-358-2381 208-364-1970 650-588-5454 650-588-5454 515-725-1226 785-296-3981 502-226-1140 225-237-3251 886-796-2463 650-588-5454 650-588-5454 877-864-9014 650-588-5454 601-359-5253 650-588-5454 650-588-5454 402-471-9379 650-588-5454 800-884-2822 650-588-5454 800-633-3453 518-474-9219 919-855-4300 701-328-4023 650-588-5454 800-633-3453 503-391-1980 800-633-3453 401-462-6390 650-588-5454 605-773-3498 650-588-5454 512-491-1157 801-538-6495 804-965-7717 804-225-2773 360-725-1837 866-322-5960 800-633-3453 800-633-3453

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

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

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Section 5: State Pharmacy Program Profiles

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Profiles of State Medicaid Drug Programs In the following State profiles, we present a general overview of the characteristics of State programs together with detailed information on the pharmaceutical benefits provided. Specifically, the following information is provided for each State: A. B. C. D.

Benefits Provided and Groups Eligible Expenditures for Drugs Administration Provisions Relating to Drugs, including: • Drug Benefit Product Coverage • Over-the-Counter Product Coverage • Therapeutic Category Coverage • Coverage of Injectables, Vaccines, and Unit Dosing • Formulary/Prior Authorization • Prescribing or Dispensing Limitations • Drug Utilization Review • Dispensing Fee • Ingredient Reimbursement Basis • Prescription Charge Formula • Maximum Allowable Cost • Incentive Fee • Patient Cost Sharing • Cognitive Services E. Use of Managed Care F. State Contacts

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ALABAMA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Medically Needy (MN)

Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Aged

Blind/ Disabled

Child

Adult

B. EXPENDITURES FOR DRUGS 2002 Expenditures

Recipients

TOTAL

$454,370,478

500,789

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$315,943,060 $37,738,144 $257,913,536 $11,592,612 $8,698,768

220,205 24,294 131,463 46,873 17,575

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$59,283,383 $825,181 $881,876 $56,041,627 $1,534,699 $0

228,391 717 798 216,945 9,931 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$79,144,035

52,193

2003** Expenditures Recipients $536,222,703

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

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C. ADMINISTRATION

Formulary/Prior Authorization

Alabama Medicaid Agency.

Formulary: Open formulary with preferred drug list. Formulary managed through restrictions on use, prior authorization, therapeutic substitution, preferred products, physician profiling, and voluntary supplemental rebates. Prior authorization required for non-preferred drugs. Anti-psychotics and HIV/AIDs drugs are exempted from the prior authorization requirements. (For additional information see: www.medicaid.state.al.us.)

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: disposable needles and syringe combinations used for insulin. Products covered with restriction: prescribed insulin. Products covered as DME: blood glucose test strips; urine ketone test strips. Prior authorization required for: total parenteral nutrition; interdialytic parenteral nutrition; Retin A; Accutane; Dipyridamole; and Synagis. Products not covered: cosmetics; fertility drugs; experimental drugs; drugs for anorexia or weight gain; hair growth products; and DESI drugs.

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization decisions may be appealed by physician submitting written notice along with medical documentation to the administrative services contractor for physician review. The request is forwarded to the Medicaid agency’s Medical Director for review.

Over-the-Counter Product Coverage: Products covered if prescribed by a physician: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; prenatal vitamins; hemorrhoidal products. Partial coverage for: topical products. Products not covered: smoking deterrent products and feminine products.

Prescribing or Dispensing Limitations

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; anoretics; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: prescribed cold medications; and contraceptives. Prior authorization required for: nutritional supplements; and Synagis. Therapeutic categories not covered: prescribed smoking deterrents.

Drug Utilization Review

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home healthcare and extended care facilities, and through physician payment when used in physicians’ offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Adult vaccines are available through the Health Department.

Prescription Refill Limit: maximum of five refills. Monthly Quantity Limit: 34-day supply. Monthly Prescription Limit: four brand limit.

PRODUR system implemented in July 1996. State currently has a DUR Board with a quarterly review. 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.

The Maximum Allowable Cost (MAC) of the drug plus a dispensing fee,

2.

The Estimated Acquisition Cost (EAC) of the drug plus a dispensing fee, or

3.

The provider’s usual and customary charge to the public for the drug.

Unit Dose: Unit dose packaging reimbursable.

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Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary” in the physician’s own handwriting.

John Searcy, M.D. Jimmy Jackson, R.Ph. Darin Elliot, Pharm.D. Greer L. Geiger, M.D. W. Kevin Green, M.D. Richard Freeman, M.D. Gary Magouirk, M.D. Paula Thompson, Pharm.D. W. Thomas Geary, Jr., M.D. Steven Rostand, M.D. Rhonda Harden, Pharm.D. Rob Colburn, R.Ph.

Incentive Fee: None. Patient Cost Sharing: Tiered 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.

New Brand Name Products Contact Louise F. Jones 334/242-5039 Prescription Price Updating Allyn Williford Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5424 T: 334/242-5034 F: 334/353-7014

F. STATE CONTACTS

Medicaid Drug Rebate Contact

State Drug Program Administrator

Lynn M. Abrell Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery AL 36103-5624 T: 334/242-2326 F: 334/353-7014 E-mail: [email protected]

Louise F. Jones, Director Pharmacy Services 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] Internet address: www.medicaid.state.al.us Prior Authorization Contact Louise F. Jones 334/242-5039

Claims Submission Contact Cyndi Crocket, Supervisor EDS 301 Technacenter Dr. Montgomery, AL 36117 334/215-0111 Medicaid Managed Care Contact

DUR Contact Louise Jones 334/242-5039

Kim Davis-Allen, Director Managed Care Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36103-5624 334/242-5011

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National Pharmaceutical Council Mail Order Pharmacy Program None Disease Management Program/Initiative Contact Mary H. Finch Associate Medical Director Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36103-5624 334/242-5610 Alabama Medicaid Agency Officials Carol Herrmann Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5600 F: 334/242-5097 E-mail: [email protected] Internet address: www.medicaid.state.al.us John Searcy, M.D. Medical Director Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103 334/242-5619 Title XIX Medical Care Advisory Committee Carol Herrmann Amanda Buttenshaw Bill Chandler Irene Collins Louis E. Cottrell, Jr. Page Dunlap William S. Eley, II Teresa Easterling Al Fox Jean Fulton Lawrence F. Gardella Melane Golson Frank Harris Frank Holden John Houston Jolene Jones Leigh Moorer Jones Olivia Kendrick Carl J. Kuhlman Roosevelt McCorvey, M.D. Linda McWilliams Holley Midgley Louise Pittman

Pharmaceutical Benefits 2004 J.A. Powell, M.D. Marsha D. Raulerson, M.D. John Searcy, M.D. Doug Sewell Karin Scott Steve Shivers Wilburn Smith, Jr., M.D. David Stone Page Walley Donald Williamson, M.D. Helen Wilson Pharmacy and Therapeutics Committee A. Z. Holloway, M.D. Richard Freeman, M.D. Ben Main, R.Ph. Gary Magouirk, M.D. David Herrick, M.D. Jackie Feldman, M.D. Sheri Lynn Boston, R.Ph. Mary McIntyre, M.D. Jimmie P. Clark, M.D. Dane Yarbrough, R.Ph. Executive Officers of State Medical and Pharmaceutical Societies Medical Association of the State of Alabama (MASA) Cary Kuhlmann Executive Director 19 S. Jackson Street P.O. Box 1900 Montgomery, AL 36102-1900 T: 334/954-2500 F: 334/269-5200 E-mail: [email protected] Internet address: www.masalink.org Alabama Osteopathic Medical Association E. Jason Hatfield, D.O. Secretary -Treasurer P.O. Box 1857 U.S. Highway 43 Winfield, AL 35594 T: 205/487-3625 F: 205/487-7559 Internet address: www.aloma.org Alabama Pharmacy Association (APA) William S. Eley, II Executive Director 1211 Carmichael Way Montgomery, AL 36106-3672 T: 334/271-4222 F: 334/271-5423 E-mail: [email protected] Internet address: www.aparx.org

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Alabama State Board of Pharmacy Jerry Moore Executive Director 1 Perimeter Park South, Suite 425 S Birmingham, AL 35243 T: 205/967-0130 F: 205/967-1009 E-mail: [email protected] Internet address: www.albop.com Alabama Independent Drugstore Association (AIDA) Sharon Taylor, Executive Director 400 Interstate Park Drive Suite 401 Montgomery, AL 36109 T: 334/213-2432 F: 334/213-2406 E-mail: [email protected] Internet address: www.aidarx.org Alabama Hospital Association Tom Cooper, CEO 500 North East Blvd. Montgomery, AL 36117 T: 334/272-8781 F: 334/270-9527 E-mail: [email protected] Internet address: www.alaha.org

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ALASKA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Medically Needy (MN)

Blind/ Child Adult Disabled

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. DRUG PAYMENTS AND RECIPIENTS 2002 Expenditure Recipients

2003 Expenditure Recipients

TOTAL

$83,324,085

70,550

$96,939,771

74,245

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$64,580,513 $11,177,801 $42,891,082 $1,864,091 $8,647,539

33,632 4,845 9,620 8,904 10,263

$74,705,928 $13,303,796 $48,808,026 $2,673,066 $9,921,040

35,317 5,015 9,877 10,400 10,025

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

$11,440,828 $7,200 $4,799 $10,337,354 $1,091,475

32,957 6 4 29,226 3,721

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$7,856,059 $8,177 $17,643 $6,492,328 $1,181,976 $155,935

29,364 8 7 23,878 5,434 37

$9,535,143 $3,204,802 $4,075,976 $1,260,868 $993,497 N/A

4,828 696 846 2,208 1,078 N/A

$10,887,513

7,554

1,257,872

1,143

TOTAL OTHER EXPENDITURES/RECIPTENTS*

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

75,000.

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C. ADMINISTRATION

Formulary/Prior Authorization

Department of Health and Social Services, Division of Health Care Services.

Formulary: No formulary. Preferred drug list (PDL) managed by exclusion of products based on contracting issues, restrictions on use, therapeutic substitution, preferred products, and physician profiling.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: cosmetics (covered with restrictions- non hair growth products); prescribed insulin; and total parental nutrition. Covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Prior authorization required for: Clorazil; Lupron Depot; ADC infant vitamins; some DME; Synagis; Panretin; and Actig Naltrexone. Products not covered: fertility drugs; experimental drugs; and intedialytic parenteral nutrition. Over-the Counter Product Coverage: Products covered with restrictions: feminine products (yeast antifungal drugs when ordered by prescription); topical products (Bacitracin ointment only). 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; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; miscellaneous GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, and NSAIDs; growth hormones. Categories not covered: anoretics; prescribed cold medications; amphetamines (except for narcolepsy and hyperactivity); prescribed smoking deterrents; 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 and extended care facilities, and through physician payment when used in physicians’ offices. Vaccines: Vaccines reimbursable at cost as part of EPSDT services, the Children’s Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

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. Medical necessity form required. Prescribing or Dispensing Limitations Monthly Quantity Limit: Prescriptions are limited to 30-day supplies (except family planning drugs). Dispensing of generic multi-source product is required. Maximum number of units for about 50 therapeutic classes and 40 narcotic analgesics. Drug Utilization Review PRODUR system implemented in June 1995. State currently has a 5-member 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) Extra fee for compounding: Long-term care pharmacies receive highest dispensing fee once per month per NDC.

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National Pharmaceutical Council Ingredient Reimbursement Basis: EAC = AWP-5%. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Medically Necessary” and the reason of necessity.

Pharmaceutical Benefits 2004 DUR Contact Dave Campana, R.Ph. 907/334-2425 New Brand Name Products Contact

Incentive Fee: None.

Dave Campana, R.Ph. 907/334-2425

Cognitive Services: Does not pay for cognitive services.

Prescription Price Updating

Patient Cost Sharing: $2.00 copayment for branded and generic products.

Dave Campana, R.Ph. 907/334-2425 Medicaid Drug Rebate Contact

F. STATE CONTACTS

Amanda Burger Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2409 F: 907/561-1684 E-mail: [email protected]

Medicaid Drug Program Administrator

Claims Submission Contact

Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected] Internet Address: www.hss.state.ak.us/dhcs

Dave Campana, R.Ph. 907/334-2425

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

Health and Social Services Department Officials Joel Gilbertson, Commissioner Department of Health and Social Services P.O. Box 110601 Juneau, AK 99811-0601 T: 907/465-3030 F: 907/465-3068 E-mail: [email protected] Jerry Fuller, Director Division of Medical Assistance, DHSS P.O. Box 110660 Juneau, AK 99811-0660 T: 907/465-3030 F: 907/465-3068 E-mail: [email protected] Prior Authorization Contact Dave Campana, R.Ph. 907/334-2425

Disease Management Program/Initiative Contact Doug Jones Acting Deputy Director Division of Medical Assistance 4501 Business Park Blvd, Suite 24 Anchorage, AK 99503 907/334-2400 E-mail: [email protected] Mail Order Pharmacy Benefit Yes, for all Medicaid recipients. Alaska DUR Committee Dave Campana, R.Ph. Anchorage, AK Heide Brainerd, R.Ph. Anchorage, AK Greg Polston, M.D. Fairbanks, AK. Charlene Hampton, R.Ph. Anchorage, AK Alexander von Hafften, M.D. Anchorage, AK

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National Pharmaceutical Council Medical Care Advisory Committee David Alexander, M.D. (Chair) Anchorage, AK Gary Givens, R.Ph. Anchorage, AK Angela Gonzalez Anchorage, AK Deborah Kiley, FNP Anchorage, AK Karen Sidell Bethel, AK Lavada “Sam” Bush Fairbanks, AK Marie Darlin Juneau, AK Brenda Knapp Juneau, AK Kathy Dillard Kodiak, AK

Pharmaceutical Benefits 2004 Alaska Pharmacists Association Nancy Davis, Executive Director 4107 Laurel Street, Suite 101 Anchorage, AK 99508-5334 T: 907/563-8880 F: 907/563-7880 E-mail: [email protected] Internet address: www.alaskapharmacy.org Alaska State Board of Pharmacy Sher Zinn Licensing Examiner P.O. Box 110806 Juneau, AK 99811-0806 T: 907/465-2589 F: 907/465-2974 E-mail: [email protected] Internet address: www.dced.state.ak.us/occ/ppha.htm Alaska State Hospital and Nursing Home Association Rod L. Betit President/CEO 426 Main Street Juneau, AK 99801 T: 907/586-1790 F: 907/463-3573 E-mail: [email protected] Internet address: www.ashnha.com

Marilyn Mories Palmer, AK David Gilbreath Soldotna,AK Jerry Fuller (Commissioner’s designee non-voting) Executive Officers of State Medical and Pharmaceutical Societies Alaska State Medical Association Jim Jordan, Executive Director 4107 Laurel Street Anchorage, AK 99508 T: 907/562-0304 F: 907/561-2063 E-mail: [email protected] Alaska Osteopathic Medical Association Holly Macriss AOA Northwest Regional Manager 1900 Point West Way, Suite 188 Sacramento, CA 95815-4705 T: 800/891-0333 F: 916/564-5105 E-mail: [email protected]

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

AHCCCS FEATURES

Capitation of the State by the Federal Government.

Primary Care Physicians as Gatekeepers

The Arizona Health Care Cost-Containment System (AHCCCS), Arizona’s Medicaid program, is a Title XIX (Medicaid) 1115 Research and Demonstration Waiver 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-for-service reimbursement. In contrast, organized health plans and capitation mark the AHCCCS model.

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 of primary care physicians was established to perform the gatekeeping function for the system. Prepaid Capitated Financing

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 prepaid 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, with the exception of behavioral health drugs which are carved out of managed care, the delivery of pharmacy services is the responsibility of each prepaid plan.

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-by-county 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.

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

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. The plan or contractor is then “at risk” to deliver the necessary services within the capitated amount. AHCCCS receives Federal, State, and county funds to operate, plus some monies from Arizona’s tobacco tax. 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

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conventional negotiation processes, provides accessible cost-effective delivery of health care without sacrificing quality performance.

for the State to monitor health care costs on a careful and continuous basis.

IMPLEMENTATION OF AHCCCS 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. Cost Sharing The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users. A statewide copayment schedule was developed for this purpose, and the medically needy participate in coinsurance cost sharing. It is expected that the imposition of nominal copayments 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 copayment 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. Limitations On Freedom-of-Choice 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-forservice health service arrangements are used as a last resort, and only in areas not covered by prepaid capitated plans.

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

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. Provider Participation Providers may participate in AHCCCS in 2 different ways. First, they may contract with prepaid capitated plans as either full or partial benefit providers. The second mode of participation is on a capped feefor-service 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. Contracting Health 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. 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.

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The Organizational Role of AHCCCS Administration

(Additional information about AHCCCS can be found on the agency’s website at www.ahcccs.state.az.us)

The AHCCCS Administration has been charged with the general implementation and monitoring of the 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.

AHCCCS Contracted Health Plans Arizona Physicians IPA, Inc. 3141 North 3rd Avenue Phoenix, AZ 85013 800/445-1683 Care1st Health Plan of Arizona, Inc. 2355 E. Camelback Rd. Suite 300 Phoenix, AZ 85016 866/560-4042

The Operational Role of the AHCCCS Administration Organizationally, the AHCCCS Administration assumes responsibility for the oversight of every day operations.

Health Choice Arizona Suite 260 1600 West Broadway Tempe, AZ 85282-1136 T: 480/968-6866 F: 800/322-8670

The AHCCCS Administration has overall responsibility for the following activity areas: • • • • • • •

MEDICAL PLANS AND ADMINISTRATORS

Eligibility Oversight Procurement of Health Plans Quality Management Health Plan Oversight Provider, Member Call Center Grievances and Complaints Fee-for-Service for IHS

Maricopa Health Plan 2502 East University Drive Phoenix, AZ 85034 800/582-8686

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.

Mercy Care Plan Suite 400 2800 North Central Phoenix, AZ 85004 T: 602/263-3000 F: 800/624-3879

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 one-year extension. In 1994, AHCCCS received a three-year extension and in 1998, it received a one-year extension. Since then, AHCCCS has received additional extensions. Currently, AHCCCS is operating under a five year waiver extension that will expire on September 30, 2006. Some 20 years after it first began, AHCCCS has grown in numbers from the first wave of 180,000 enrollees to approximately 1 million beneficiaries, (Oct. 1, 2004) representing 18 percent of Arizona’s population. AHCCCS has also become a model as managed care is increasingly by being implemented in other States’ Medicaid programs.

Phoenix Health Plan/Community Connection 7878 North 16th Street, Suite 105 Phoenix, AZ 85020 800/747-7997 Pima Health System Suite A-200 5055 East Broadway Tucson, AZ 85711 800/423-3801 University Family Care 575 East River Road Tucson, AZ 85704 888/708-2930

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Phoenix Area Indian Health Services (IHS) Two Renaissance Square 40 N. Central Avenue Phoenix, AZ 85004-5036 602/364-5039

Yavapai County LTC Yavapai County Department of Medical Assistance 6717 East Second Street Prescott, AZ 86314 520/771-3560

Tucson Area Indian Health Services (IHS) 7900 South J. Stock Road Tucson, AZ 85746 520/295-2405

STATE CONTACTS

Navajo Area Indian Health Services (IHS) P.O. Box 9020 Window Rock, AZ 86515-9020 928/871-5811 Long-Term Care Contractor List Cochise Health Systems Cochise County Health & Social Services 1415 West Melody Lane, Building A P.O. Box 4249 Bisbee, AZ 85603-4249 800/285-7485 DES/DDD 1789 West Jefferson, 4th Floor Phoenix, AZ 85007 866/229-5553 Evercare Select 314 N. 3rd Avenue, Suite 100 Phoenix, AZ 85013 800/293-0039 Maricopa Long Term Care Plan 2502 East University Drive Phoenix, AZ 85034 800/852-8686 Mercy Care Plan Suite 400 2800 North Central Phoenix, AZ 85004 800/624-3879 Pima Long Term Care Pima Health System 5055East Broadway Suite A-200 Tucson, AZ 85711 800/423-3801

AHCCCS Officials Anthony D. Rodgers, Director AHCCCS 801 E. Jefferson Street Phoenix, AZ 85034 T: 602/417-4111 F: 602/252-6536 E-mail: [email protected] Internet address: www.ahcccs.state.az.us Dell Swan Pharmacy Program Administrator AHCCCS 701 East Jefferson Street MD 8000 Phoenix, AZ 85034 602/417-4726 E-mail: [email protected] Executive Officers of State Medical and Pharmaceutical Societies Arizona Medical Association Chic Older Executive Vice President 810 West Bethany Home Road Phoenix, AZ 85013 T: 602/246-8901 F: 602/242-6283 E-mail: [email protected] Internet address: www.azmedassn.org Arizona Pharmacy Association Kathy Boyle Executive Director 1845 E. Southern Ave. Tempe, AZ 85282-5831 T: 480/838-3385 F: 480/838-3557 E-mail: [email protected] Internet address: www.azpharmacy.org

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

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Arizona Osteopathic Medical Association Amanda Weaver Executive Director 5150 N. 16th St., Suite A-122 Phoenix, AZ 85016 T: 602/266-6699 F: 602/266-1393 E-mail: [email protected] Internet address: www.az-osteo.org Arizona State Board of Pharmacy Hal Wand Executive Director 4425 W. Olive Avenue, Suite 140 Glendale, AZ 85302 T: 623/463-2727 F: 623/934-0583 E-mail: [email protected] Internet address: www.pharmacy.state.az.us Arizona Hospital and Healthcare Association John R. Rivers, FACHE President/CEO 2901 North Central Avenue Suite 900 Phoenix, AZ 85012 T: 602/445-4300 F: 602/445-4299 E-mail: [email protected] Internet address: www.azha.org

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ARKANSAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

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‹

‹

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Inpatient Hospital Care

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Outpatient Hospital Care

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Laboratory & X-ray Service

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Nursing Facility Services

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Physician Services

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Dental Services

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B. EXPENDITURES FOR DRUGS 2002 Expended

2003 Expended Recipients

Recipients

TOTAL

$279,644,642

356,233

$325,295,608

398,819

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$157,798,100 $17,336,361 $128,477,401 $5,658,548 $6,325,790

118,809 12,289 70,462 22,298 13,760

$178,457,300 $16,740,556 $148,620,681 $6,158,213 $6,937,850

120,706 11,538 73,243 22,945 12,980

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$4,608,841 $106,947 $2,808,184 $326,251 $1,367,459

6,164 201 2,067 1,231 2,665

$5,491,687 $128,939 $3,010,610 $534,266 $1,817,872

7,673 260 2,508 1,562 3,343

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$33,825,156 $295,773 $1,266,719 $29,880,903 $2,381,761 $0

138,273 306 808 122,032 15,127 0

$46,906,430 $1,918,203 $1,215,050 $42,456,630 $1,316,547 $0

167,697 2,513 895 155,252 9,037 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$83,412,545

92,987

$94,440,191

102,743

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. Source: CMS, MSIS Report, FY 2002 and Arkansas Medical Management Information System, FY 2003.

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C. ADMINISTRATION

Formulary/Prior Authorization

Department of Human Services, Division of Medical Services, Pharmacy Program.

Formulary: State covers outpatient drugs whose manufacturers have signed a rebate agreement with CMS. General exclusions include:

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered with restrictions: 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; experimental drugs; and vitamins (other than prenatal vitamins for pregnant women). Prior authorization required for: nitroglycerin patches; agents for impotence; Synagis; Respigam; Xenicalhyper lipidemia; Remicade; Regranex; Kineret; Enbrel; Xolair; and Humira. Over-the-Counter Product Coverage: Products covered: digestive products (H2 antagonist). Limited coverage for: allergy, asthma and sinus products; analgesics; cough and cold preparations (under 21 years and long-term care limited needs); digestive products (non-H2 antagonist); feminine products; topical products. Products covered with restriction: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; estrogens; growth hormones; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; ENT anti-inflammatory agents; antihistamine drugs; misc. GI drugs; prescribed smoking deterrents. Partial coverage for: prescribed cold medications. Therapeutic categories not covered: anorectics.

1.

Agents used for hair growth.

2.

Vitamin products except prescription prenatal vitamins.

3.

Drugs determined by the FDA to be ineffective (DESI drugs).

4.

Sedatives and hypnotics in the benzodiazepine category (partial coverage).

5.

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.

Drug utilization managed by physician profiling and prior authorization (may require a Federal Med/Watch form to document why a generic can not be dispensed rather than a brand-name product). Prior Authorization: State currently has a prior authorization procedure. Beneficiaries have a right to appeal prior authorization decisions. Physician must submit letter explaining medical necessity leading to the request for the medication. For off-label use, the appeal must document all failed treatments leading to the request for the medication. Prescribing or Dispensing Limitations Prescription Refill Limit: 5 refills within 6 months are allowed. New Rx required every 6 months. Monthly Quantity Limit: 31-day supply. Monthly Prescription Limit: Three prescriptions per month per recipient, except unlimited for certified LTC recipients and recipients under 21 years old. Others can receive extension of three more per month.

Coverage of Injectables: Injectable medicines are reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians offices. Some products may require prior authorization.

Drug Utilization Review

Vaccines: Vaccines reimbursable as part of EPSDT services, the Children’s Health Insurance Program, and the Vaccines for Children Program.

Dispensing Fee: $5.51 effective 7/1/99. Effective 3/1/02, non-MAC generics receive an additional $2.00 dispensing fee. LTC pharmacies generally receive one dispensing fee per NDC per month.

Unit Dose: Unit dose packaging reimbursable.

PRODUR system implemented in March 1997. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing

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Ingredient Reimbursement Basis: EAC = AWP-14% (Brand), AWP-20% (Generic).

F. STATE CONTACTS Medicaid Drug Program Administrator

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 800 drugs (see www.medicaid.ar.us). Override requires physician documentation on MedWatch form as to why the generic cannot be dispensed.

Suzette Bridges, P.D., Administrator Pharmacy Program Division of Medical Services Dept. of Human Services P.O. Box 1437, Slot S 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected] Prior Authorization Contact Suzette Bridges, P.D. 501/683-4120

Incentive Fee: $2.00 additional dispensing fee on non-MAC generics.

DUR Contact

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

Copay

$10.00 or less

$0.50

$10.01 to $25.00

$1.00

Pamela Ford, P.D. Pharmacist II Division of Medical Services Dept. of Human Services P.O. Box 1437, Slot S 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

$25.01 to $50.00

$2.00

DUR Board

$50.01 or more

$3.00

ArKids

$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.

Steve Bryant, P.D. Gary Bass, P.D. Ken Lancaster, P.D. Debbie Hayes Ann Blaylock, A.P.N. Thomas Lewellen, D.O. Michael N. Moody, M.D. Laurence Miller, M.D. P. Justin Boyd, P.D. New Brand Name Products Contact

Cognitive Services: Does not pay for cognitive services.

Suzette Bridges, P.D. 501/683-4120

E. USE OF MANAGED CARE

Prescription Price Updating

An estimated 300,000 Medicaid recipients were enrolled with Primary Care Physicians and approximately 70,000 children are enrolled in ArKids at the end of 2004. Pharmaceutical benefits are provided through the State.

First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

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Medicaid Drug Rebate Contacts

Department of Human Services Officials

Audits: Suzette Bridges, P.D., 501/683-4120

Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 201 Little Rock, AR 72203-1437 T: 501/682-8650 F: 501/682-6836 E-mail: [email protected] Internet address: www.state.ar.us/dhs

Dispute Resolution: Dana Boyer Rebate Analyst EDS 500 President Clinton Ave, Suite 400 Little Rock, AR 72201 T: 501/374-6608 F: 501/372-2971 E-mail: [email protected]

Roy Jeffus, Director Division of Medical Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 T: 501/682-1671 F: 501/682-1197 E-mail: [email protected]

Claims Submission Contact John Herzog, Account Manager EDS 500 President Clinton Ave, Suite 400 Little Rock, AR 72201 T: 501/374-6608 F: 501/372-2971 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Arkansas Hospital Association James R. Teeter President/CEO 419 Natural Resources Drive Little Rock, AR 72205 T: 501/224-7878 F: 501/224-0519 E-mail: [email protected] Internet address: www.arkhospitals.org

Medicaid Managed Care Contact Kellie Phillips Program Administrator Medical Assistance Division of Medicaid Services Dept. of Human Services P.O. Box 1437, Slot 410 Little Rock, AR 72203 T: 501/682-8306 F: 501/682-1197 E-mail: [email protected] Disease Management/Patient Education Programs Disease/Medical State: Diabetes Program Name: Arkansas Medicaid Diabetes Project Program Manager: Coalition of Dept. of Health and Medicaid Sponsor: Eli Lilly and Company Disease/Medical State: Behavioral Health Program Name: Arkansas Behavioral Health Project Program Manager: Medicaid Sponsor: Comprehensive NeuroScience /Eli Lilly and Company Disease Management/ Patient Education Contact

Arkansas Pharmacists Association Mark Riley Executive Director 417 S. Victory Street Little Rock, AR 72201-2932 T: 501/372-5250 F: 501/372-0546 E-mail: [email protected] Internet address: www.arpharmacists.org Arkansas State Board of Pharmacy Charles S. Campbell Executive Director 101 E. Capitol, Suite 218 Little Rock, AR 72201 T: 501/682-0190 F: 501/682-0195 E-mail: [email protected] Internet address: www.state.ar.us/asbp

Suzette Bridges, P.D. 501/683-4120 Mail Order Pharmacy Benefit None

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Arkansas Osteopathic Medical Association Ed Bullington Executive Director 412 Union Station 1400 West Markham Little Rock, AR 72201 T: 501/374-8900 F: 501/374-8959 E-mail: [email protected] Internet address: www.arkosteomed.org Arkansas Medical Society Ken LaMastus Executive Vice President P.O. Box 55088 Little Rock, AR 72215 T: 501/224-8967 F: 501/224-6489 E-mail: [email protected] Internet address: www.arkmed.org

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

CALIFORNIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN)

Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

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Inpatient Hospital Care

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Outpatient Hospital Care

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Laboratory & X-ray Service

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Nursing Facility Services

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Physician Services

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Dental Services

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

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$3,402,508,001

2,651,229

RECEIVING ASSISTANCE, TOTAL Aged Blind/Disabled Children Adult

$2,552,720,446 $582,176,474 $1,826,731,055 $49,316,799 $94,496,118

1,379,776 278,543 593,945 304,963 202,325

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Children Adults

$499,284,360 $248,136,400 $223,302,948 $10,574,655 $17,270,357

281,471 130,533 58,736 55,277 36,925

POVERTY RELATED, TOTAL Aged Disabled Children Adults BCCA Women

$126,084,007 $40,135,036 $75,923,867 $5,580,840 $2,671,613 $1,772,651

135,070 27,679 22,313 51,160 32,398 1,520

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$224,419,188

854,912

2003** Expenditures Recipients $4,219,504,969

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

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Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

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

Formulary: The Medi-Cal List of Contract Drugs is a preferred drug list. It contains over 600 drugs, in differing strengths and dosage forms, listed generically. Patients can get prior authorization for unlisted drugs or for listed drugs that are restricted to specific use(s), if medically justified. Manufacturers frequently petition Medi-Cal to add drugs to the List of Contract Drugs. Based on Medi-Cal’s five criteria (safety, efficacy, misuse potential, essential need, and cost), a drug may be added to the list by contractual agreement with the manufacturer to provide the State a negotiated rebate. The Medi-Cal website at: http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h tml/faqpage.htm has details of how the drug contracting process works.

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: The Medi-Cal pharmacy benefit covers practically all FDAapproved drugs, including both legend and over-thecounter products. There are very few drugs or classes of drugs that are non-benefits. Non-benefits include common household remedies; non-legend analgesics and cough/cold medications, except when specifically listed; multivitamin preparations, except certain pre-natal and pediatric products; cosmetics; fertility drugs; and experimental drugs. Most other products are potential benefits. In general, products that are listed on the Medi-Cal List of Contract Drugs do not require prior authorization. Those not on the List of Contract Drugs do require prior authorization. Physician-administered drugs: The Medi-Cal List of Contract Drugs applies to drugs dispensed from pharmacies to patients. Drugs administered directly in a physician's, dentist's, or podiatrist's office are not bound by the List of Contract Drugs. Coverage of Injectables: Injectable medicines are 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. Vaccines: Vaccines are reimbursable by schedule as part of the Vaccines for Children Program. Vaccines for adults are covered through the prescription drug program or as administered in a physician's office.

Examples of general limitations and exclusions (other uses require prior authorization): 1.

CNS stimulants, e.g., 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.

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

4.

Some antibiotics have diagnostic and/or age restrictions.

5.

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

6.

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.

7.

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.

8.

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 drugs rated lessthan-effective by FDA are not covered.

Unit Dose: Unit dose packaging reimbursable.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prior Authorization: Nearly all drugs not included on the Medi-Cal list of Contract Drugs require prior authorization. State currently has a formal prior authorization procedure to appeal prior authorization decisions. 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). This is done by completing a Treatment Authorization Request (TAR) form. 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. TARs may be approved for: covered items or services not included on the Medi-Cal List of Contract Drugs (including special circumstance such as the need to override 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. An exception is allowed for refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is to be pro-rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted) does not exceed the fee for the same prescription when refilled as a routine service. Monthly Quantity Limit: This is flexible, but should be consistent with the medical needs of the patient. Limited to 100 days’ supply on most drugs. Many maintenance drugs are subject to minimum quantity or maximum frequency of billing controls.

Monthly Prescription Limit: Limited to 6 per month without prior authorization. The limit does not apply to family planning drugs, patients in nursing facilities, or to AIDS or cancer drugs. Hospital Discharge Medications: Quantities furnished as discharge medications are limited to no more than a 10-day supply. Charges are incorporated in the hospital’s claims for inpatient services. Drug Utilization Review Prospective DUR system implemented in August 1995. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $7.25 ($8.00 LTC), effective 9/1/04. Ingredient Reimbursement Basis: EAC = AWP-17% Prescription Charge Formula: Reimbursement is based on the lowest of: 1.

Estimated Acquisition Cost (EAC) + dispensing fee, less $0.50 for most patients, or less $0.10 for nursing home patients. 2. Federal Upper Limit (FUL) + dispensing fee, less $0.50 for most patients, or less $0.10 for nursing home patients. 3. State Maximum Allowable Ingredient Cost (MAIC) + dispensing fee, less $0.50 for most patients, or less $0.10 for nursing home patients. 4. Pharmacy’s usual price to general public, less $0.50 for most patients, or less $0.10 for nursing home patients. State law requires that reimbursement for blood factors be by NDC and not exceed 120 percent of the average selling price during the preceding quarter. Maximum Allowable Cost: State imposes a combination of Federal and State-specific limits on generic drugs. Maximum Allowable Ingredient Costs (MAICs) are established for about 50 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: $1.00 copayment for branded and generic products. Cognitive Services: Does not pay for cognitive services, but this is under consideration.

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Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Approximately 2.7 million Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through the State and managed care plans. Certain psychiatric drugs (antipsychotics, lithium, MAO inhibitors) and some anti-Parkinson drugs are carved out of managed care. Most AIDS drugs are no longer carved out of managed care. AIDS Healthcare Foundation Positive HealthCare 6255 W. Sunset Blvd., 21st Floor Los Angeles, CA 90028 323/860-5231 Alameda Alliance for Health 1240 South Loop Road Alameda, CA 94502 510/747-4500 Altamed Senior BuenaCare 5425 East Pomona Boulevard Los Angeles, CA 90022 323/728-0411 Blue Cross of California P.O. Box 9054 Oxnard, CA 93031 800/407-4627 Center for Elders Independence 1955 San Pablo Avenue Oakland, CA 94612 510/433-1150 Community Health Group 740 Bay Blvd. Chula Vista, CA 91910 619/498-6457 County of Contra Costa Contra Costa Health Plan 595 Center Avenue, Suite 100 Martinez, CA 94553 925/313-6008 Health Net of California 3400 Data Drive, 1st Floor West Rancho Cordova, CA 95670 800/675-6110 Health Plan of San Joaquin 1550 W. Fremont Street, Suite 200 Stockton, CA 95203-2643 209/939-3500

Inland Empire Health Plan 303 East Vauderbilt Way, Suite 400 San Bernardino, CA 92408 909/890-2000 Kaiser Foundation Health Plan, Inc. 393 E. Walnut Street Pasadena, CA 91188 800/390-3510 Kern Health Systems Kern Family Health Care 1600 Norris Road Bakersfield, CA 93308 661/391-4036 LA Care Health Plan 555 W. Fifth Street, 20th Floor Los Angeles, CA 90013 213/694-1250 Molina Healthcare of California One Golden Shore Drive Long Beach, CA 90802 562/432-3666 On Lok Senior Health Services-Alameda 159 Washington Boulevard Fremont, CA 94539 415/292-8888 On Lok Senior Health Services-SF 1333 Bush Street San Francisco, CA 94109 415/292-8888 Orange County Organized Health System CalOPTIMA 1120 West La Veta Ave. Orange, CA 92868 714/246-8400 Placer County Managed Care Network 379 Nevada Street Auburn, CA 95603 888/215-5453 San Francisco Health Authority San Francisco Health Plan 568 Howard Street, Fifth Floor San Francisco, CA 94105 415/547-7800 San Francisco City & County Public Health Family Mosaic Project 1309 Evans Avenue San Francisco, CA 94124 415/206-7600

California-4

National Pharmaceutical Council San Mateo Health Commission Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA 94080 650/616-0050

Pharmaceutical Benefits 2004 Western Health Advantage 1331 Garden Highway Suite 100 Sacramento, CA 95833 916/563-3189

F. STATE CONTACTS Santa Barbara Regional Health Authority Santa Barbara Health Initiative 110 Castilian Drive Goleta, CA 93117 805/685-9525 (Northern CA) 800/421-2560 (Southern CA) Santa Clara Family Health Plan 210 E Hacienda Ave Campbell, CA 95008 408/376-2000 Santa Cruz -Monterey Managed Care Commission Central Coast Alliance for Health 375 Encinal Street, Suite A Santa Cruz, CA 95060 800/700-3874

State Drug Program Administrator J. Kevin Gorospe, Pharm.D. Chief, Pharmacy Policy Unit California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] Internet Address: www.medi-cal.ca.gov New Brand Name Products Contact J. Kevin Gorospe, Pharm.D. 916/552-9500

Scan Health Plan Senior Care Action Network 3780 Kilroy Airport Way, Suite 600 Long Beach, CA 90801 562/989-5100

Prior Authorization Contact

Sharp Health Plan 4305 University Avenue, Suite 200 San Diego, CA 92105 619/228-2377

Ellis Ellis, Pharm.D. Pharmaceutical Counsultant II California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

Solano-Napa County Commission on Medical Care Partnership Health Plan of California 360 Campus Lane, Suite 100 Fairfield, CA 94534 707/863-4100 Sonoma County Partners for Health Managed Care Network 415 Humboldt Street Santa Rosa, CA 95404 707/565-4600 Sutter Senior Care 1234 U Street Sacramento, CA 95818 916/446-3100 Universal Care 1600 E. Signal Hill Street Signal Hill, CA 90806 800/635-6668

J. Kevin Gorospe, Pharm.D. 916/552-9500 DUR Contact

Medi-Cal Drug Utilization Review Board (DUR Board) Timothy E. Albertson, M.D., Ph.D. University of California-Davis Pulmonary/Critical Care Medicine Sacramento, CA Craig Jones, M.D. Director, Division of Allergy/Immunology Department of Pediatrics LA County/USC Medical Center Calabasas, CA

California-5

National Pharmaceutical Council Janeen G. McBride, Pharm.D. Associate Vice President Medimpact Healthcare Systems, Inc. San Diego, CA Gary M. McCart, Pharm.D. Professor of Clinical Pharmacy University of California Medical Center San Francisco, CA Kenneth Schell, Pharm.D. Clinical Operations Manager Pharmacy Services Kaiser Permanente San Diego, CA Stephen M. Stahl, M.D., Ph.D. Director Clinical Neuroscience Research Center UCSD School of Medicine San Diego, CA Andrew L. Wong, M.D. Chief of Rheumatology UCLA Medical Center Sylmar, CA Prescription Price Updating EDS Federal Corp. P.O. Box 13029 Sacramento, CA 95813-4029 916/636-1000 Medicaid Drug Rebate Contact Craig Miller Chief, Drug Rebate and Vision Section California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] Claims Submission Contact EDS Federal Corp. P.O. Box 13029 Sacramento, CA 95813-4029 916/636-1000

Pharmaceutical Benefits 2004 Medicaid Managed Care Contact Ronald Sanui, Pharm D. Pharmaceutical Consultant II California Department of Health Services Medi-Cal Managed Care Division 1501 Capitol Ave. P.O. Box 997413, MS 4404 Sacramento, CA 95814 916-449-5138 E-mail: [email protected] Disease Management Program/Initiatives Contact Marcia Ehinger, M.D. Senior Medical Consultant California Department of Health Services Medi-Cal Policy Division 1501 Capitol Ave., MS 4600 P.O. Box 997413 Sacramento, CA 95814 T: 916/552-9400 F: 916/555-9960 E-mail: [email protected] Mail Order Drug Benefit State currently has a mail order pharmacy capability in the Medi-Cal program. All fee-for-service beneficiaries are entitled to participate. Department of Health Services Sandra Shewry, Director Department of Health Services P.O. Box 997413, MS 000 Sacramento, CA 95899 T: 916/440-7400 F: 916/440-7404 E-mail address: [email protected] Stan Rosenstein Deputy Director Medical Care Services California Department of Health Services 1501 Capitol Ave. P.O. Box 942732 Sacramento, CA 95814 T: 916/ 440-7800 F: 916/ 440-7805 E-mail: srosenst.dhs.ca.gov Medi-Cal Contract Drug Advisory Committee William B. Ness, M.D. Lincoln, CA Bruce K. Uyeda, Pharm.D. Mountain View, CA

California-6

National Pharmaceutical Council Adrian M. Wong, Pharm.D. San Francisco, CA Richard H. White, M.D. U.C. Davis Medical Center Division of General Medicine Sacramento, CA Shirley Ann Floyd Blue Cross of California Bakersfield, CA 93301

Pharmaceutical Benefits 2004 California Healthcare Association C. Duane Dauner President 1215 K Street, Suite 800 Sacramento, CA 95814 T: 916/443-7401 F: 916/552-7596 E-mail: [email protected] Internet address: www.calhealth.org

Executive Officers of State Medical and Pharmaceutical Associations/Boards California Medical Association Jack C. Lewin, M.D. Executive Vice-President and CEO 1201 J Street, Suite 200 Sacramento, CA 95814 T: 916/444-5532 F: 415/882-3349 Internet address: www.cmanet.org Osteopathic Physicians & Surgeons of California Kathleen S. Creason, M.B.A. Executive Director 1900 Point West Way, Suite 188 Sacramento, CA 95815-4703 T: 916/561-0724 F: 916/561-0728 E-mail: [email protected] Internet address : www.opsc.org California Pharmacists’ Association Carlo Michelotti, R.Ph., M.P.H. Chief Executive Officer 4030 Lennane Drive Sacramento, CA 95834 T: 916/779-1400 F: 916/779-1401 E-mail: [email protected] Internet address: www.cpha.com California State Board of Pharmacy Stanley Goldenberg, R.Ph. President 400 R Street, Suite 4070 Sacramento, CA 95814 T: 916/445-5014 F: 916/327-6308 Internet address: www.pharmacy.ca.gov

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Pharmaceutical Benefits 2004

California-8

National Pharmaceutical Council

Pharmaceutical Benefits 2004

COLORADO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Aged

Medically Needy (MN) Blind/ Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures

Recipients

TOTAL

$202,286,461

153,520

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult Unknown

$131,455,323 $42,740,055 $78,779,997 $3,365,340 $6,568,168 $1,763

81,187 18,549 26,398 18,079 18,160 1

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$6,751,922 $127,100 $226,817 $4,875,966 $1,515,915 6,124

40,538 128 129 29,415 10,854 12

$64,079,216

31,795

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $225,297,507

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Vaccines: Vaccines reimbursable as part of the EPSDT Program.

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

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary. Managed through restrictions on use and prior authorization.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: Products covered: prescribed insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; prescribed vitamins (except prenatal); and experimental drugs. Disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips are considered DME and do not fall under the State’s drug benefit. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and NSAIDs; analgesics; and digestive products. Products covered with restrictions: cough and cold preparations (< 21); feminine products (must be medically necessary); topical products (must be medically necessary); and smoking deterrent products (prior authorization, once in a lifetime benefit, 90-day supply in conjunction with smoking cessation program). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; cardiac drugs; contraceptives; ENT antiinflammatory agents; hypotensive agents; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, and NSAIDs; anticoagulants; antihistamines; anti-psychotics; anxiolytics, sedatives, and hypnotics, chemotherapy agents; prescribed cough and cold medications; estrogens; growth hormones; misc. GI drugs; sympathominetics (adrenergic); vitamins; acne products; leukocyte stimulants; LHRH/GnRH; injectables; plasma products; Epoetin; fluoride preparations; antisera; Oxycontin; erectile dysfunction products; Ambien; Sonata; Toradol; Amerge; Axert; Frova; Imitres; Maxalt; Relpax; Zomig; Anzemet; Emend; Dytril, Zofran; and prescribed smoking deterrents. Products not covered: anoretics. 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. Prior authorization is required for self-administration at home.

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. Normal quantity limit is a 30-day supply. However, reasonable amounts for more than a 30-day supply for chronic conditions are recommended. Maximum supply is determined by the medication. Standard limit of 4 bottles per month Other Limits: Additional quantity limits may be applied to certain drugs. Oxycontin: 2 tablet (any strength) per day limit without prior authorization. Drug Utilization Review PRODUR system implemented in December 1998. DUR Board meets quarterly. Lock-In Review Procedures: The Department receives computer processed printouts designed to discover over-utilization of drugs prescribed by physicians, dispensed by vendors, and received by eligible recipients. Pharmacy Payment and Patient Cost Sharing Dispensing fee: $4.00 as of July 1, 2001. Institutional pharmacies 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 = AWP13.5% or WAC (wholesaler acquisition cost) + 18%. AWP-35% for generics. Other: FUL, State Mac, usual and customary.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

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: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires Medically Necessary with explanation of medical necessity (MedWatch form).

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 13.5%, 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;

The State MAC is the maximum ingredient cost allowed by the Department for certain multiplesource drugs. The establishment of a MAC is subject, but not limited to, the following considerations:

(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.

(1) Multiple manufacturers; (2) Broad wholesale price span; (3) Availability of drugs to retailers at the selected cost;

The Department will determine the average wholesale price that will be placed in the drugpricing file as follows:

(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.

(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 Medi-Span, 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 Medi-Span.

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Pharmaceutical Benefits 2004

(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 MediSpan 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.

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

F. STATE CONTACTS Medicaid Drug Program Administrator

Incentive Fee: None.

Martha Warner Pharmacy Supervisor Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-3176 F: 303/866-2573 E-mail: [email protected]

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

DUR Contact

- 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.

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Over 208,000 Medicaid recipients were enrolled in managed care in FY 2003. Recipients receive pharmaceutical benefits through the Managed Care Organization. Managed Care Organizations Total Long-Term Care 303 East 17th Avenue, Suite 650 Denver, CO 80203 303/896-4664

Catherine Traugott Pharmacist Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: [email protected] DUR Board Gail Bosch, R.Ph., C.G.P. David A. Downs, Jr., M.D. Lucy Williams Loomis, M.D., M.S.P.H. Robert D. McCartney, M.D., F.A.C.P. Mary Newell, R.Ph. Candace A. Reith, Pharm.D. Terrie A. Sajbel, Pharm.D. Edra B. Weiss, M.D., F.A.A.P. Timothy D. Hynek, R.Ph.

Kaiser Permanente Colorado-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Brand Names Products Contact

Mail Order Pharmacy Program

Martha Warner 303/866-3176

None Health Care Policy & Financing Department Officials

Prescription Price Updating Martha Warner 303/866-3176

Karen K. Reinertson Executive Director Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818 T: 303/866-2993 F: 303/866-4411 E-mail: [email protected] Internet address: www.chcpf.state.co.us

Medicaid Drug Rebate Contacts Vince Sherry Drug Rebate Manager Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-5408 F: 303/866-2573 E-mail: [email protected]

Vivianne M. Chaumont, Director Medical Assistance Office Department of Healthcare Policy and Financing 1570 Grant Street Denver, CO 80203 303/866-3058

Claims Submission Contact ACS, State Healthcare 600 17th Street Suite 600 North Denver, CO 80202 T: 800/237-0757 F: 303/534-0439

Medical Services Board Michael Oliva Julie Reiskin (President) Mary Ellen Faules Joan M. Johnson Wendell Phillips Joe Rall Maguerite Salazar Steve Tool (Vice President) Mathew Dunn, M.D. Sally Schaefer David Bolin

Medicaid Managed Care Contact Katie Brookler Managed Care Manager Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2416 F: 303/866-2573 E-mail: [email protected]

Medical Advisory Council

Disease Management/Patient Education Programs

Donald W. Schiff, M.D. Littleton, CO

Disease/Medical State: Asthma Program Name: Asthma Management Program Program Manager: Sue Tripathi, Ph.D. Program Sponsor: National Jewish Medical and Research Center

Molly A. Markert Aurora, CO

Disease/Medical State: Diabetes Program Name: Diabetes Disease Management Program Program Manager: Sue Tripathi, Ph.D. Program Sponsor: McKesson Health Solutions, Inc.

Walter Daniels, D.D.S. Denver, CO

Disease Management/Patient Education Contact

Douglas Clinkscales Denver, CO

Katie Brookler, 303/866-2416

Cathy Corcoran Golden, CO

Mary Jo Jacobs, M.D. Denver, CO

Rodney Fair, O.D. Brighton, CO

Colorado-5

National Pharmaceutical Council Ernestine Kotthoff-Burrell Englewood, CO Carol Bartley Denver, CO Mary Ellen Kuhlman, M.S.W. Grand Junction

Pharmaceutical Benefits 2004 Colorado Health and Hospital Association Larry H. Wall President 7335 East Orchard Road, Suite 100 Greenwood Village, CO 80111-2512 T: 720/489-1630 F: 720/489-9400 Internet address: www.cha.com

Dan Stenerson Aurora, CO Mark Kunart, D.O. Aurora, CO Robert Slay Lakewood, CO Executive Officers of State Medical and Pharmaceutical Societies Colorado Medical Society Alfred Gilchrist Executive Director 7351 Lowry Boulevard Denver, CO 80230 T: 720/859-1001 F: 303/771-8659 E-mail: [email protected] Internet address: www.cms.org Colorado Pharmacists Society Val Kalnins, R.Ph., Executive Director 6825 E. Tennessee Avenue, Suite 510 Denver, CO 80224-1662 T: 303/756-3069 F: 303/756-3649 E-mail: [email protected] Internet address: www.copharm.org Colorado Society of Osteopathic Medicine Marie Kowalsky Executive Director 650 South Cherry Street, Suite 510 Denver, CO 80246 T: 303/322-1752 F: 303/332-1956 E-mail: [email protected] Internet address: www.coloradodo.org Colorado State Board of Pharmacy Susan L. Warren Program Director 1560 Broadway, Suite 1310 Denver, CO 80202 T: 303/894-7750 F: 303/894-7764 E-mail: [email protected] Internet address: www.dora.state.co.us/pharmacy Colorado-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

CONNECTICUT A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

2002 Expenditures

Recipients

B. EXPENDITURES FOR DRUGS

TOTAL

$356,980,484

123,704

$86,045,876 $16,590,546 $68,770,620 $183,663 $501,047

26,172 5,940 15,311 2,686 2,235

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$107,981,037 $25,232,717 $82,442,392 $171,259 $134,669

31,035 10,618 19,884 332 201

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$3,928,268 $665,123 $2,090,017 $1,002,861 $69,818 $100,449

5,859 577 1,002 3,228 981 71

$159,025,303

60,638

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $403,802,170

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION State of Connecticut Department of Social Services through three regional offices and twelve sub-offices.

Vaccines: Vaccines reimbursable as part of the Children Health Insurance Program. Unit Dose: Unit dose packaging not reimbursable.

D. PROVISIONS RELATING TO DRUGS

Formulary/Prior Authorization

Benefit Design

Formulary: Open formulary, managed through prior authorization. However, the following products are 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.

Drug Benefit Product Coverage: Products covered: prescribed insulin, disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips. Products not covered: cosmetics; fertility drugs; experimental drugs; total parenteral nutrition; interdialytic parenteral nutrition; and weight loss products. Over-the-Counter Product Coverage: allergy, asthma, and sinus products; cough and cold preparations (children < 19 years) and topical products. Products covered with restrictions: digestive products (non H2 antagonists) – liquid generics only (legend drugs not covered); digestive products (H2 antagonists) – after first 60 days, diagnosis required on the prescription for continued use; birth control products; antihistamines; and decongestants. Products not covered: smoking deterrent products; analgesics; feminine products; iron; calcium; 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; antipsychotics; 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. Prior authorization required for; Brand Medically Necessary prescriptions; early refills; and prescriptions costing more than $500. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in home health care, extended care facilities, and in physicians offices.

Prior Authorization: State currently has a prior authorization procedure. Clients can request an administrative hearing to appeal prior authorization decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: 5 refills per prescription except for oral contraceptives, which have a 12month limit. Monthly Quantity Limit: Maximum 240 tablets or capsules/30-day supply. Oral contraceptives: 3 months supply may be dispensed at one time. Physicians are encouraged to prescribe drugs generically, when possible. Drug Utilization Review Pro-DUR system implemented September 1996. Retro-DUR since September 1991; the State currently has a 9 member DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.15, effective 7/1/04. Ingredient Reimbursement Basis: EAC = AWP-12%. Special rules for Factor VIII (AAC + 8%), OTCs (AWP x # units x 1.15), and enteral and parenteral nutritionals (AWP x # units x 1.15). Prescription Charge Formula: Federal MAC or EAC plus dispensing fee; or usual and customary if lower. Special rules for blood factor VIII and enteral/parenteral nutrition products. Maximum Allowable Cost: State imposes a combination of Federal and State specificUpper Limits on generic drugs. Effective 1/1/2003, the Department implemented a state MAC to include additional multi-source generic products that are not

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

on the FUL list. The State MAC reimbursement is AWP-40%.

F: 860/424-5206 E-mail: [email protected] Internet address: www.dss.state.ct.us

Patient Cost Sharing: None. Department of Social Services Officials Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Connecticut had more than 371,000 Medicaid recipients enrolled in managed care in 2003. Over 80 percent (305,000) recovered pharmaceutical services through managed care plans. Managed Care Organizations Anthem Blue Cross/Blue Shield of CT Blue Care Family Plan Paula Smyth, Director Medicaid Managed Care 370 Bassett Road North Haven, CT 06473-4201 T: 203/654-3506 F: 203/234-5310 Community Health Network of CT Sylvia Kelly, CEO 290 Pratt - 2nd Floor Meriden, CT 06450 T: 203/237-4000 F: 203/634-8411

Patricia A. Wilson-Coker Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06016-5033 T: 860/424-5008 F: 860/566-2022 E-mail: [email protected] David Parrella, Director Medical Care Administration Department of Social Services 25 Sigourney Street Hartford, CT 06106 T: 860/424-5116 F: 860/424-5114 DUR Contact James R. Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

Health Net Janice Perkins, Vice President One Far Mill Crossing, Box 904 Shelton, CT 06484-0944 T: 203/225-8630 F: 203/225-4175

Connecticut DUR Board

First Choice of CT, Preferred One Douglas Hayward, Chief Operating Officer 23 Maiden Lane North Haven, CT 06473 T: 203/239-7444 F: 203/239-3381

Lori Jane Duntz Lord, R.Ph. Greenville Drug

F. STATE CONTACTS Medicaid Drug Program Administrator Evelyn A. Dudley Manager, Pharmacy Unit Department of Social Services Medical Operations Unit #4 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5654

Kenneth Fisher, R.Ph. Brooks Pharmacy Arturo Morales, M.D. St. Francis Hospital

Dennis J. Chapron, R.Ph. Pharmokinetics Lab Keith Lyke, R.Ph. Pelton’s Pharmacy Frederick N. Rowland, M.D. St. Francis Hospital and Medical Center Richard Gannon, Pharm.D. Hartford Hospital Kathryn Mashey, DPM Community Health Services

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Michael Moore, R.Ph. Hebrew Home Hospital

Farmington, CT

Prescription Price Updating

Stella Cretella West Haven, CT

Ellen Arce, R.Ph. Pharmacy Manager EDS 1000 Stanley Street New Britain, CT 06053 T: 860/832-5885 F: 860-832-5921 E-mail: [email protected]

Richard Carbray, Jr., R.Ph. Newington, CT Kenneth Marcus, M.D. New Haven, CT Peggy Memoli, R.Ph. (Vice Chair) Stratford, CT

Medicaid Drug Rebate Contacts Afrika Hinds-Ayala Health Program Associate Department of Social Services Medical Operations Unit #4 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

Joseph Misiak, M.D. Windsor, CT Lucille Russell, M.D. Rawayton, CT Carl Sherter, M.D. (Chair) Southbury, CT Lawrence Sobel, R.Ph. West Hartford, CT

Ellen Arce, R.Ph. (Rebates & Disputes) 860/832-5885 Claims Submission Contact

Dorothy Stubbe, M.D. New Haven, CT

Ellen Arce, R.Ph. 860/832-5858

Robert Zavoski, M.D. West Simsbury, CT

Medicaid Managed Care Contact

Executive Officers of State Medical and Pharmaceutical Societies

Rose Ciarcia Director, Managed Care Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5139 F: 860/424-4958 E-mail: [email protected]

Connecticut State Medical Society Timothy B. Norbeck, Executive Director 160 St. Ronan Street New Haven, CT 06511-2390 T: 203/865-0587 F: 203/865-4997 E-mail: [email protected] Internet address: www.csms.org

Mail Order Pharmacy Program

Connecticut Pharmacists Association Margherita R. Guiliano, R.Ph. Executive V.P. 35 Cold Spring Road, Suite 121 Rocky Hill, CT 06067-3161 T: 860/563-4619 F: 860/257-8241 E-mail: [email protected] Internet address: www.ctpharmacists.org

None Disease Management Contact David Parrella Director, Medical Care Administration T: 860/424-5116 Elderly Drug Coverage Program Contact Evelyn Dudley 860/424-5654 Pharmaceutical and Therapeutics Committee Holly Bessoni-Lutz, R.N.

Connecticut Osteopathic Medical Society Donald Halpin, Executive Director P.O. Box 487 Winchester, MA 01800-0487 T: 781/721-9900

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

F: 781/721-4400 E-mail: [email protected] Connecticut Commission Pharmacy Michelle Sylvestre, R.Ph. Board Administrator Department of Consumer Protection 165 Capitol Avenue Hartford, CT 06106 T: 860/713-6065 F: 860/713-7242 E-mail: [email protected] Internet address: www.ctdrugcontrol.com/rxcommission.htm Connecticut Hospital Association, Inc. Jennifer Jackson President and CEO 110 Barnes Road Wallingford, CT 06492-0090 T: 203/265-7611 F: 203/284-9318 E-mail: [email protected] Internet address: www.chime.org

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Connecticut-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

DELAWARE A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Aged

Blind/ Disabled

Child

Adult

B. EXPENDITURES FOR DRUGS 2002 Expenditures TOTAL

Recipients

$100,112,623

125,461

$48,342,702 $6,124,532 $28,909,766 $5,126,585 $18,181,819

47,053 2,456 10,035 22,562 12,000

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adults BCCA Women

$1,583,883 $176,789 $636,901 $688,345 $53,731 $28,117

4,248 141 337 3,473 278 19

$50,186,038

74,160

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $109,844,743

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

Delaware-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Prior Authorization: State currently has a formal prior authorization procedure. Standard procedures for clients to request a fair hearing to appeal prior authorization decisions.

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

Prescribing or Dispensing Limitations

D. PROVISIONS RELATING TO DRUGS

Monthly Limit on Scripts: 15 medications per 30 days.

Benefit Design

Prescription Refills: Prescription blank has space for physician to authorize renewals.

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe 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; experimental drugs; and quality of life medications.

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. State has a DUR Board that meets bimonthly.

Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; and topical products. Products covered with restrictions: smoking deterrent products (prior authorization and quantity limits). Products not covered: feminine products.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.65.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine 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, and NSAIDs; anoretics; antibiotics; antilpemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; prescribed col medications; growth hormones; prescribed smoking deterrents; Regranex; Zyvox; Soma Accutane Cipro; Cholinesterase inhibitors; Modafanil; and Epoetin. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in extended care facilities, and through both the prescription drug program and physician payment when used in physicians’ offices. Vaccines: Vaccines reimbursable under the CHIP Program and Vaccines for Children program.

Ingredient Reimbursement Basis: EAC = AWP14.0%. (AWP-16% for LTC) Prescription Charge Formula: Payment is based on AWP-14.0% 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. Override requires completion of an FDA MedWatch form. Incentive Fee: None. Patient Cost Sharing: $0.50-$3.00 Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 90,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through the State. Managed Care Organizations

Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary with preferred drug list. PDL managed through preferred products and prior authorization.

DelawareCare 2751 Centerville Road, Suite 400 Wilmington, DE 19808 215/937-8285

Delaware-2

National Pharmaceutical Council First State Health Plan 1801 Rockland Road, Suite 300 Wilmington, DE 19803 302/576-7603

Pharmaceutical Benefits 2004 Medicaid Drug Rebate Contacts Cynthia R. Denemark, R.Ph. 302/453-8453 Claims Submission Contact

F. STATE CONTACTS

Cynthia R. Denemark, R.Ph. 302/453-8453

State Drug Program Administrator

Medicaid Managed Care Contact

Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected] Internet address: www.dmap.state.de.us

Mary Marinari Health Policy Analyst Managed Care/QA DSS Herman Holloway Campus Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9548 F: 302/255-4481 E-mail: [email protected]

Prior Authorization Contact Cynthia R. Denemark, R.Ph. 302/453-8453

Mail Order Pharmacy Benefit None

DUR Contact Cynthia R. Denemark, R.Ph. 302/453-8453 DUR Board Calvin Freedman, R.Ph. (Chair) Scott Harrison, D.O. Richard Steele, R.Ph. Susan Fullerton, A.P.N. Mark Borer, M.D. Nadia Helenga, Pharm.D. Christopher Sauls, R.Ph. Frank Falco, M.D. (Vice Chair) Sebastion Hamilton, R.Ph. Albert Rizzo, M.D. Michael Marcus, M.D. New Brand Name Products Contact Joli Martini Pharmacist Consultant-Clinical Reviews EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected] Prescription Price Updating Cynthia R. Denemark, R.Ph. 302/453-8453

Health and Social Services Department Officials Vincent P. Meconi Secretary Dept. of Health & Social Services 1901 North DuPont Highway-Main Bldg. New Castle, DE 19720 T: 302/255-9040 F: 302/255-4429 E-mail: [email protected] Internet address : www.state.de.us/dhhs Harry Hill Deputy Director Planning and Development Dept. of Health & Social Services 1901 North DuPont Highway-Lewis Bldg. New Castle, DE 19720 T: 302/577-4901 F: 302/255-4425 E-mail: [email protected] Pharmaceutical and Therapeautics Committee Cedric T. Barnes, D.O. Louis Bartoshesky, M.D. Renee Beaman, R.N. Kimberly A. Couch, Pharm.D. Calvin Freedman, R.P.h. Valerie Green, M.D. Pat Klishevich, R.Ph. James Lafferty

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Brian Levine, M.D. Michael N. Marcus, M.D. M. Diana Metzger, M.D. Tamara J. Newell, A.P.N. Obi Onyewu, M.D. James A. Owen, R.Ph. Michael J. Pasquale, M.D. Jose Quinones Albert A. Rizzo, M.D. Executive Officers of State Medical and Pharmaceutical Societies Medical Society of Delaware Mark Meister Executive Director 131 Continental Drive, Suite 405 Newark, DE 19713 T: 302/658-7596 F: 302/658-9669 E-mail: [email protected] Internet address: www.msdhub.com Delaware Pharmacists Society Patricia Carroll-Grant, R.Ph., CDE Executive Director P.O. Box 454 Smyrna, DE 19977-0454 T: 800/782-3716 F: 302/659-3089 E-mail: [email protected] Internet address: www.depharmacy.net

Delaware Healthcare Association Joseph M. Letnaunchyn President and CEO 1280 South Governors Avenue Dover, DE 19904-4802 T: 302/674-2853 F: 302/734-2731 E-mail: [email protected] Internet address: www.deha.org

Delaware Osteopathic Medical Society Edward Sobel, D.O. Executive Director P.O. Box 8177 Talleyville, DE 19803-8177 T: 302/764-1198 F: 302/764-1322 E-mail: [email protected] Internet address: www.deosteopathic.org Delaware State Board of Pharmacy David W. Dryden, R.Ph., J.D. Executive Secretary Jesse Cooper Building, Room 205 P.O. Box 637 Dover, DE 19903 T: 302/744-4547 F: 302/739-3071 E-mail: [email protected] Internet address: www.professionallicensing.state.de.us/boards

Delaware-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Categorically Needy Aged

Blind/ Child Disable d ‹ ‹

Medically Needy (MN)

Adult

Aged

Blind/ Disabled

Child

Adult

‹

‹

‹

‹

‹

Prescribed Drugs

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$68,050,981

45,216

$81,762,504

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$45,487,560 $4,038,389 $39,946,424 $282,114 $1,220,633

28,198 3,279 21,040 1,256 2,623

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$9,287,462 $1,685,420 $6,992,364 $115,789 $493,889

5,984 1,132 3,355 666 831

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$9,410,167 $3,096,675 $6,096,888 $164,442 $52,162 $0

6,432 2,294 2,657 1,330 151 0

TOTAL OTHER EXPENDITURE/RECIPIENTS*

$3,865,792

4,602

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

District of Columbia-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Vaccines: Vaccines reimbursable at cost as part of the EPSDT service and The Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization 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 ferrous sulfate. Prior authorization required for: cosmetics; 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: fertility drugs; experimental drugs; total parenteral nutrition; interdialytic parenteral nutrition; anesthetics; infant formulas; cold tar preparations; reusable needles/syringes (non-insulin); and all other nonlegend items. Over-the-Counter Product Coverage: Products covered with restrictions: oral analgesics; contraceptive foams and jellies; prenatal, pediatric and geriatric vitamins; and bowel preparation kits. Products not covered: allergy, asthma, and sinus products; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products.

Formulary: Open formulary with restrictions on use, prior authorization, and therapeutic substitution. Appeals for coverage of an excluded product can be made to The Office of Appeals. Providers may also appeal prior authorization decisions to First Health Services Corporation’s Risk Manager. Prescribing or Dispensing Limitations 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. Other limits on specific products. Monthly Dollar Limits: $1,500 limit. Physicians are to request prior authorization for prescriptions that exceed this amount. Drug Utilization Review

Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; 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 (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, and NSAIDs; anoretics; growth hormones; misc. GI drugs; erectile dysfunction products; Brand Medically Necessary drugs; immunosuppressants; amphetamines; Stadol; Levocamitine; Hepatitis C medications; and Synagis. Therapeutic categories not covered: anabolic steroids.

PRODUR system implemented in September 1996. The District currently has a DUR Board that meets monthly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.50. Ingredient Reimbursement Basis: AWP-10%. Prescription Charge Formula: The lesser of: FUL or the AWP-10% plus the dispensing fee or usual and customary to the public. Maximum Allowable Cost: The District does not impose MAC limits on generic drugs. Incentive Fee: None.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians’ offices.

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.

District of Columbia-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 90,000 Medicaid recipients were enrolled in managed care in 2003. Recipients enrolled in managed care receive pharmaceutical benefits through managed care plans. Managed Care Organizations D.C. Chartered Health Plan 1025 15th Street, N.W. Washington, DC 20005 202/408-4720

District of Columbia DUR Board Christopher Keeyes, Pharm.D. (Chair) Chairman, Clinical Pharmacy Associates 316 Talbott Avenue Laurel, MD 20707 301/617-0555 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

Amerigroup 750 First Street, NE, Suite 1120 Washington, DC 20002 800/600-4441 Health Right, Inc. 1101 14th Street, NW, Suite 900 Washington, DC 20005 202/418-0380

Dr. Kim Bullock Providence Hospital Emergency Room 1150 Varnum St., NE Washington, DC 20017 202/269-7863

F. STATE CONTACTS

Prior Authorization Contacts

State Drug Program Administrator

Cheryl S. Wilson 202/442-9078

Cheryl S. Wilson Risk Manager-Pharmacy/ DME Department of Health Medical Assistance Administration 825 North Capitol Street, NE Suite 5135 Washington, DC 20002 T: 202/442-9078 F: 202/442-4790 E-mail: [email protected] Internet address: www.dchealth.dc.gov

Medicaid Drug Rebate Contact Jeffrey Dzieweczynski, R.Ph., M.S. ACS State Healthcare 750 First Strweet, NE Washington, DC 20002 T: 202/906-8353 F: 202/906-8399 E-mail: [email protected] New Brand Name Products Contact

DUR Contact Christopher A. Keeys, Pharm.D., BCPS, R.Ph. Chairman Clinical Pharmacy Associates, Inc. 316 Talbott Avenue Laurel, MD 20707 T: 301/617-0555 F: 301/617-0225 E-mail: [email protected]

Cheryl S. Wilson 202/442-9078 Prescription Price Updating Contact Christine Quinn Account Manager ACS State Heathcare 750 First Street, NE Washington, DC 20002 T: 202/906-8304 F: 202/906-8378 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Claims Submission Contact

Executive Officers of District Medical and Pharmaceutical Societies

Jacqueline Bonner Clinical Manager First Health Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/273-6961 E-mail: [email protected]

Medical Society of the District of Columbia K. Edward Shanbacker 2175 K Street, NW, Suite 200 Washington, DC 20037 T: 202/466-1800 F: 202/452-1542 E-mail: [email protected] Internet address: www.msdc.org

Medicaid Managed Care Contact Washington D.C. Pharmacy Association Herbert Kwash, R.Ph., President 6406 Georgia Avenue, N.W. Washington, DC 20012-2960 T: 202/829-1515 F: 202/829-1515

Maude R. Holt Chief Administrator-Manor Care Department of Health Medical Assistance Administration 825 North Capitol Street, NE Washington, DC 20002 T: 202/442-9014 F: 202/442-4790 E-mail: [email protected]

Osteopathic Association of the District of Columbia K. Joseph Heaton, D.O., President 2517 North Glebe Road Arlington, VA 22207 T: 703/522-8404 F: 703/522-2692

Mail Order Pharmacy Program None Department of Human Services Officials Gregory Pane, M.D. Director Department of Health 825 North Capitol Street, NE Fourth Floor Washington, DC 20002 T: 202/671-5000 F: 202/442-4795 E-mail: [email protected] Internet Address: www.dchealth.dc.gov Robert Maruca Senior Deputy Director Department of Health Medical Assistance Administration 825 North Capitol Street, NE Fifth Floor Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected] Internet address: www.dchealth.dc.gov

DC Board of Pharmacy Beverly Mims, Chairperson 825 North Capitol Street, NE, Room 224 Washington, DC 20002 T: 202/442-4775 T: 202/442-9200 F: 202/442-9431 E-mail: gramseur@dchealth .com Internet address: www.dchealth.dc.gov/prof_license District of Columbia Hospital Association Robert Malson, President 1250 Eye Street, NW, Suite 700 Washington, DC 20005 T: 202/682-1581 F: 202/371-8151 E-mail: [email protected] Internet address: www.dcha.org

District of Columbia-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004 **2003 data provided by the Florida Agency for Health Care Administration.

FLORIDA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures

Recipients

2003** Expenditures Recipients

TOTAL

$1,736,991,594

1,245,841

$2,422,440,384

1,292,241

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$1,003,983,709 $170,559,577 $745,290,114 $38,098,660 $50,035,358

559,948 80,626 236,377 152,574 90,371

$1,371,908,887 $238,260,026 $994,536,618 $61,235,847 $77,786,396

593,679 82,337 243,728 170,765 96,849

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult Other

$79,151,203 $6,303 $62,557,905 $2,228,296 $14,358,699

26,944 7 9,963 3,206 13,768

$234,190,202 $31,015,312 $169,380,236 $4,379,348 $29,414,779 $527

45,851 6,050 19,159 2,856 17,785 1

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$392,630,319 $140,952,724 $182,755,926 $63,888,019 $5,033,650 $0

400,492 74,911 46,604 249,619 29,358 0

$486,460,426 $173,981,996 $203,471,205 $94,203,449 $14,803,776

454,297 65,907 45,142 258,882 84,366

TOTAL OTHER EXPENDITURE/RECIPIENTS

$261,226,363

258,457

$329,880,869

198,414

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

District of Columbia-5

National Pharmaceutical Council

Pharmaceutical Benefits 2003

Source: CMS, MSIS Report, FY 2002 and Florida Medicaid Statistical Information System, FY 200

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

D. PROVISIONS RELATING TO DRUGS

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians’ offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; total parenteral nutrition; interdialytic parenteral nutrition; and urine ketone test strips (children under age 21only). Products covered with restrictions (non-PDL products require prior authorization): disposable needles and syringe combinations used for insulin; blood glucose test strips. Prior authorization required for: Actiq; Albumin; Aranesp; Procrit; Botox; Cytogam; Fuzeon; growth hormone for adults; Intravenous Immune Globulin (IVIG); Neupogen; Leukine; Neulasta; Neurontin; Neutrexin; Panretin; Orfadin; Oxycontin; Proleukin; Provigil; Targretin; Valcyte; Venofer; Vfend; Xenical; Regranex (long-term care); and nutritional supplements and non-preferred products. Products not covered: cosmetics; fertility drugs; and experimental drugs.

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Preferred Drug List (PDL) with mandatory limits and exclusions. All covered drugs are available through the preferred drug process. General exclusions include excluding products based on contracting issues, restrictions on use, prior authorization, therapeutic substitution, preferred products, physician profiling and supplemental rebates. Specific limits and exclusions include: 1. 2. 3.

Over-the-Counter Product Coverage: Products covered with restrictions: analgesics (selected aspirin and Tylenol products); cough and cold preparations (select products); digestive products (non-H2 antagonists); feminine products; and smoking deterrent products. Products not covered: allergy, asthma, and sinus products; digestive products (H2 antagonists); and topical products.

4.

5.

Therapeutic Category Coverage: Therapeutic categories covered: anaboilic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; antipsychotics; 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. Partial coverage for: prescribed cold medications. Prior authorization required for: analgesics, antipyretics, and NSAIDs; growth hormones; mental health drugs; antiretrovirals for HIV; drugs not included on the Medicaid preferred drug list; and brand name prescriptions beyond the four brand cap unless exempted. Therapeutic categories not covered: anoretics.

6. 7.

8.

Vitamins and phosphate binders only for dialysis patients. Prostheses; appliances; devices; and personal care items. 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. Nursing home floor stock drugs.

Prior Authorization: State currently has a formal prior authorization procedure. Direct appeal to AHCA and/or formal request for administrative hearing required to appeal prior authorization decisions. Prescribing or Dispensing Limitation Prescription Refill Limit:

Florida-6

1. Limited to four brand name RXs per month with exceptions for specific therapeutic groups. Exemptions are: Anti-Retrovirals for HIV, AntiPsychotics, Depressants and Convulsants,

National Pharmaceutical Council

2.

3. 4.

5.

6.

Pharmaceutical Benefits 2003

Family Planning, and Diabetic supplies and insulin, unlimited generic prescriptions. Drugs not included in the Preferred Drug list (PDL) require PA. Anti-retrovirals and mental health are exempted. Maintenance medication should be dispensed and billed for at least a one-month supply. Refills must be authorized by the prescriber andcan be made for up to one year, except that controlled substances can be refilled only in accordance with Federal and State regulations. 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.

E. USE OF MANAGED CARE Approximately 644,000 Medicaid recipients (30% of all recipients) received pharmaceutical benefits through managed care plans (inclusion of such benefits is mandated under State law) in FY 20022003. Managed Care Organizations Amerigroup Florida, Inc. (FKA Physicians Health Care Plans, Inc.) 4200 W. Cypress Street, Suite 900 Tampa, Fl 33607-4173 T: 813/830-6900 F: 813/314-2045

Drug Utilization Review PRODUR system implemented in July 1993. 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. Heritage Information Systems contracts to provide DUR and prescriber pattern profiling and clinical review assistance. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.23, effective 3/11/86. Ingredient Reimbursement Basis: AWP-15.40 % or WAC+5.75%. (effective 7/1/04) 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 as well as State-specific limits on generic drugs. MAC override by physicians requires completed MedWatch form and prior authorization. Incentive Fee: No incentive fee. Patient Cost Sharing: No copayment Cognitive Services: Does not pay for cognitive services.

Buena Vista Medicaid Vista Health Plan, Inc. (FKA Beacon and Discovery) 300 South Park Road Hollywood, FL 33021 866/847-8235 Citrus Health Care, Inc. 5420 Bay Center Drive, Suite 250 Tampa, FL 33609 T: 877/624-8787 F: 813/490-8907 Healthease of Florida, Inc. 8735 Henderson Road, Ren 2 Tampa, FL 33634 T: 800/278-0656 F: 813/290-6332 Humana Family c/o Humana Medical Plan, Inc. 3501 SW 160th Street Miramar, FL 33027 T: 800/533-5001 F: 305/626-5086 Jackson Memorial Health Plan 1801 NW 9th Ave., Suite 700 Miami, FL 33136 T: 800/721-2993 F: 305/545-5212 Personal Health Plan 324 Datura Street, Suite 401 West Palm Beach, FL 33401 T: 561/659-1270 F: 561/833-9786

Florida-7

National Pharmaceutical Council Preferred Medical Plan, Inc. 4950 SW 8th Street Coral Gables, FL 33134 T: 305/447-8373 F: 305/447-4959 StayWell Health Plan of Florida, Inc. 8735 Henderson Road, Ren C Tampa, FL 33634 T: 813/935-5227 F: 813/290-6332 United Healthcare of Florida, Inc. 13621 N.W. 12th Street Sunrise, FL 33323 800/910-3145 Vista South Florida (FKA Foundation Health Plan) 300 South Park Road Hollywood, FL 33021 T: 800/441-5501 F: 954/986-6082

Pharmaceutical Benefits 2003 Prior Authorization Contact Bruce McCall, Pharm.D. 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: ahca.myflorida.com DUR Contact Linda G. Barnes 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] Medicaid DUR Board Arijit Aichbhaumik, R.Ph. Plant City, FL

F. State Contacts State Drug Program Administrator Jerry F. Wells, Bureau Chief Medicaid Pharmacy Services 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] Internet address: ahca.myflorida.com Agency for Health Care Administration Officials

Lois Adams, R.Ph. Orlando, FL Bryan Bognar, M.D. Lutz, FL Leanne Lai, Ph.D. Ft. Lauderdale, FL David Levine, DPM, D.O. Ft. Lauderdale, FL Earlene Lipowski, Ph.D., R.Ph. Gainesville, FL

Alan Levine Secretary Agency for Health Care Administration 2727 Mahan Drive, MS 1 Tallahassee, FL 32308 T: 850/922-3809 F: 850/488-0043 E-mail: [email protected]

Larry Mattingly, D.O. Orange Park, FL

Thomas W. Arnold Deputy Secretary for Medicaid Agency for Health Care Administration 2727 Mahan Drive, MS 8 Tallahassee, FL 32308 T: 850/488-3560 F: 850/488-2520 E-mail: [email protected]

Peggann Zaenger, Pharm.D. Jacksonville, FL

Jeane McCarthy, M.D., Ph.D. St. Petersburg, FL Richard Roberts, Pharm.D. Jacksonville, FL

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National Pharmaceutical Council

Pharmaceutical Benefits 2003

Prescribing Pattern Review Panel

Medicaid Drug Rebate Contacts

Stephen Clark, M.D. Walter Flesner, D.O. Cynthia Griffin, Pharm.D. Dennis Penzell, D.O. John Steele, M.D. George Thomas, M.D.

Regina Wiggins Rebate Coordinator 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]

Pharmaceutical and Therapeutics Committee Robert Blackburn, D.O. (Chair) Spring Hill, FL James Brookins, M.D. Tampa, FL Leanne Lai, Ph.D. Ft. Lauderdale, FL Martin Lazoritz, M.D. Gainesville, FL John Lelekis, R.Ph., M.B.A. Belleair, FL Jeane McCarthy, M.D., Ph.D. St. Petersburg, FL Lorianne McElheney, R.Ph. Palmetto, FL

Claims Submission Contact Kevin Whittington Clinical Program Coordinator ACS State Healthcare 9040 Roswell Road Roswell, GA 850/201-1111 Medicaid Managed Care Contact Melanie Brown-Woofter AHCA Administrator Agency for Health Care Administration 2727 Mahan Drive, MS 8 Tallahassee, FL 32308 T: 850/487-2355 F: 850/410-1676 E-mail: [email protected] Mail Order Pharmacy Program

Dorinda Segovia, Pharm.D. Hialeah, FL Jerry Jean Stambaugh, Pharm.D. Lantana, FL Craig A. Trigueiro, M.D. Bradenton, FL New Brand Name Products Contact Jerry F. Wells 850/487-4441

State has a mail order pharmacy benefit under its diabetes demonstration waiver. Disease Management/Patient Eduction Programs Disease/ Medical State: AIDS/HIV Program Manager: Donna Sabatino Program Sponsor: AIDS Healthcare Foundation Disease/ Medical State: Asthma Program Manager: Lisa Casanta Program Sponsor: Pfizer Health Solutions

Prescription Price Updating First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

Disease/ Medical State: Cardiovascular Disease Program Manager: Lisa Casanta/ Joyce Stickles Program Sponsor: Pfizer Health Solutions/ Life Masters Supported Selfcare, Inc. Disease/ Medical State: Diabetes Program Manager: Nicole Cook/ Diana Schmidt Program Sponsor: DiabetikSmart/ Bristol-Myers Squibb

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National Pharmaceutical Council

Pharmaceutical Benefits 2003

Disease Management Program/Initiative Contact

Florida Hospital Association Wayne N. Nesmith President 306 East College Avenue Tallahassee, FL 32301-1522 T: 850/222-9800 F: 850/561-6230 E-mail: [email protected] Internet address: www.fha.org

Maresa Thomas Medicaid Health Systems Development Agency for Health Care Administration 2727 Mahan Drive, MS 20 Tallahassee,FL 32308 T: 850/487-0737 F: 850/410-1676 E-mail: [email protected] Executive Officers of State Medical and Pharmaceutical Societies Florida Medical Association, Inc. Sandra B. Mortham Executive Vice President and CEO 123 Adams Street Tallahassee, FL 32301 T: 850/224-6496 F: 850/222-8030 E-mail: [email protected] Internet address: www.fmaonline.org Florida Pharmacy Association Michael Jackson, R.Ph. Executive Director 610 North Adams Street Tallahassee, FL 32301-1114 T: 850/222-2400 F: 850/561-6758 E-mail: [email protected] Internet address: www.pharmview.com Florida Osteopathic Medical Association Stephen R. Winn Executive Director The Hull Building 2007 Apalachee Parkway Tallahassee, FL 32301 T: 850/878-7364 F: 850/942-7538 E-mail: [email protected] Internet address: www.foma.org Florida State Board of Pharmacy Dana Droz, R.Ph., J.D. Executive Director 4052 Bald Cypress Way, Bin C04 Tallahassee, FL 32399-3254 T: 850/245-4292 ext. 3600 F: 850/413-6982 E-mail: [email protected] Internet address: www.doh.state.fl.us/mqa/pharmacy

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

GEORGIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Aged

Medically Needy (MN) Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$749,552,199

1,076,904

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adults

$448,422,546 $49,087,789 $337,070,842 $28,579,385 $33,684,530

383,966 30,164 155,825 123,343 74,634

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adults

$16,602,873 $5,773,374 $10,829,303 $196 $0

9,145 3,893 5,248 4 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adults BCCA Women

$79,977,136 $3,873,063 $3,943,280 $60,781,933 $10,358,627 $1,020,233

351,470 2,310 2,328 277,697 68,181 954

$204,549,644

332,323

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $1,073,715,230

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

Georgia-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION Department of Community Health, Division of Medical Assistance.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: Most Federal Legend products with CMS rebates except as otherwise noted. Selected OTC prducts are also covered with prescriptions. Products covered with restrictions: human insulins (Novo Nordisk human insulins and disposable needles and syringe combinations used for insulin administration are preferred); blood glucose test strips (Roche products only); urine ketone test strips; (total parenteral nutrition (21 and younger); and interdialytic parenteral nutrition (21 and younger). Products requiring prior authorization: Marinol; Betaseron, Avonex, Rebif, Leukine, Crinone 8%, Forteo, growth hormone, immune globulin, Fuzeon, Penlac, Epoetin; interferons; lactulose; Neupogen; top.vit.A derivatives; Toradol; Regranex; Viagra; Cialis; Levitra; Oral Diflucan 50mg, 100mg & 200mg; Panretin Gel; Vfend; Zetia; topical testosterone; Insulin Pen Delivery Systems and Cartridges for adults; PPIs; Oral Lamisil; ESRD drugs; Oral Sporanox; Botox; Oxycontin; brand names and multi-source. See PDL for a comprehensive list of covered products (www.dch.state.ga.us-providerspharmacy-PDL). 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 & Mebaral ); DESI drugs; and smoking cessation products. Over-the-Counter Product Coverage: Products covered: with a prescription; analgesics (Ibuprofen suspension) covered with restriction for ages less than 21; loratadine; diphenhydramine; enteric coated asprin; topical products; PIN-X; NIX; Lice-B- Gone; OTC iron and multivitamins; Klout; and meclizine. Products not covered: allergy, asthma, and sinus products other than those listed as covered; digestive products; feminine products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: Most therapeutic categories are covered, including but not limited to the following and their exceptions: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamines; hyperlipidemic agents; antipsychotics; cardiac drugs; chemotherapy agents; prescribed cold medications (partial coverage); 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; anxiolytics, sedatives, and hypnotics; growth hormones; immunoglobulins; COX-II’s; Quinolones; Cephalosporins; Atypical Antipsychotics; ADHD/Ophthalmic Prostaglandin Agents/ Beta Adrenergic Neb/Inhaled Corticosteroids; Bone Ossification; COX-IIs/ CCB’s/ Nasal Steroids; RB’s/ Serotonin Receptor Agonists; Topical Immunodulators; Urinary Tract Antispas modics; and Immunodulators. Therapeutic categories not covered: anoretics; prescribed smoking deterrents; and fertility drugs. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the EPSDT service, the CHIP program, and as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Closed formulary with restrictions on use (quantity level limits), PA, preferred products, and physician profiling. Prior Authorization: State currently has a formal prior authorization procedure with right of appeal. Clients may write to the Medicaid Medical Director to appeal coverage and prior authorization decisions. Prescribing or Dispensing Limitations: Prescription Refill Limit: Maximum of five refills for adults, six for children. May be overridden at POS by the pharmacist for certain maintenance drugs. Monthly Quantity Limit: 34-day supply maximum. Monthly Dollar Limit: $2,999.99 requires an override; >$9,999.99 requires paper claim and a copy of the prescription. Drug Utilization Review On-line PRODUR system implemented in October 2000. State has a 20 member DUR Board (4-6 meetings per year).

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy Payment and Patient Cost Sharing

Department of Community Health

Dispensing Fee: $4.33-$5.13, effective 6/15/02 Non-profit pharmacy: $4.33 (non-generics); $4.83 (generics) For profit pharmacy: $4.63 (non-generics); $5.13 (generics)

Tim Burgess, Commissioner Department of Community Health 2 Peachtree Street, NW, Suite 4043 Atlanta, GA 30303-3159 T: 404/656-4507 F: 404/651-6880 E-mail: [email protected]

Ingredient Reimbursement Basis: EAC = AWP 11% or MFN price. Prescription Charge Formula: Lower of average wholesale price (AWP) minus 11% plus dispensing fee, MAC plus fee, or usual and customary. Maximum Allowable Cost: State imposes a combination of Federal Upper Limits as well as State- Specific Limits on generic drugs. Override requires Prior Approval (Brand Medically Necessary and MedWatch form). Approximately 1,300 drugs on the State-specific MAC list. Incentive Fee: $0.50 for generic drug. Patient Cost Sharing: $0.50 per prescription for generics or preferred drugs. $0.50 - $3.00 for nonpreferred and brand drugs, dependent on the cost of the drug. 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

Mark Trail, Chief Medical Assistance Plans Department of Community Health 2 Peachtree Street, NW, Suite 3733 Atlanta, GA 30303-3159 T: 404/657-1502 F: 866/283-0128 E-mail: [email protected] Prior Authorization Contact Manny Conduah, Pharm.D. Clinical Program Manager Express Scripts, Inc. 300 Colonial Center Parkway Roswell, GA 30076 T: 770/552-3793 F: 770/992-8949 E-mail: [email protected] DUR Contact Pat Zeigler Jeter, M.P.A., R.Ph. DUR Coordinator-Rebate Pharmacist Department of Community Health Division of Medical Assistance 2 Peachtree Street, 37th Floor Atlanta, GA 30303-3159 T: 404/657-9181 F: 404/657-5461 E-mail: [email protected]

State Drug Program Administrator Jerry L. Dubberly, R.Ph., M.B.A. Director, Pharmacy Services Department of Community Health Division of Medical Assistance 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303-3659 T: 404/657-4044 F: 404/657-5461 E-mail: [email protected] Internet address: www.dch.state.ga.us

Medicaid DUR Board William W. Bina, III, M.D. Bruce Welsh Bode, M.D. Joseph R. Bona, M.D. Kimberly S. Carroll, M.D. Jennifer Kent Davis, Pharm.D, M.B.A. Stacy Michael Dickens, R.Ph., CDM Gregory Allen Foster, M.D. Davis Markowitz Greenberg, M.D. Julie Ann Hixson-Wallace, Pharm.D., BCPS Andrew M. Howe, Pharm.D. Marilavinia Jones, M.D. James Russell Lee, Jr., R.Ph., CGP Robyn Loris, Pharm.D. J. Russell May, Pharm.D. Vanessa D. Mickles, Pharm.D. Mathew Perri, III, R.Ph., Ph.D. (Chair)

Georgia-3

National Pharmaceutical Council Raymond Rossenberg, M.D. Richard S. Singer, D.D.S. Cynthia Allen Wainscott Gary M. Williams, M.D. (Vice-Chair) New Brand Name Products Contact Etta L. Hawkins, R. Ph. Medicaid Program Pharmacy Manager Department of Community Health Division of Medical Assistance 2 Peachtree Street, 37th Floor Atlanta, GA 30303-3159 T: 404/657-4044 F: 404/657-5461 E-mail: [email protected] Prescription Price Updating Manny Conduah, Pharm.D. 770/552-3793 Medicaid Drug Rebate Contact Pat Zeigler-Jeter, M.P.A., R.Ph. 404-657-9181 Claims Submission Contact Mary Kay Kruchten Senior Account Manager Express Scripts, Inc. 6625 W. 78th St., BL-0440 Bloomington, MN 55439 T: 952/837-7401 F: 952/837-7184 E-mail: [email protected] Medicaid Managed Care Contact Kathy Driggers Chief of Medicaid Managed Care Department of Community Health 2 Peachtree Street, NW, 36th Floor Atlanta, GA 30303 T: 404/657-7793 F: 404/656-5537 E-mail: [email protected] Disease Management/Patient Education Programs Disease/Medical State: Asthma Program Name: Asthma Disease State Management Program Program Mamager: Charmaine Heard, M.D. Sponsor: Georgia Department of Community Health

Pharmaceutical Benefits 2004 Disease Management Program/Initiative Contact Charmaine Heard, M.D. Medical Director Department of Community Health 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303-3159 T: 404/463-7638 F: 404/657-5461 E-mail: [email protected] Mail Order Pharmacy Benefits None Medical Assistance Advisory Committee 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 David Cook, Executive Director 1330 W. Peachtree Street, NW, Suite 500 Atlant, GA 30309 T: 404/876-7535 F: 404/881-5021 E-mail: [email protected] Internet address: www.mag.org Georgia Pharmacy Association Buddy Harden Executive Vice President 50 Lenox Pointe, NE Atlanta, GA 30324-3170 T: 404/231-5074 F: 404/237-8435 E-mail: [email protected] Internet address: www.gpha.org Georgia Osteopathic Medical Association Holly Barnwell Executive Director 2037 Grayson Highway, Suite 200 Grayson, GA 30017 T: 770/493-9278 F: 770/908-3210 E-mail: [email protected] Internet address: www.goma.org

Georgia-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Georgia State Board of Pharmacy Sylvia L. Bond Executive Director 237 Coliseum Drive Macon, GA 31217-3858 T: 478/207-1686 F: 404/656-0513 E-mail: [email protected] Internet address: www.sos.state.ga.us/plb/pharmacy/ Georgia State Medical Association Price R. Walker, M.D. President P.O. Box 9516 Columbus, GA T: 706/322-6890 F: 706/322-8361 Georgia Hospital Association Joseph A. Parker President 1675 Terrell Mill Road Marietta, GA 30067 T: 770/249-4522 F: 770/955-5801 E-mail: [email protected] Internet address: www.gha.org

Georgia-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Georgia-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

HAWAII A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002* Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$81,453,811

39,320

$97,386,406

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$46,778,608 $12,383,241 $34,312,136 $27,304 $55,927

20,066 7,063 12,263 361 379

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$3,666,738 $2,392,598 $1,274,140 $0 $0

1,958 1,527 431 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$25,699,618 $10,230,442 $15,354,226 $114,950 $0 $0

12,272 6,724 5,215 333 0 0

$5,308,847

5,024

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

Hawaii-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

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

Formulary: Open formulary managed through preferred products and prior authorization. Preferred drug list implemented in 2004. Prior Authorization: State currently has a formal prior authorization procedure. A fair hearing may be requested for appeal of prior authorization decisions.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered as DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products requiring prior authorization: total parenteral nutrition (for home infusion); interdialytic parenteral nutrition (for home infusion); Clorazil; brand products on FUL price list; Betaseron; Oxycontin; and non preferred PDL drugs. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; and digestive products (non-H2 antagonists). Products covered with restrictions; cough and cold preparations (select products, others require prior authorization); digestive products (H2 antagonists-cimatidine and ranitidine, others require prior authorization); topical products (for noncosmetic purposes only); and smoking deterrent products (Xyban only, others require prior authorization).

Vaccines: Vaccines reimbursable as part of EPSDT service, CHIP, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable

Monthly Quantity Limit: Physicians are encouraged to prescribe a 30-day supply or 100 units. State has implemented maximum doses for certain drugs, including Epogen, Liptor, Zofran, and Zomig. Drug Utilization Review PRODUR system implemented in September 1997. State currently has a DUR board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.67, effective May 9, 1990. Ingredient Reimbursement Basis: EAC = AWP10.5%.

Therapeutic Category Coverage: Products covered: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anxiolytics; sedatives; and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents Prior authorization required for: anabolic steroids; anorectics; non-sedating antihistamine drugs; atypical anti-psychotics; prescribed cold medications; proton pump inhibitors; 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 physicians’ offices.

Prescribing or Dispensing Limitations

Prescription Charge Formula: Payment for prescription and OTC drugs listed in the formulary is limited to the State or Federally established MAC price, or Estimated Acquisition Cost (EAC) or AWP10.5% when equal to average selling price plus dispensing fee, or billed amount, whichever is lowest. 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 Approximately 125,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive most of their pharmaceutical benefits through managed care plans. State has specific guidelines for the pharmacy benefit for Medicaid recipients enrolled in managed care plans. Drugs prescribed by dentists are “carved out” of managed care and provided through the State.

Hawaii-2

National Pharmaceutical Council Managed Care Organizations AlohaCare, Inc. Mr. John McComas 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814 808/973-1650 Hawaii Medical Service Association (HMSA) QUEST Administration 818 Keeaumoku Street Honolulu, HI 96814 808/948-0111 Kaiser Foundation Health Plan, Inc. Ms. Virginia Vierra 1441 Kapiolani Blvd, Suite 1600 Honolulu, HI 96814 808/944-0261

F. STATE CONTACTS Medicaid Drug Program Administrator Lynn S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kamokila Boulevard, Suite 506B Kapolei, HI 96707 T: 808/692-8116 F: 808/692-8131 Internet address: www.med-quest.us Prior Authorization Contact Lynn S. Donovan, R.Ph. 808/692-8116 DUR Contact Kathleen Kang-Kaulupali Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kamokila Blvd., Room 506-B Kapolei, HI 96707 T: 808/692-8065 F: 808/692-8131 Medicaid DUR Board Myron Shirasu, M.D. (Internal Medicine) 321 North Kuakini Street, Suite 200 Honolulu, HI 96817 808/523-8611

Pharmaceutical Benefits 2004 Linda Tom, M.D. (Geriatric Medicine), Vice-Chair 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.) DHS/MQD/MSB P.O. Box 700190 Kapolei, HI 96709-0190 808/692-8065 Joy Higa, Pharm.D. (Long Term Care), Chair DHS/MQD/MSB P.O. Box 700190 Kapolei, HI 96709-0190 808/692-8065 Jerry Smead, R.Ph. (Ambulatory Care) Kaiser Parmanente Hawaii Region P.O. Box 700190 Kapolei, HI 96709-0190 808/692-8065 Kerry Kitsu, R.Ph. (Community, chain) DHS/MQD/MSB P.O. Box 700190 Kapolei, HI 96709-0190 808/692-8065 New Brand Name Products Contact Lynn S. Donovan, R.Ph. 808/692-8116 Prescription Price Updating ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 Attn: Hawaii Medicaid T: 800/358-2381 F: 770/730-5198 Medicaid Drug Rebate Contacts Martha Kessinich Drug Rebate Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 800/358-2381 F: 770/730-5198

Gregory E.M. Yuen, M.D. (Psychiatry) 1188 Bishop Street, Suite 806 Honolulu, HI 96813 808/599-5050

Hawaii-3

National Pharmaceutical Council Claims Submission Contact Becky Garrigan Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Attn: Hawaii Medicaid T: 800/358-2381 F: 770/730-5198 E-mail: [email protected] Disease Management/Patient Education Contact Lynn S. Donovan, R.Ph. 808/692-8116

Pharmaceutical Benefits 2004 Shaun F. Young President P.O. Box 1198 Honolulu, HI 96807-1198 T: 808/282-3722 F: 808/432-5535 E-mail: [email protected] Hawwaii Assoc .of Osteopathic Physicians and Surgeons Ronald H. Kienitz, President 545 Ohohia Street Honolulu, HI 96819 T: 808/831-3000 F: 808/834-5763

Mail Order Pharmacy Benefit None Department of Human Services Officials Lillian Koller Director Department of Human Services 1390 Miller Street, Room 209 Honolulu, HI 96813 T: 808/586-4997 F: 808/586-4890 E-mail: [email protected] Angie Payne Acting Administrator, Med-Quest Division Department of Human Services P.O. Box 399 Honolulu, HI 96809-0339 T: 808/692-8050 F: 808/692-8173 E-mail: [email protected]

Hawaii State Board of Pharmacy Lee Ann Teshima Executive Officer P.O. Box 3469 Honolulu, HI 96801 T: 808/586-2694 F: 808/586-2689 E-mail: [email protected] Internet address: www.state.hi.us/dcca/pvl Healthcare Association of Hawaii Richard E. Meiers President and CEO 932 Ward Avenue, Suite 430 Honolulu, HI 96814-2126 T: 808/521-8961 F: 808/599-2879 E-mail: [email protected] Internet address: www.hah.org

Executive Officers of State Medical and Pharmaceutical Societies Hawaii Medical Association Paula Arcena Executive Director 1360 S. Beretania Street, Suite 200 Honolulu, HI 96814-1520 T: 808/536-7702 F: 808/528-2376 E-mail: [email protected] Internet address: www.hmaonline.net

Hawaii Pharmacist Association Hawaii-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

IDAHO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Child Disabled

Medically Needy (MN) Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Aged

Blind/ Disabled

Child

Adult

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$121,780,793

125,537

$72,269,410 $5,418,059 $66,398,243 $270,352 $182,756

23,218 2,078 20,077 842 221

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$12,870,890 $326,033 $384,836 $11,104,429 $1,055,592 $0

63,429 147 178 56,523 6,581 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$36,640,493

38,890

2003** Expenditures Recipients $132,143,091

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

Idaho-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Program, the Vaccines for Children Program, and the State Vaccine Program.

C. ADMINISTRATION Division of Medicaid Idaho Department of Health & Welfare

Unit Dose: Unit dose packaging reimbursable when used in unit dose systems.

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

Formulary Authorization Formulary:None. Pharmacy program is managed through an enhanced prior authorization program (Smart PA), restrictions on use, therapeutic substitution, preferred products, physician profiling, and generic substitution for multi-source products.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin. Products covered through DME: blood glucose test strips; urine keton test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs.

Prior Authorization: State currently has a formal prior authorization procedure and a prior authorization committee. Informal reconsideration of denied prior authorization requests followed by a formal appeal process Written “notice of appeal” required for fair hearing.

OTC Coverage: Products covered: permethrin; Prilosec OTC; oral iron salts; insulin and insulin syringes. Products not covered: allergy, asthma, and sinus products; analgesics, cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products.

Prescribing or Dispensing Limitations Monthly Quantity Limit: Prescription drugs are limited to a 34-day supply. Limits on the number of refills per script and early refills. The following drugs are limited to a 100-day supply: cardiac glycosides, thyroids, prenatal vitamins, nitroglycerin, fluoride, fluoride and vitamin combinations, non-legend oral iron salts and 3 cycles of birth control.

Therapeutic Category Coverage: Therapeutic categories covered: anticonvulsants; anti-psychotics; chemotherapy agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics; antipyretics, and NSAIDs; antibiotics; anticoagulants; anti- depressants; antidiabetic agents; antihistamines; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; contraceptives; ENT-anti- inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; PPIs; Cox IIs; Triptans; long acting opiods; urinary incontinence products; select prenatal vitamins; stimulants; antiemetics; retinoids; topical antiacne products; Provigil; Aldara; Synagis; Regranex; Androgel; Prolastin; Klonopin Wafers; Marinol; Nascobal; Xenical; Penlac; Prozac Weekly; Remeron Sol. Tabs; Restasis; Strattera; Taladine; Thalomid; Triostat; Triptans; Zetia; Xanax XR; Xolair; Vytorin; and brand names of FUL and SMAC drugs. Therapeutic categories not covered: anorectics; prescribed cold medications; and smoking deterrents.

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: Discounted AWP = AWP-12% as determined by First DataBank Data File Service or manufacturer direct price for selected manufacturers. Prescription Charge Formula: Lower of FUL, SMAC or Discounted AWP plus a dispensing fee or provider’s usual and customary price to the general public.

Coverage of Injectables: Injectable medicines reimbursable through the Physician Payment when used in home health care extended care facilities, and physicians offices.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires failure of two generic formulations and submission of a Med Watch form.

Vaccines: Vaccines reimbursable as part of the EPSDT service, The Children’s Health Insurance

Incentive Fee: None. Patient Cost Sharing: No copayment. Idaho-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Board Members: Gary Wilburn, R.Ph. Don Smith, R.Ph. Kent Jensen, R.Ph. Joseph Steiner, Pharm. D. Nancy Mann, M.D. Kevin Clifford, M.D. Robert Ting, M.D.

Cognitive Services: Does not pay for cognitive services.

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

Staff: Tamara Eide, Pharm. D., Dept. Contact Vaughn Culbertson, Pharm.D. Project Dir.

F. STATE CONTACTS Medicaid Drug Program Administrator Ike Gayfield Bureau Chief-Acting Pharmacy Manager Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1829 F: 208/364-1864 E-mail: [email protected] Internet address: www.healthandwelfare.idaho.gov

New Brand Name Products Contact Mary Wheatley, R.Ph. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1832 F: 208/364-1864 E-mail: [email protected]

Prior Authorization Contact

Prescription Price Updating

Ike Gayfield Bureau Chief-Acting Pharmacy Manager 208/364-1829

Katie Ayad, CPhT Technical Records Specialist II Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1970 F: 208/364-1864 E-mail: [email protected]

Pharmacy and Therapeutics Committee Bob Comstock, R.Ph. Catherine Gundlach, Pharm.D. Cindy Bunde, P.A. George Pfoertner, M.D. Phil Peterson, M.D. Richard J. Pines, D.O. (vice-chair) Rick Sutton, R.Ph. Thomas Rau, M.D. Richard Markuson, R.Ph. Selma Gearhardt, Pharm. D. Stephen Montamat, M.D. W. Terry Gipson, M.D. (chair)

Medicaid Drug Rebate Contact Mary Wheatley, R.Ph. 208/364-1832 Claims Submission Contact Electronic Data Systems (EDS) P.O. Box 23 Boise, ID 83707 T: 208/395-2000 F: 208/395-2030

DUR Contact Tamara Eide, Pharm.D., BCPS, FASHP Pharmacy Service Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1821 F: 208/364-1864 E-mail: [email protected]

Medicaid Managed Care Contact State currently has no managed care program. Mail Order Pharmacy Program State currently has no mail order pharmacy program.

Medicaid DUR Board Idaho-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Health and Welfare Department Officials

Mark Leeper Disabled Community

Karl Kurtz, Director Dept. of Health & Welfare 450 West State Street Boise, ID 83720-0036 T: 208/334-5500 F: 208/334-6558 E-mail: [email protected]

Marla Lewis Kootenai County Welfare Department Mary Lou Long St. Luke’s Hospice Randy Robinson Legal Aid- Lewiston

David Rogers, Administrator Department of Health and Welfare Division of Medicaid Americana Building 3232 Elder Street Boise, ID 83705 T: 208/334-5747 F: 208/364-1811 E-mail: [email protected]

Representative Bill Sali Idaho House of Representatives Dick Schultz Division of Health Mark Turner, M.D. Board Certified Physician

Title XIX Medical Care Advisory Committee Judith Baily Idaho Medical Association

Robert VandeMerwe Idah Heatlh Care Association

Bill Bankula Idaho Association of Develomental Disabilities

Gene Wiggers AARP

Senator Skip Brandt Idaho Senate

Marcie Young Idaho Medicaid Program

Leslie Clement Idaho Medical Program

Executive Officers of State Medical and Pharmaceutical Societies Idaho Medical Association Robert Seehusen, CEO P.O. Box 2668 305 West Jefferson Boise, ID 83701 T: 208/344-7888 F: 208/344-7903 E-mail: [email protected] Internet address: www.idmed.org

JoAn Condie Idaho State Pharmacy Association April Crandall Mental Health Provider’s Association Greg Dickerson Mental Health Provider’s Association Bill Foxcroft Idaho Primary Care Association

Idaho State Pharmacy Association JoAn Condie Executive Director P.O. Box 140117 Boise, ID 83714-0117 T: 208/424-1107 F: 208/376-3131 E-mail: [email protected] Internet address: www.idahopharmacy.org

Bonnie Haines Idaho Hospital Association Elizabeth Henry American Indian Tribes Deedra Hunt Aged Community Linda Johann Individual

Idaho-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Idaho State Board of Pharmacy Richard K. Markuson, R.Ph. Executive Director P.O. Box 83720 Boise, ID 83720-0067 T: 208/334-2356 F: 208/334-3536 E-mail: [email protected] Internet address: www.state.id.us.bop Idaho Hospital Association Steven A. Millard President 615 North Seventh Street P.O. Box 1278 Boise, ID 83701 T: 208/338-5100 F: 208/338-7800 E-mail: [email protected] Internet address: www.teamiha.org

Idaho-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Idaho-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

ILLINOIS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$1,222,947,241

1,199,933

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$428,095,975 $50,859,185 $361,528,367 $8,870,084 $6,838,339

211,001 20,248 126,826 48,180 15,747

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$489,678,297 $138,597,747 $270,370,434 $542,742 $80,167,374

314,648 55,634 85,271 839 172,904

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$123,171,941 $4,663,774 $15,624,787 $98,238,455 $4,305,676 $339,249

495,926 2,288 5,122 455,846 32,478 192

OTHER EXPENDITURES/RECIPIENTS*

$182,001,028

178,358

2003** Expenditures Recipients $1,469,190,682

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

Illinois-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

Illinois Department of Public Aid, Division of Medical Assistance.

Formulary: Open formulary. State PDL is managed through restrictions on use, prior authorization, and preferred products.

D. PROVISIONS RELATING TO DRUGS

Prior Authorization: State currently has a formal prior authorization procedure and a Drugs and Therapeutics Committee. Manufacturers can appeal a decision to place products on non-preferred status to the Drug and Therapeutics Committee. Recipients can appeal prior authorization decisions through the Department’s Bureau of Administrative Hearings.

Benefit Design

Drug Benefit Product Coverage: Products covered: total parenteral nutrition; interdialytic; parenteral nutrition; and urine ketone test strips. Products covered with restrictions: (PDL applies): prescribed insulin; disposable needles and syringe combinations used for insulin; and blood glucose test strips. Products not covered: cosmetics; DESI-ineffectives; fertility drugs; and experimental drugs. OTC Coverage: Products covered: analgesics and smoking deterrent products. Products covered with restrictions (PDL applies): allergy, asthma, and sinus products; digestive products (non-H2 antagonist); and topical products. Products not covered: cough and cold preparations; digestive products (H2 antagonists) and feminine products. Therapeutic Category Coverage: Categories covered: anticogulants; anticonvulsants; chemotherapy agents; contraceptives; prescribed smoking deterrents; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, and NSAIDs, antibiotics; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives and hypnotics; cardiac drugs; ENT antiinflammatory agents; prescribed cold medications; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and Cox IIs. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and through both the Prescription Drug Program and physician payment when used in physician offices. PDL rules apply. Vaccines: Vaccines are reimbursable as part of the EPSDT service and the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Prescribing or Dispensing Limitations

Prescription Refill Limit: Maximum of eleven refills. Monthly Quantity Limit: As medically appropriate. Also edit for maximum daily quantities. Drug Utilization Review

PRODUR system implemented in January 1993. Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $3.40 for branded drugs; $4.60 for generics. Ingredient Reimbursement Basis: EAC = B: AWP12%. 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. Override requires prior authorization. (i.e., letter from physician justifying medical need for the brand drugs) Incentive Fee: None. Patient Cost Sharing: $3.00 for branded drugs. No copay for generics. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 140,000 Medicaid recipients were voluntarily enrolled in MCOs in 2003. Recipients receive pharmaceutical benefits through managed care plans. Illinois-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Managed Care Organizations

DUR Contact

Amerigroup Illinois 211 Wacker Drive Suite 1350 Chicago, IL 60606-3101 T: 312/214-0400 F: 312/214-0424

Pamela Bunch 217/524-7478

United Health Care of IL 233 N. Michigan Ave. 8th Fl-12th Fl. Chicago, IL 60607 T: 312/424-4460 F: 312/424-5584 Harmony Health Plan of Illinois 125 South Wacker Drive Suite 2600 Chicago, IL 60606 T: 312/630-2025 F: 312/368-1784 Humana Health Plan 30 South Wacker Drive Suite 3100 Chicago, IL 60606 T: 800/599-1754 F: 312/601-0314 Family Health Network 910 West Van Buren 6th Floor Chicago, IL 60607 T: 312/491-1956 F: 312-491-1175

F. STATE CONTACTS State Drug Program Administrator Pamela Bunch Medicaid Pharmacy Manager Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/524-7478 F: 217/524-7535 E-mail: [email protected] Internet address: www.dpaillinois.com

New Brand Name Products Contact Lisa Voils Special Assistant to Medicaid Deputy Administrator Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/782-2570 F: 217/7825672 E-mail: [email protected] Internet address: www.dpaillinois.com Prescription Price Updating First DataBank 111 Bayhill Dr. San Bruno, CA 94066 650/588-5454 Medicaid Drug Rebate Contact Brandley Wallner, Chief Bureau of Budget and Cash Management Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62702 T: 217/524-7161 F: 217/785-4174 E-mail: [email protected] Claims Submission Contact Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/782-2570 F: 217/782-5672 Medicaid Managed Care Contact Kelly Carter, Chief Bureau of Contract Management Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/524-7478 F: 217/524-7535 E-mail: [email protected]

Prior Authorization Contact Pharmacy Unit Staff 217/524-2570

Illinois-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Mail Order Pharmacy Benefit State has a mail order pharmacy benefit. Any Medicaid beneficiary can choose to receive pharmacy services from a Medicaid enrolled mail order pharmacy. Elderly Expanded Drug Coverage Program Circuit Breaker Pharmacutical Assistance Program Jane LeBegue, Manager Illinois Department of Aging 101 W. Jefferson Springfield, IL 62704 T: 217/524-4009 F: 217/524-9213 E-mail: [email protected] Physician-Administered Drug Program Contact Cheryl Bechner 217/782-5565 Illinois Medicaid Agency Officials Barry Maram, Director Illinois Department of Public Aid 201 South Grand Avenue, East, Third Floor Springfield, IL 62794 T: 217/782-1200 F: 217/524-7120 E-mail: [email protected] Dr. Anne Marie Murphy, Director Medicaid and SCHIP Programs Illinois Department of Public Aid 201 South Grand Avenue, East, Third Floor Springfield, IL 62763-0001 T: 217/782-7570 F: 217/524-5672 Title XIX Medical Care Advisory Committees Robert Anselmo, R.Ph. Wauconda, IL Diane Coleman Forest Park, IL Robyn Gabel Chicago, IL Susan Hayes Gardon Chicago, IL Alvin Holley Chicago, IL Michael Jones Springfield, IL

Kim Mitroka Christopher, IL Leticia Overholt Wilmette, IL Richard Perry, D.D.S. OakPark, IL Eli Pick Des Plaines, IL Pedro A. Poma, M.D. Chicago, IL Stephen Saunders, M.D., M.P.H. Springfield, IL John S. Shlofrock Northfield, IL Deborah Kinsey Springfield, IL Neil Winston, M.D. Chicago, IL Executive Officers of State Medical and Pharmaceutical Societies Illinois State Medical Society Craig A. Backs, M.D. President 20 N. Michigan Avenue, Suite 700 Chicago, IL 60602 T: 312/782-1654 F: 312/782-2023 E-mail: [email protected] Internet address: www.isms.org Illinois Pharmacists Association J. Michael Patton Executive Director 204 West Cook Street Springfield, IL 62704-2526 T: 217/522-7300 F: 217/522-7349 E-mail: [email protected] Internet address: www.ipha.org Illinois Osteopathic Medical Society Elizabeth Forkins Harano Executive Director 142 East Ontario Avenue, Suite 1023 Chicago, IL 60611-2854 T: 312/202-8174 F: 312/202-8224 E-mail: [email protected] Internet address: www.ioms.org

Illinois-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Illinois State Board of Pharmacy Alisha Purchase Board Liaison Illinois Department of Professional Regulation Pharmacy Section 320 West Washington Street Springfield, IL 62786 217/782-0458 Internet address: www.dpr.state.il.us/who/phar.asp Illinois Hospital Association Kenneth C. Robbins President Center for Health Affairs 1151 East Warrenville Road P.O. Box 3015 Naperville, IL 60566 T: 630/276-5400 F: 630/505-9457 E-mail: [email protected] Internet address: www.ihatoday.org

Illinois-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Illinois-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

INDIANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Blind/ Aged Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$636,357,519

490,386

$627,575,345

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$315,484,522 $52,184,587 $217,167,920 $17,736,334 $28,395,681

200,489 16,691 59,727 70,416 53,655

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$56,010,936 $400,906 $1,018,867 $53,085,594 $1,391,683 $113,886

156,012 482 777 145,439 9,198 116

$264,862,061

133,885

TOTAL OTHER EXPENDITURES/RECIPENTS*

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

Indiana-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Ingredient Reimbursement Basis:

Office of Medicaid Policy and Planning

EAC = Brand: AWP-13.5% Generic: AWP-20%

*NOTE WELL—All requests for information by, or on behalf of, drug manufacturers must be made ONLY to: [email protected]

Legend Drug Reimbursement Methodology: Lower/Lowest of:

Phone requests will not be accepted.

1. D. PROVISIONS RELATING TO DRUGS

2. 3. 4.

Benefit Design Drug Benefit Product Coverage: Products covered: All FDA-approved legend drugs from rebating labelers, excluding those products specifically noncovered by State law (e.g., cosmetics; enhancement drugs; and experimental drugs). For more detailed coverage information see www.indianamedicaid.com or www.indiana.pbm.com.

Federal MAC, if applicable, plus a dispensing fee. State 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 as well as State-specific limits on generic drugs. Overide requires “Brand Medically Necessary” plus prior authorization (as of September 2001). Incentive Fee: None.

Over-the-Counter Product Coverage: Indiana has a Medicaid OTC drug formulary. Listed drugs are reimbursed based on State MAC.

Patient Cost Sharing: $3.00 Cognitive Services: None.

Therapeutic Category Coverage: All coverage in accordance with OBRA ’90 & ’93.

E. USE OF MANAGED CARE

Coverage of Injectables: Covered. Vaccines: Covered.

Approximately 246,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans.

Unit Dose: In accordance with OBRA 1990 Requirements. MCFA policy only.

Managed Care Organizations

Formulary/Prior Authorization

Harmony Health Management, Inc. 504 Broadway, Suite 200 Gary, IN 46404-4300 219/880-4400

Formulary: Preferred Drug List (see www.indianapbm.com-pharmacyservices) Prior Authorization: State has a prior authorization program with formal appeal process.

Managed Health Services 1099 N. Meridian Street, Suite 400 Indianapolis, IN 46204 800/944-9661

Prescribing or Dispensing Limitations Monthly Quantity Limit: None.

MDwise 1099 N. Meridian Street, Suite 320 Indianapolis, IN 46204 317/630-2828

Drug Utilization Review

PRODUR system implemented in March 1996. State currently has a DUR Board with a monthly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.90, effective 05/30/02.

AmeriChoice 333 N. Alabama Suite 350 Indianapolis, IN 46204 317/263-0355

Indiana-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

CareSource 151 N. Delaware Street, Suite 1840 Indianapolis, IN 46204 937/531-3000

Health Care Economist Marko Mychaskiw, R.Ph., Ph.D. Pharmacologist Terry Lindstrom, Ph.D.

Molina 8001 Broadway, Suite 400 Merrillville, IN 46410 219/736-9101

Representative from HMO Vicki Perry

Health Care Excel P.O. Box 53380 Indianaplois, IN 53380 317/347-4500

First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 650/588-5454

F. STATE CONTACTS

Medicaid Drug Rebate Contact

Prescription Pricing Updating

State Drug Program*

Martha Kessenich Rebate Accounting Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 770/730-3292 F: 866/759-4100 E-mail: [email protected]

Marc Shirley, R.Ph. Pharmacist Office of Medicaid Policy and Planning Room West 382 Indiana State Government Center South 402 W. Washington Street Indianapolis, IN 46204-2739 T: 317/232-4307 F: 317/232-7382 Internet address: www.indianamedicaid.com

Claims Submission Contact

*NOTE WELL—All requests for information by, or on behalf of, drug manufacturers must be made ONLY to: [email protected]

ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866-322-5960 x4032 F: 866/759-4100

Phone requests will not be accepted.

Medicaid Managed Care Contact

DUR Contact

Managed Care Director Office of Medicaid Policy and Planning 402 W. Washington Street Room W382, MS07 Indianapolis, IN 46204-2739 T: 317/233-4697 F: 317/232-7382

DUR Board Secretary Office of Medicaid Policy & Planning Room W382, Indiana Sate Government Center South 402 West Washington Street Indianapolis, IN 46204 T: 317/232-4307 F: 317/232-7382 Medicaid DUR Board Physicians Neil Irick, M.D. Patricia Treadwell, M.D. John J. Wernert, M.D. Philip N. Eskew, Jr., M.D. (Vice-Chair) Pharmacists Paula J. Ceh, Pharm.D. Brian W. Musial, R.Ph. (Chair) Thomas A. Smith, P.D., M.S., F.A.S.C.P. G. Thomas Wilson, R.Ph., J.D.

Disease Management Program/Initiatives Contact Kathryn A. Moses Director of Chronic Diseases Office of Medicaid Policy and Planning, Indiana State Government Center South, Room W382 402 W. Washington Street Room W382, MS07 Indianapolis, IN 46204 317/233-7346 Mail Order Pharmacy Program None

Indiana-3

National Pharmaceutical Council Administration Officials Mitch Roob, Secretary Family & Social Services Administration Room 461, MS 25 P.O. Box 7083 402 W. Washington Street Indianapolis, IN 46207 T: 317/233-4690 F: 317/233-4693 E-mail: [email protected] Jean M. Labrecque, Director Office of Medicaid Policy and Planning 402 West Washington Street, Room W382 Indianapolis, IN 46204-2739 T: 317/234-2407 F: 317/232-7382 E-mail: [email protected]

Pharmaceutical Benefits 2004 Indiana Optometric Association Marjorie Knotts, O.D. Indiana Pharmaceutical Association Monica Foye Indiana Psychological Association Paul Schneider, Ph.D. Indiana State Chiropractic Association Michael Gallagher Indiana Ambulance Association Vacant Indiana Association for Home Care Todd Stallings Indiana Academy of Ophthalmology Kim Williams

Medicaid Advisory Committee Indiana Council of Community Mental Health Centers James F. Jones Indian State Medical Association Vacant Indiana State Chapter of American Academy of Pediatrics Vacant Indiana Hospital Association L. Richard Gohman Indiana Dental Association Ed Popcheff Indiana State Psychiatric Association Vacant Indiana State Osteopathic Association Edward A. White, D.O. Indiana State Nurses Association Ernest C. Klein Indiana State Licensed Practical Nurses Association Vacant Indiana State Podiatry Association Kirk S. Holston, D.P.M. Indiana Health Care Association John Kukla

Indiana Speech and Hearing Association Susan Holbert Agricultural Interests Vacant Business and Industrial Interests Lula E. Baxter Labor Interests Donald Mulligan, Sr. Insurance Interests Vacant Taxpayer Interests Vacant Parent Advocates (2) Vacant Citizens’ Representatives (3) Vacant Indiana State Senate Represenative Senator Jim Merritt Indiana State House of Representatives (2) Representative William Crawford Representative Jeffrey Espich Indiana State Health Commissioner’s Representative Joe Hunt (ex-officio) Administrator’s Representative Melanie Bella (ex-officio)

Indiana-4

National Pharmaceutical Council Indiana Division of Mental Health and Addiction Representatitve Katy Howard (ex-officio) Indiana Therapeutics Committee Judith Ann Monroe, M.D. Nancy F. Stater, M.D. Michael C. Sha, M.D. (Chair) Stephen Dunlop, M.D. (Vice Chair) James T. Poulos, M.D. Bill Malloy, M.S., Pharm.D., B.C.P.S. Bruce G. Hancock, M.S., R.Ph.

Pharmaceutical Benefits 2004 Indiana Hospital and Health Association Kenneth G. Stella President One American Square Suite 1900 Indianapolis, IN 46282 T: 317/633-4870 F: 317/633-4875 E-mail: [email protected] Internet address: www.inha.org

Executive Officers of State Medical and Pharmaceutical Societies Indiana State Medical Association Richard R. King, J.D. Executive Director 322 Canal Walk Indianapolis, IN 46202-3268 T: 317/261-2060 F: 317/261-2076 E-mail: [email protected] Internet address: www.ismanet.org Indiana Pharmacists Alliance Lawrence J. Sage Executive Vice President 729 N. Pennsylvania, Suite 1171 Indianapolis, IN 46204-1171 T: 317/634-4968 F: 317/632-1219 Email: [email protected] Internet address: www.indianapharmacists.org Indiana Osteopathic Association Michael H. Claphan Executive Director 3520 Guion Road, Suite 202 Indianapolis, IN 46222-1672 T: 317/926-3009 F: 317/926-3984 Email: [email protected] Internet address: www.inosteo.org Indiana State Board of Pharmacy Joshua Bolin Director 402 W. Washington Street, Room W066 Indianapolis, IN 46204-2739 T: 317/234-2067 F: 317/233-4236 Email: [email protected] Internet address: www.in.gov/hpb/boards/isbp

Indiana-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Indiana-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

IOWA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

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‹

‹

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‹

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Inpatient Hospital Care

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Outpatient Hospital Care

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Laboratory & X-ray Service

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Nursing Facility Services

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Physician Services

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Dental Services

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B. EXPENDITURES FOR DRUGS 2002 Expenditures

Recipients

TOTAL

$277,753,942

245,711

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$134,268,348 $16,496,475 $93,745,177 $9,755,348 $14,271,348

112,725 6,468 32,850 42,757 30,650

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$12,771,499 $3,985,026 $7,050,585 $112,460 $1,623,428

5,887 2,020 1,716 300 1,851

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$12,521,471 $420,755 $738,034 $9,796,078 $1,566,604 $0

58,277 677 672 48,440 8,488 0

$118,192,624

68,822

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $331,222,324

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

Iowa-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and through physician payment when used in home health care, extended care facilities, and physicians’ offices.

C. ADMINISTRATION State Department of Human Services, Bureau of Long Term Care.

D. PROVISIONS RELATING TO DRUGS

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Products covered requiring prior authorization: PPIs; dipyridamole; epoetin; filgrastim; vitamins and minerals; ergotamine derivatives; narcotic agonist-antagonist nasal sprays; isotretinoin; oral antifungals; nonparenteral vasopressin derivatives; and Serotonin 5HT1 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; and DESI drugs. For additional information on drug product coverage, see www.iowamedicaidpdl.com.

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: No formulary. Preferred drug list managed through prior authorization. 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:

Over-the-Counter Product Coverage: Products covered with restriction (selected products): allergy, asthma, and sinus products; analgesics; cough and cold preparations; and topical products. Products not covered: digestive products (non-H2 antagonists and H2 antagonists); feminine products; and smoking deterrent products.

Prescribing or Dispensing Limitations: Maximum 30 day supply except select maintenance drugs (90 days) including oral contraceptives, cardiac drugs, hypotensive agents, antidiabetic agents, diuretics, anticonvulsants and thyroid/antithyroid agents. Drug Utilization Review

The Iowa Department of Human Services adopted an administrative rule that permits coverage for certain non-prescription drugs. A list of covered OTC products, may be found at www.iowamedicaidpdl.com.

PRODUR system implemented in July 1997. State currently has a DUR Board that meets 8 times per year.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; antipsychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; amphetamines; antihistamines; anxiolytics, sedatives, and hypnotics; prescribed cold medications; growth hormones; and misc. GI drugs. Partial coverage for: prescribed smoking deterrents. Therapeutic categories not covered: anorectics; drugs for strictly cosmetic purposes and hair growth; fertility drugs; and drugs without signed Medicaid rebate agreements.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.26, effective 7/1/03. Ingredient Reimbursement Basis: EAC = AWP-12%. 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 as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment of $0.50-$3.00 for brand products, depending on the cost of the drug. Iowa-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004 DUR Contact

Cognitive Services: State pays for pharmaceutical case management.

Julie Kuhle, R.Ph. Project Coordinator Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010

E. USE OF MANAGED CARE Approximately 280,000 Medicaid beneficiaries were enrolled in managed care organizations in 2004. This includes both medical managed care organizations and the behavioral care carve-out program. Iowa Medicaid recipients enrolled in managed care receive pharmaceutical benefits through the State fee-forservice payment program.

Medicaid DUR Commission Richard Rinehart, M.D. Connie Connolly, R.Ph. Ronald Miller, M.D., M.B.A. Bruce Alexander, R.Ph., Pharm. D. Sandi Birchem, D.O. Dan Murphy, R.Ph. Julie Kuhle, R.Ph., Project Coordinator Cheryl Clark, R.Ph. Janalyn Phillips, R.Ph. Susan Parker, Pharm.D. Craig Logemann, R.Ph., Pharm.D. Sara Schutte-Schenck, D.O.

Managed Care Organizations Coventry Health Care of Iowa Cheryl Barkau Account Manager 4600 Westown Parkway, Suite 301 West Des Moines, IA 50266 515/225-1234 Magellan Heath Services Joan Discher, COO 2600 Westown Parkway, Suite 200 West Des Moines, IA 50266 515/273-0306

New Brand Name Products Contact Susan L. Parker, Pharm.D. 515/725-1226 Prescription Price Updating

F. STATE CONTACTS

Patrick Danlen POS Account Manager Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010

State Drug Program Administrator Susan L. Parker, Pharm.D. Pharmacy Consultant Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010 E-mail: [email protected] Internet address: www.iowamedicaidpdl.com

Medicaid Drug Rebate Contacts Patrick Danlen 515/725-1226

Prior Authorization Contact

Claims Submission Contact

Sandy Pranger, R.Ph. Clinical Pharmacy Manager Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1272 F: 515/725-1010

Patrick Danlen 515/725-1226 Medicaid Managed Care Contact Dennis Janssen, Chief Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1136 F: 515/725-1010 E-mail: [email protected]

Iowa-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Mail Order Pharmacy Program

Iowa Nurses Association Linda Goeldner 1501 42nd Street, Suite 471 West Des Moines, IA 50266

State currently has a mail order pharmacy program. Participating pharmacies must be enrolled as an Iowa Medicaid provider.

Iowa Medical Society Karla Fultz McHenry Vice President Public Policy and Advocacy 1001 Grand Avenue West Des Moines, IA 50265

Pharmaceutical and Therapeutics Committee Bradley J. Archer, M.D. Cheryl L. Clarke, R.Ph., C.D.M. William R. Doucette, Ph.D. Michael A. Flaum, M.D. Carole A. Frier, D.O. Hayley, L. Harvey, D.D.S., M.S. Susan Purcell, R.Ph., C.G.P. Priscilla Ruhe, M.D. Mary F. Winegardner, PA-C, M.P.A.S.

Opticians Assn. of Iowa Ben Bolar, President McFarland Eye Wear 3600 W. Lincoln Way Ames, IA 50014 Iowa Senate Sen. Maggie Tinsman 3541 E. Kimberly Road Davenport, IA 52807

Iowa Human Services Department Officials Kevin W. Concannon, Director Dept. of Human Services Hoover State Office Bldg., 5th Floor Des Moines, IA 50319-0014 T: 515/281-5452 F: 515/281-7791 E-mail: [email protected]

Senator Jack Hatch 696 18th Street Des Moines, IA 50314 Iowa Dept. of Public Health Dr. Robert Russell Public Health Dental Director Lucas State Office Bldg., 5th Floor Des Moines, IA 50319-0075

Eugene Gessow Medicaid Director Department of Human Services Hoover State Office Building, 5th Floor Des Moines, IA 50319-6242 T: 515/281-6249 F: 515/281-8512 E-mail: [email protected]

Public Representatives Brian Sheesley Director of Research Iowa Health Systems 1415 Woodland, Suite 218 Des Moines, IA 50309-3203

Title XIX Medical Assistance Advisory Council College of Medicine Stacey T. Cyphert, Ph.D. Special Advisor to the President for Science Health Government Relations Senior Assistant Director of University Hospitals and Clinics The University of Iowa Iowa City, IA 52242-1009

John Grush 226 Benton Boone, IA 50036 Jodi Tomlonovic Executive Director Family Planning Council of Iowa 108 Third Street, Suite 220 Des Moines, IA 50309

House of Representatives Joe Hunter # 5 Hunter Lane Bertendorf, IA 52722

Iowa Speech & Hearing Association Barbara Nebel Children’s Therapy Service 950 Office Park Road, Suite 100 West Des Moines, IA 50265

Deborah Berry 241 Madison Street Waterloo, IA 50703

Iowa-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Iowa Hospital Association Tracy Warner 100 E. Grand Avenue, Suite 100 Des Moines, IA 50309-1835

Iowa Optometric Association Gary Ellis 1454 30th Street, Suite 204 West Des Moines, IA 50266-1312

Iowa Health Care Association Steve Ackerson Executive Director 6750 Westown Parkway, Suite 100 West Des Moines, IA 50266-7726

Iowa Podiatric Medical Association Dr. Richard Spencer Spencer Foot & Ankle Clinics 110 East McLane Osceola, IA 50213

Iowa Assn. for Home Care Larry L. Breeding Executive Director 1520 High Street, Suite 203-B Des Moines, IA 50309

Iowa Psychological Society Mark Peltan, Ph.D. Mercy Medical Center-North Iowa 1000 4th Street, SW Mason City, IA 50401-2921

Iowa Chiropractic Society Gene Handley 1605 N. Ankeny Boulevard Ankeny, IA 50021-4159

Iowa Association of Hearing Health Professionals Bev Thomas, Executive Director 1001 Office Park Road, Suite 105 West Des Moines, IA 50265

Iowa Pharmacy Association Thomas Temple, R.Ph., M.S. Executive Vice President and CEO 8515 Douglass, Suite 16 Des Moines, IA 50322

Alliance for the Mentally Ill of Iowa Margaret Stout 5911 Meredith Drive, Suite E Urbandale, IA 50322 Iowa Psychiatric Society James J. Pullen, M.D. 1500 Crown Colony Court, Suite 640 Des Moines, IA 50310

Iowa Assn. of Homes and Services for the Aging Dana Petrowsky President and CEO 1701 48th Street, Suite 203 West Des Moines, IA 50266-6723

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

Iowa Association of Community Providers Michelle Wray Abbe Inc. 800 First Street, NW Cedar Rapids, IA 52405

Iowa Academy of Family Physicians Dr. Dave Carlyle 1215 Duff Avenue Ames, IA 50010

Iowa Dental Association Larry Carl Executive Director 505 5th Avenue, Suite 333 Des Moines, IA 50309

Iowa Physical Therapy Association Lorelie Heisinger Attorney at Law 411 Seasons Drive Waterlou, IA 50701

Iowa Council of Health Care Centers George W. Appleby Carney, Appleby, Neilson and Skinner PLC 303 Locust Street, 400 Homestead Building Des Moines, IA 50309

Iowa Physician Assistant Society Don St. John University of Iowa Behavioral Health 200 Hawkins Drive Iowa City, IA 52242

Iowa Osteopathic Medical Association Leah McWilliams Executive Director 950 12th Street Des Moines, IA 50309-1001

Iowa Association of Nurse Practitioners Kathleen Gradoville, C.P.N.P. Blank School Based Health Center

Iowa-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Iowa Association of Rural Health Clinics Ed Friedmann 1013 1st Street, Box C Redfield, IA 50233

Iowa Osteopathic Medical Association Leah McWilliams Executive Director 950 12th Street Des Moines, IA 50309-1001 T: 515/283-0002 F: 515/283-0355 E-mail: [email protected] Internet address: www.ioma.org

Iowa Occupational Therapy Association Angela Hansen-Abbas 161 315th Street Perry, IA 50220 The ARC of Iowa Vacant

Iowa State Board of Pharmacy Examiners Lloyd K. Jessen Executive Secretary/Director 400 SW 8th Street, Suite E Des Moines, IA 50309-4688 T: 515/281-5944 F: 515/281-4609 E-mail: [email protected] Internet address: www.state.ia.us/ibpe

Des Moines University-Osteopathic Medical Center Vacant Iowa Chapter-Nat’l. Association of Social Workers Jay J. Cayner, A.C.S.W., L.I.S.W. Assistant Hospital Director and Director, Social, Patient, and Family Services University of Iowa Hospitals and Clinics 200 Hawkins Drive Iowa City, IA 52242

Iowa Hospital Association J. Kirk Norris President 100 East Grand Avenue, Suite 100 Des Moines, IA 50309-1835 T: 515/288-1955 F: 515/283-9366 E-mail: [email protected] Internet address: www.ihaonline.org

Iowa Chapter-Am. Academy of Pediatrics Rizwan Z. Shah, M.D. Children’s Health Center 1212 Pleasant Street Des Moines, IA 50309 Iowa State Association of Counties Jill Davisson Supervisor P.O. Box 2957 Clinton, IA 52733 Executive Officers of State Medical and Pharmaceutical Societies Iowa Medical Society Michael Abrams Executive Vice President 1001 Grand Avenue West Des Moines, IA 50265 T: 515/223-1401 F: 515/223-0590 E-mail: [email protected] Internet address: www.iowamedical.org Iowa Pharmacy Association Thomas R. Temple, R.Ph., M.S. Executive Vice President and CEO 8515 Douglas Des Moines, IA 50322-2927 T: 515/270-0713 F: 515/270-2979 E-mail: [email protected] Internet address: www.iarx.org

Iowa-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

KANSAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

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‹

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‹

‹

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Inpatient Hospital Care

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Outpatient Hospital Care

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Laboratory & X-ray Service

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Nursing Facility Services

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Physician Services

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Dental Services

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B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$220,800,602

157,618

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$99,282,654 $9,283,080 $82,468,988 $2,944,174 $4,586,412

61,641 4,097 30,470 15,227 11,847

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$14,150,472 $2,617,843 $9,464,393 $802,606 $1,265,630

10,958 1,251 2,729 3,799 3,179

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$9,866,701 $232,385 $506,336 $8,430,609 $697,371 $0

45,961 170 266 39,595 5,930 0

$97,500,775

39,058

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $228,920,787

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

Kansas-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

State Department of Social and Rehabilitation Services, Health Care Policy Division.

Formulary: State currently maintains a formulary along with a Preferred Drug List (PDL). (See www.srskansas.org/hcp/medicalpolicy/pharma for a listing of PDL categories.) The formulary/ PDL is managed through restrictions on use, preferred products, and physician profiling. Prior authorization required for non-PDL products.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin and syringe combinatios used for insulin. Products covered under DME: disposable needles used for insuline (prior authorization required); blood glucose test strips; urine ketone test strips; total parenteral nutrition; and 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; digestive products; feminine products; and topical products. Products covered with restrictions: allergy, asthma, and sinus products (some-for children); cough and cold preparations; and smoking deterrent products (patches covered for limited time period). Products not covered: OTC nutritional supplements. 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; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: prescribed cold medications; prescribed smoking deterrents. Prior authorization required for: anorectics; growth hormones; triptans; nasal steroids; PPIs, statins; coxII inhibitors; wound products; brand name drugs with bioequivalent generics; and all non-preferred drugs. 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 program when used in physician offices. Vaccines: Vaccines reimbursed as part of the Vaccines for Children Program.

Prior Authorization: State currently has a formal prior authorization procedure. The individual appealing may request an administrative hearing to appeal a prior authorization decision 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 Monthly Prescription Limit: 5 single source scripts/month. 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: 31-day supply. Other: Narcotics, Viagra, Cialis, Levitra, Ketorolac, Toradol Relenza and triptans have other specific limits. Drug Utilization Review PRODUR system implemented in November 1996. State currently has a DUR Board that meets every two months. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.40, effective 7/1/02. Ingredient Reimbursement Basis: EAC Brand, = AWP-13%. Generics, AWP-27%. IV fluids, AWP50%. 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.

Unit Dose: Unit dose packaging not reimbursable. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits on generic drugs. Kansas-2

National Pharmaceutical Council Override requires prior authorization and MedWatch form. Incentive Fee: None. Patient Cost Sharing: A recipient copay charge of $3.00 (effective 7/02) applies to each new and refill prescription not specifically exempted under Federal regulations. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 105,000 Medicaid Recipients were enrolled in MCOs in FY 2003. Recipients receive most pharmaceutical benefits through managed care plans. However, Hemophilia drugs and certain other specific compounds are carved out of managed care. Managed Care Organizations First Guard Health Plans 4001 Blue Pkwy, Suite 300 Kansas City, MO 64130 888/827-5698

F. STATE CONTACTS State Drug Program Administrator Mary H. Obley, Pharmacist Pharmacy Program Manager Health Care Policy Division Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-South Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected] Internet address: www.srskansas.org/hcp/medicalpolicy/pharmacy New Brand Name Products Contact Mary H. Obley, Pharmacist 785/296-3981 Prior Authorization Contact Mary H. Obley, Pharmacist 785/296-3981

Pharmaceutical Benefits 2004 DUR Contact Vicki L. Schmidt, Pharmacist Health Care Policy Division Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-South Topeka, KS 66612-1570 T: 785/274-4287 F: 785/267-7670 E-mail: [email protected] DUR Board Michael Burke, M.D., Ph.D. (Chair) Barry Sarvis, R.Ph. Dennis W. Grauer, Ph.D. John Lowdermilk, R.Ph. R. Kevin Bryant, M.D., C.M.D Brenda Schewe, M.D. Roger D. Unruh, D.O. Linda Kroeger, ARNP, FNP Prescription Price Updating Mary H.Obley, Pharmacist 785/296-3981 Medicaid Preferred Drug List Advisory Committee Michael Burke, M.D., Ph.D. Kristen H. Fink, Pharm.D. Robert Haneke, Pharm.D. Glenn Harte, Pharm.D. Vernon Mills, M.D. Brenda Schewe, M.D. Donna Sweet, M.D. Dennis Tietze, M.D. Kenneth Mishler, Pharm.D. Medicaid Drug Rebate Contacts Policy: Mary H. Obley, Pharmacist Pharmacy Program Manager 785/296-3981 Technical: Cindy LaClair Rebate Analyst EDS 3600 SW Topeka Boulevard, Suite 204 Topeka, KS 66611 T: 785/274-5987 F: 785/267-7687 E-mail: [email protected] Claims Submission Contact EDS 3600 SW Topeka Boulevard, Suite 204 Topeka, KS 66611 T: 785/274-4200 F: 785/267-7687

Kansas-3

National Pharmaceutical Council Medicaid Managed Care Contact Debra Bachmann, R.N. IV Manager, HealthWave Title XIX Department of Social and Rehabilitation Services Health Care Policy Division 915 SW Harrison, Rm. 651-South Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected] Mail Order Pharmacy Program None Social and Rehabilitation Services Department Officials Gary J. Daniels, Acting Secretary Department of Social and Rehabilitation Services Docking State Office Bldg. 915 SW Harrison, 6th Floor Topeka, KS 66612 T: 785/296-3271 F: 785/296-2173 E-mail: [email protected] Scott C. Brunner, Director Medical Policy/Medicaid Department of Social and Rehabilitation Services 915 SW Harrison, 5th Floor Topeka, KS 66612 T: 785/296-3773 F: 785/296-0509 E-mail: [email protected] Medical Care Advisory Committee Contact Nialson Lee, B.S.N., M.H.A Administrator, Health Care Systems and Policy/ Medical Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-S Topeka, KS 66612-1570 T: 785/296-4753 F: 785/2964813 E-mail: [email protected]

Pharmaceutical Benefits 2004 Kansas Pharmacists Association John L. Kiefhaber, Executive Director 1020 SW Fairlawn Road Topeka, KS 66604-2275 T: 785/228-2327 F: 785/228-9147 E-mail: [email protected] Internet address: www.kansaspharmacy.org Kansas Association of Osteopathic Medicine Charles Wheelen, Executive Director 1260 SW Topeka Boulevard Topeka, KS 66612 T: 785/234-5563 F: 785/234-5564 E-mail: [email protected] Internet address: www.ostheopathic-kansas.org Kansas State Board of Pharmacy Debra Billingsley, Executive Secretary Landon State Office Building 900 Jackson, Room 560 Topeka, KS 66612-1231 T: 785/296-4056 F: 785/296-8420 E-mail: pharmacy@ pharmacy.state.ks.us Internet address: www.accesskansas.org/pharmacy Kansas Hospital Association Tom Bell President 215 Southeast Eighth Avenue P.O. Box 2308 Topeka, KS 66603-2308 T: 785/233-7436 F: 785/233-6955 E-mail: [email protected] Internet address: www.kha-net.org

Executive Officers of State Medical and Pharmaceutical Societies Kansas Medical Society Vernon Mills, President 623 SW 10th Avenue Topeka, KS 66612 T: 785/235-2383 F: 785/235-5114 E-mail: [email protected] Internet address: www.kmsonline.org

Kansas-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

KENTUCKY

1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

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‹

‹

‹

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Inpatient Hospital Care

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Outpatient Hospital Care

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Laboratory & X-ray Service

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Nursing Facility Services

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Physician Services

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‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$661,409,737

489,416

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$466,733,445 $37,620,114 $388,598,724 $16,398,100 $24,116,507

245,159 15,676 140,619 55,943 32,921

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$21,156,198 $5,714,524 $4,820,219 $2,774,925 $7,846,530

20,816 2,250 1,765 8,607 8,194

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Woman

$47,434,056 $595,876 $1,664,425 $41,796,311 $3,377,444 $0

155,883 627 981 136,285 17,990 0

$126,086,038

67,558

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $685,229,661

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

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

Kentucky-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Department for Medicaid Services, within the Cabinet for Health Services.

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 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; syringe combinations used for insulin. Products covered with restrictions (i.e., require prior authorization): total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles used for insulin; blood glucose test strips; and urine ketone test strips.

Formulary: Closed Formulary. The Kentucky Medicaid Program maintains a closed formulary and covers all rebated products. The State manages the formulary through a variety of techniques including the exclusion of products based on contracting issues, restrictions on use, prior authorization, algorithms, and preferred products. Prior authorization required for many brand name products with generic equivalents.

C. ADMINISTRATION

Over-the-Counter Product Coverage: Products covered with restrictions (i.e., require prior authorization): allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (H2 and non-H2 antagonists); feminine products and topical products. Products not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; anoretics; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; prescribed cold medications; growth hormones; hypotensive agents; misc. GI drugs; topical steroids; erectile dysfunction products; Leukotriene inhibitors; Synagis; Respigam; Zetia; CNS stimulants for ADHD and other disorders; Avodart; Proscar; anti-fungals for nails; Serotonin 5HT1 Receptor Agonosts; GCSF products; Recombinant Human Erythropoietin agents; and Xolair. Therapeutic categories not covered: prescribed smoking deterrents; agents for cosmetic purposes or hair growth and agents to promote fertility. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through both the Prescription Drug Program and physician payment when used in physician offices. Reimbursement is limited to antineoplastic drugs with “J” codes in physician offices, several antibiotics, Depo-Provera for birth control.

Prior Authorization: State currently has a prior authorization procedure. 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 30 day supply unless the prescriber requests an exception to his policy. Drug Utilization Review

PRODUR system implemented in 1987. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $4.51, effective 1/16/01. Ingredient Reimbursement Basis: EAC = AWP-12%. Prescription Charge Formula: Reimbursement consists of the lowest of: (1) the usual and customary charge; (2) the FMAC, if any, plus a dispensing fee; or (3) the EAC plus a dispensing fee, or (4), SMAC if any, plus a dispensing fee.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Necessary,” “Brand Medically Necessary,” or Prior Authorization. Incentive Fee: None. Patient Cost Sharing: $1.00 Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE

R. Michael Cayce, R.Ph. Garry A. Hamm. R.Ph. Dan Yeager, R.Ph. (non-voting) DUR Contact Debra Bahr, R.Ph. Pharmacy Services Program Manager Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected] Drug Management Review Advisory Board

Approximately 153,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through both the State and managed care plans. Medications prescribed by a board certified psychiatrist are carved out of managed care. Managed Care Organization Passport Health Plan Joyce Schifano, Executive Director

F. STATE CONTACTS Medicaid Drug Program Administrator Dan Yeager, R.Ph. Interim Pharmacy Director Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected] Internet address: www.chs.ky.us/dms Prior Authorization Contact Dan Yeager, R.Ph. 502/564-7940 Pharmacy and Therapeutics Advisory Committee Robert C. Hughes, M.D. (Chair) Truman Perry, M.D. Dale E. Toney, M.D. Christopher A. Cunha, M.D. Carol Lee Steltenkamp, M.D., M.B.A. Connie Gayle White, M.D. (Vice-Chair) Naren N. James, M.D. Carmel Wallace, M.D. Andrew T. Cooley, M.D. Janet Poe Wright, Pharm.D.

Richard Arnold, M.D. (Chair) Phillip Bressoud, M.D. Phillip Baier, O.D. Patricia Freeman, R.Ph., Ph.D. James S. Davis, M.D. Karen Barnes, M.D. Janice Sullivan, M.D. Madonna H. Ringswald, D.O. John Spencer, Pharm.D. Sandra Thornbury Jacob Hutti, Pharm.D. Misha Glendening, A.R.N.P. Pam Koob, Ph.D. A.R.N.P. Scott Moody, Pharm.D. (non-voting) New Brand Name Products Contact Debra Bahr, R.Ph. 502/564-7940 Prescription Price Updating UNYSIS Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860 Medicaid Drug Rebate Contact Betsy Scott Department for Medicaid Services CHR Building, 6 E-B 275 East Main Street Frankfort, KY 40621 T: 502/564-5472 F: 502/564-3232 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Claims Submission Contact

Bettie Speicher Weyler Donnie Wilhite John Withrow

Unisys Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

Executive Officers of State Medical and Pharmaceutical Societies Kentucky Medical Association William T. Applegate Executive Vice President 4965 U.S. Highway 42, Suite 2000 Louisville, KY 40222-6301 T: 502/426-6200 F: 502/426-6877 E-mail: [email protected] Internet address: www.kyma.org

Medicaid Managed Care Contact Lorraine Dumas Department of Medicaid Services CHR Building, 6 E-C 275 E. Main St Frankfort, KY 40621 T: 502/564-4923 F: 502/564-0223 E-mail: [email protected] Mail Order Pharmacy Program Sate currently has a mail order pharmacy program. Mail order pharmacy program is open to all Medicaid recipients. Must use a pharmacy that participates in the Kentucky Medicaid Program. Department for Medicaid Services Officials James W. Holsinger, Jr., M.D., Secretary Cabinet for Health and Family Services CHR Building, 5 C-A 275 East Main Street Frankfort, KY 40621 T: 502/564-6786 F: 502/564-0274 Shannon Turner, Acting Commissioner Department for Medicaid Services Sixth Floor 275 East Main Street Frankfort, KY 40621 T: 502/564-4321 F: 502/564-0509 State Advisory Council on Medical Assistance Frank Butler Elvin E. Dodson Bob Gray William P. Mattingly Marsha Mercer Marcia Morgan Chester A. Nava Jr., D.P.M. (chair) Kristin V. Paul, R.N. Vickie L. Prichard William K. Rich, D.M.D Leslie Rogers Nancy Steele Suzanne Watkins, O.D. William T. Watkins, M.D.

Kentucky Pharmacists Association Mike Mayes, FACHE Executive Director 1228 U.S. Highway 127 South Frankfort, KY 40601 T: 502/227-2303 F: 502/227-2854 E-mail: [email protected] Internet address: www.kphanet.org Kentucky State Board of Pharmacy Jeffrey L. Osman Interim Executive Director 23 Millcreek Park Frankfort, KY 40601-9230 T: 502/573-1580 F: 502/573-1582 E-mail: [email protected] Internet address: www.pharmacy.ky.gov Kentucky Society of Health-System Pharmacists Dwaine K. Green Executive Vice President One Quality Street Lexington, KY 40507-1428 T: 859/433-3641 F: 859/257-7297 E-mail: [email protected] Internet address: www.kshp.org Kentucky Osteopathic Medical Association J. Tom Underwood, Executive Director 1501 Twilight Trail Frankfort, KY 40601 T: 502/223-5322 F: 502/223-4937 Internet address: www.koma.org

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Kentucky Hospital Association Michael T. Rust President 2501 Nelson Miller Parkway Louisville, KY 40223 T: 502/426-6220 F: 502/426-6226 E-mail: [email protected] Internet address: www.kyha.com Kentucky Association of Health Care Facilities Rich Miller, President 9403 Mill Brook Road Louisville, KY 40223 T: 502/425-5000 F: 502/425-3431 E-mail: [email protected] Internet address: www.kahcf.org

Kentucky-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Kentucky-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

LOUISIANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$682,557,080

689,973

$827,713,132

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$417,471,680 $102,349,922 $273,812,613 $18,906,266 $22,402,879

265,688 40,066 117,247 65,315 43,060

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$9,814,798 $3,765,950 $3,341,251 $80,023 $2,627,574

6,976 1,276 1,654 313 3,733

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$103,843,466 $2,384,492 $2,321,558 $93,885,845 $5,251,571 $0

327,000 1,455 1,603 295,607 28,335 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$151,427,136

90,309

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

Louisiana-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Prescribing or Dispensing Limitations

Department of Health and Hospitals.

Prescription Refill Limit: Permitted as indicated by physician within 6 months and not to exceed 5 refills.

D. PROVISIONS RELATING TO DRUGS

Monthly Quantity Limit: New prescription must be 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. Monthly limit of 8 prescriptions per recipient.

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 as DME: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; experimental drugs; and cough and cold preparation. Over-the-Counter Product Coverage: Products not covered (with limited exceptions): 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/products covered: all except cosmetics; cough and cold preparations; DESI drugs; and experimental drugs. Prior authorization required for: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; and sympathominetics (adrenergic). Partial coverage for: anoretics; prescribed cold medications.

Other: Viagra and other drugs to treat impotence are limited to a quantity of 6 pills per month. Drug Utilization Review PRODUR system implemented in April 1996. State has a DUR Board that meets quarterly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.45 on average to $5.77 maximum, effective 7/1/94. Ingredient Reimbursement Basis: EAC = AWP13.5% for Independent Pharmacies. AWP-15% for chain pharmacies. (Chain pharmacies are defined as ownership of more than fifteen (15) Medicaid enrolled pharmacies under common ownership.) Prescription Charge Formula: Medicaid reimbursement for pharmacy services will be based on the lower of: 1.

Coverage of Injectables: Injectable medicines reimbursable under the Prescription Drug Program and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable at cost as part of EPSDT service and Vaccines for Children Program.

3.

Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization

4.

Formulary: Open formulary with preferred drug list (PDL). General management techniques include restrictions on use, prior authorization, and preferred products. Prior Authorization: State currently has a formal prior authorization procedure but no method of appealing a prior authorization decision.

2.

AWP minus 13.5% for independent pharmacies and AWP minus 15% for chain pharmacies 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. Louisiana Maximum Allowable Costs (LMAC) or the Federal Upper Limit plus the dispensing fee. AWP for multi-source drugs when lower than FUL or LMAC. The provider’s usual and customary charge to other payors.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Approximately 800 drugs are listed on the State-specific MAC list. Override requires “Brand Necessary” or “Brand Medically Necessary.” Incentive Fee: None.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Patient Cost Sharing: $ 0.50 - $3.00 copayment depending of the cost of the prescription, effective 7/13/95.

Baton Rouge, LA Susan Hinton, Pharm.D. New Orleans, LA

Cognitive Services: Does not pay for cognitive services

Richard A. Soileu, Pharm.D. New Iberia, LA

E. USE OF MANAGED CARE

Paul Staab, M.D. Marrero, LA

Does not use MCOs to deliver services to Medicaid recipients.

Charmaine Venters, M.D. Baton Rouge, LA

F. STATE CONTACTS

New Brand Name Products Contact

State Drug Program Administrator

Mary J. Terrebonne, P.D. 225/342-9768

Mary J. Terrebonne, Pharm.D. Pharmacy Director Department of Health & Hospitals 1201 Capital Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected] Internet address: www.lamedicaid.com Department of Health and Hospital Administration Officials Frederick P. Cerise, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821-0629 T: 225/342-9500 F: 225/342-9508 E-mail: [email protected] Ben A. Bearden, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821-9030 T: 225/342-3891 F: 225/342-9508 E-mail: [email protected]

Prescription Price Updating Maggie Vick Unisys 8591 United Plaza Boulevard, Suite 300 Baton Rouge, LA 70809 T:225/237-3251 F: 225/237-3334 E-mail: [email protected] Medicaid Drug Rebate Contacts Technical: Timothy Williams, 225/342-5194 Policy: Mary J. Terrebonne, 225/342-9768 Disputes: Katie Landry, 225/342-0427 Claims Submission Contact Doug Hasty Project Manager Unisys 8591 United Plaza Blvd., Suite 300 Baton Rouge, LA 70809 T: 225/237-3391 F: 225/237-3334 E-mail: [email protected] Mail Order Pharmacy Program State has a voluntary mail order pharmacy program open to all Medicaid recipients.

DUR Contact

Medicaid Managed Care Contact

Mary J. Terrebonne, Pharm.D. 225/342-9768

Mary J. Terrebonne, P.D. 225/342-9768

DUR Board Edwin Adams, Pharm.D. Monroe, LA Ken Ardoin, Senior Manager Westlake, TX Sylvia Heidingsfelder, M.D.

Medical Care Advisory Committee Sandra C. Adams (Chairperson) Brenda Armstrong Ralph D. Balentine Dr. Donnie Batie Francine Boyles Dr. Floyd A. Buras Jennifer Canaday

Louisiana-3

National Pharmaceutical Council Marcia Daigle Sen. John L. “Jay” Dardenne, Jr. Partricia DeMichele Daily Dupre, Jr. Wanda Ellis Warren Hebert Paul Hildreth Robert D. Horneman Amelia Lafont Rep. Jerry L. “Luke” LeBlane Dr. Charles Clinton Lewis Kay Marcel Dr. Robert L. Marier June Peach Dr. Keith M. Perrin Ms. Bea Piker Tawana Pounders Sean Prados Willa Rawls Sen. J. “Tom” Schedler Greg Scott Mary Scott Richard “Andy” Soileau Mary Tonore Dr. Leonard Weather, Jr. Linda Welch Ms. Ann Williamson Medicaid Pharmaceutical and Therapeutics Committee Mr. Joseph Adams, R.Ph. Mandeville, LA Donnie Batie, M.D. Baton Rouge, LA Frederick P. Cerise, M.D. Baton Rouge, LA Richard Doskey, M.D. Metairie, LA Blackwell B. Evans, Jr., M.D. New Orleans, LA Conchetta W. Fulton, M.D. New Orleans, LA

Larry Hebert, M.D. Baton Rouge, LA Charles W. Jastram, Jr., R.Ph. New Orleans, LA Ernest W. Kinchen, M.D. Lafayette, LA Michael L. Kudla, M.D.

Pharmaceutical Benefits 2004 Lake Charles, LA James R. Lang Many, LA W. Chapman Lee, M.D. Baton Rouge, LA Catherine A. McDonald, M.D. Lafayette, LA Marty R. McKay, R.Ph. Alexandria, LA John B. Pope, M.D. Shreveport, LA Carolyn Tackett Hammond, LA Ann Henderson Tilton, M.D. New Orleans, LA Roxane Townsend, M.D. Baton Rouge, LA Leonard J. Weather, Jr., M.D. New Orleans, LA Lolie C. Yu, M.D. New Orleans, LA Pharmacy Advisory Committee Ken Ardoin Michelle Wolf-Selfo Scott Napoli Lamar Pritchard Allan Brinkhaus Clovis Burch Horace Bynum Wayne T. Harris Tim Jacks Ruth “Cookie” Jean Ricky Guidry Carl Aron Andy Soileau Marty McKay Jerry Wallace Kirt Soileau Kyle Ardoin Sandy Blake Peggy Van Jessica Monroe David Osborn Leann Causey Executive Officers of State Medical and Pharmaceutical Societies

Louisiana-4

National Pharmaceutical Council Louisiana State Medical Society Dave L. Tarver Executive Vice President 6767 Perkins Road, Suite 100 Baton Rouge, LA 70808 T: 225/763-8500 F: 225/763-6122 E-mail: [email protected] Internet address: www.lsms.org

Pharmaceutical Benefits 2004 Baton Rouge, LA 70898-0720 T: 225/928-0026 F: 225/923-1004 E-mail: [email protected] Internet address: www.laha.org

Louisiana Osteopathic Medical Association Nancy Bellemare, D.O. President 215 Friedrichs Avenue Metairie, LA 70005-4516 800/621-1773, ext. 8188 E-mail: [email protected] Internet address: www.loma-net.org Louisiana State Board of Pharmacy Malcolm J. Broussard Executive Director 5615 Corporate Boulevard, Suite 8E Baton Rouge, LA 70808-2537 T: 225/925-6496 F: 225/925-6499 E-mail: [email protected] Internet address: www.labp.com Louisiana Pharmacists Association Donna Mayeux Executive Director 234 Joseph Street P.O. Box 14446 Baton Rouge, LA 70802 T: 225/408-2730 F: 225/381-7424 E-mail: [email protected] Internet address: www.louisianapharmacists.com Louisiana Society of Health-System Pharmacists Tommy Mannino President 8550 United Plaza Boulevard, Suite 1001 Baton Rouge, LA 70809 T: 225/922-4520 F: 225/922-4611 E-mail: [email protected] Internet address: www.lshp.org

Louisiana Hospital Association John A. Matessino President and CEO 9521 Brookline Avenue Louisiana-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Louisiana-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MAINE

1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS

TOTAL

2002 Expenditures Recipients $250,331,526 224,664

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adults

$108,471,190 $11,438,641 $82,399,461 $2,552,699 $12,080,389

60,793 4,719 28,595 10,124 17,355

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adults

$6,010,987 $4,459,097 $1,488,866 $19,514 $43,510

2,105 1,633 372 40 60

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$54,374,249 $14,428,282 $27,044,560 $12,399,263 $502,144 $0

60,765 8,407 9,424 41,078 1,856 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$81,475,100

101,001

2003** Expenditures Recipients $268,547,563

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

1

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

Maine-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

State Department of Human Services, Bureau of Medical Services.

Formulary: Closed formulary with restrictions on use, prior authorization, and preferred products. (The Maine Care Preferred Drug List can be seen at www.ghsinc.com.)

D. PROVISIONS RELATING TO DRUGS Benefit Design 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 (with HbA1e values); urine ketone test strips. Products not covered: cosmetics; fertility drugs; experimental drugs; total parenteral nutrition; interdialytic parenteral nutrition (part of procedure); vitamins and vitamin preparations (except pregnancy); and injectables when oral medication is available for equally effective treatment.

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization may be obtained in the case of necessary exceptions. Fair hearing appeal of denials through the Office of Administrative Hearings. State has no formal prior authorization committee. Prescribing or Dispensing Limitations Monthly Prescription Limit: 5 brand name scripts per month Monthly Quantity Limit: 34-day for brand name drugs and 90 days for generic drugs per month.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; digestive products (non H2 antagonists); topical products; and feminine products. Products covered with restrictions: H2 antagonists (limited coverage after 1/1/01); smoking deterrent products (by Rx only). Products not covered: cough and cold preparations.

Prescription Refill Limit: maximum of 11 refills per prescription.

Therapeutic Category Coverage: Therapeutic categories covered: (prior authorization required): anabolic steroids; analgesics, antipyretics, and NSAIDs; anoretics; antibiotics anticoagulants; anticonvulsants; anti-depressants; 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; prescribed smoking deterrents; sympathominetics (adrenergic); thyroid agents; injectable arthritis medications; acute migraine medications; Synvisc; antifungals; EPO; Synagis, and erectile dysfunction products.

Pharmacy Payment and Patient Cost Sharing

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and in physician offices.

Incentive Fee: None.

Vaccines: Vaccines reimbursable based on cost as part of the EPSDT service (admin. fees), as part of the Children’s Health Insurance Program, and as part of the Vaccines for Children Program.

Drug Utilization Review PRODUR system implemented in 1995. State currently has a DUR Board that meets 12 times per year.

Dispensing Fee: $3.35 - $12.50 (Effective 1/20/2004) Ingredient Reimbursement Basis: EAC = AWP15%. Prescription Charge Formula: Lowest of usual and customary, FUL, AWP-15%, or Maine MAC. Maine MAC includes 1,232 drug products in addition to FUL products. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires prior authorization.

Patient Cost Sharing: $2.50 per script up to a maximum of $25.00 per month. Cognitive Services: State does not pay for cognitive services.

Unit Dose: Unit dose packaging not reimbursable.

Maine-2

National Pharmaceutical Council

E. USE OF MANAGED CARE State does not use managed care organizations to provide service services to Maine Medicaid beneficiaries. Approximately 150,000 Medicaid recipients were enrolled in primary care case management in 2003. Medicaid recipients enrolled in primary care case management receive pharmaceutical benefits through the State.

F. STATE CONTACTS State Drug Program Administrator Bruce McClenahan Pharmacy Unit Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 866/796-2463 F: 207/287-8601 E-mail: [email protected] Internet address: www.maine.gov/bms

Pharmaceutical Benefits 2004 Andy Cook, M.D. Laurie Roscoe, R.Ph. Reggie Gracie, R.Ph. Jessica R. Osterheld, M.D. New Brand Name Products Contact Bruce McClenahan 866/796-2463 Prescription Price Updating Bruce McClenahan 866/796-2463 Medicaid Drug Rebate Contact Rossi Rowe Insurance Recovery/ Drug Rebate Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1838 F: 207/287-1788 E-mail: [email protected]

Prior Authorization Contact Bruce McClenahan 866/796-2463 Pharmacy Advisory Group Alroy Chow, M.D. Tim Clifford, M.D. Edward Ervin, M.D. Jabbar Fazeli, M.D. Thomas Hayward, M.D. Lawrence Losey, M.D. James Raczek. M.D. John Grotton, R.Ph. Paula Knight, R.Ph. Dennis Lyons, R.Ph. Steve McPike, R.Ph. Gary Roy, R.Ph.

Claims Submission Contact Marcia Pykare Manager of Data Processing Goold Health Systems P.O. Box 1090 Augusta, ME 04332-1090 T: 207/622-7153 F: 207/623-5125 E-mail: [email protected] Medicaid Managed Care Contact Bruce McClenahan 866/796-2463 Mail Order Pharmacy Program

DUR Contact

State has a mail order Medical Assistance pharmacy program.

Bruce McClenahan 866/796-2463

Disease Management Program/Initiative Contact

Maine DUR Board

Bruce McClenahan 866/796-2463

Timothy Clifford, M.D. William Alto, M.D. Michael Ouellette, R.Ph. James Demosthenes, R.Ph. Julie Pease, M.D. Syd Sewall, M.D. Gary Roy, R.Ph. Robert Weiss, M.D. Jabbar Fazeli, M.D.

Maine-3

National Pharmaceutical Council Human Services Department Officials John R. Nichols, Commissioner Department of Human Services State House Station 11 221 State Street Augusta, ME 04333-0011 T: 207/287-1921 F: 207/287-3005 E-mail: [email protected] Internet address: www.maine.gov/dhs Christine Gianopoulos, Acting Director Bureau of Medical Services Department of Human Services State House Station 11 442 Civic Center Drive Augusta, ME 04333-0011 T: 207/287-2674 F: 207/287-2675 E-mail: [email protected] Internet address: www.maine.gov/bms Executive Officers of State Medical and Pharmaceutical Societies Maine Medical Association Gordon Smith, Esq. Executive Vice President Frank O. Stred Building P. O. Box 190 Manchester, ME 04351 T: 207/622-3374 F: 207/622-3332 E-mail: [email protected] Internet address: www.mainemed.com

Pharmaceutical Benefits 2004 Maine Board of Pharmacy Kelly L. Mclaughlin Office of Licensing and Registration 35 State House Station Augusta, ME 04333 T: 207/624-8620 F: 207/624-8637 E-mail: [email protected] Internet address: www.maine.us/prf/olr/ Maine Hospital Association Steve Michaud President 33 Fuller Road Augusta, ME 04330 T: 207/622-4794 F: 207/622-3073 E-mail: [email protected] Internet address: www.themha.org Maine Health Care Association Richard A. Erb President and CEO 317 State Street Augusta, ME 04330 T: 207/623-1146 F: 207/623-4080 E-mail: [email protected] Internet address: www.mehca.org

Maine Pharmacy Association Polly LeVasseur, President 127 Pleasant Hill Road Scarborough, ME 040704 T: 207/396-5340 F: 207/396-5341 E-mail: [email protected] Internet address: www.mparx.com Maine Osteopathic Association Kellie Miller, M.S. Executive Director 693 Western Avenue, #1 Manchester, ME 04351 T: 207/623-1101 F: 207/623-4228 E-mail: [email protected] Internet address: www.mainedo.org

Maine-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MARYLAND A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$320,313,995

181,101

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult Unknown

$177,261,021 $36,606,581 $134,096,117 $3,025,652 $3,484,807 $47,864

84,026 16,294 51,811 7,317 8,561 43

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$79,642,289 $51,496,176 $22,625,834 $3,390,163 $2,130,116

36,286 18,001 11,248 2,816 4,221

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$43,538,946 $14,076,445 $17,110,997 $11,615,154 $736,350 $0

47,229 8,115 5,620 26,700 6,794 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$19,871,739

13,560

2003** Expenditures Recipients $429,589,193

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

Maryland-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION State Department of Health and Mental Hygiene, Division of Health Care Financing.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: legend drugs; prescribed insulin; disposable needles and syringe combinations used for insulin; total parenteral nutrition; and interdialytic parenteral nutrition (must be medically necessary). Products covered under DME: blood glucose test strips; urine ketone test strips. Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs; prescriptions and injections for central nervous system stimulants; 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 certain other items as specified in the State's Medicaid Plan. Over-the-Counter Product Coverage: Products covered: contraceptives; oral ferrous sulfate; allergy, asthma, and sinus products (specific preferred products); analgesics (enteric coated aspirin only); H2 antagonists (specific preferred products). Products not covered: cough and cold preparations; non H2 antagonists; feminine products (except contraceptives); 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; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: prescribed legend cold medications; prescribed legend smoking deterrents. Prior authorization required for: growth hormones; synagis; and nutritional supplements for tube-fed recipients. 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 both the Prescription Drug Program and 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: Open formulary with a preferred drug list (PDL) managed through preferred products and prior authorization. Prior authorization required for all non-PDL products. Prior Authorization: State currently has a prior authorization procedure. A general appeals procedure is available when a physician can provide additional information to justify the medical necessity of a particular product. Preauthorization is needed for any prescription with a usual and customary charge exceeding $400. Prior authorization is also needed for early refills, nutritional supplements, brand medically necessary and excessive quantities. Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of eleven refills. The original prescription and its refills may not exceed a 360-day supply. 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.

*Prior authorization required for all drugs not on the preferred drug list.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy Payment and Patient Cost Sharing

Helix Family Choice, Inc. 8094 Sandpiper Circle Baltimore, MD 21236 410/933-3021

Dispensing Fee: $2.69 - $4.69 as of July 2004. $2.69 - non-PDL Brand. $3.69 - PDL Generic $3.69-Nursing Home non-PDL Brand $4.69 - Nursing Home PDL or Generic

Jai Medical Systems, Inc. 5010 York Road Baltimore, MD 21212 410/433-2200 Maryland Physicians Care MCO 7104 Ambassador Road Suite 100 Baltimore, MD 21244 410/277-9710

Ingredient Reimbursement Basis: Estimated Acquisition Cost (EAC) equals/lowest of: 1. Wholesale Acquisition Cost (WAC) plus 8%. 2.

Direct cost plus 8%.

3.

Distributor's price plus 8%.

4.

Average Wholesale Price (AWP) minus 12%.

Prescription Charge Formula: Reimbursement will be the lower of: (1) the calculated ingredient cost plus a dispensing fee; (2) the usual and customary fee.

Diamond Plan Coventry Health Care of Delaware, Inc. Ambassador Center D 7125 Ambassador Road Suite 100 Woodlawn, MD 21244 866/212-5305 Priority Partners MCO Baymeadow Industrial Park 6704 Curtis Court Glen Burnie, MD 21060 410/424-4400

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 MedWatch form documenting the reason for the request. Incentive Fee: $1.00 higher for dispensing a lower cost multisource product. Patient Cost Sharing: Copayment = $2.00 for Brands not on the PDL; $1.00 for generics and drugs on the PDL. Does not apply to managed care, family planning, nursing home residents, recipients under 21 years old, or generic drugs.

Ameri Group 857 Elkridge Landing Road, #300 Linthicum, MD 21090 410/859-5800

F. STATE CONTACTS State Drug Program Administrator

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 471,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through the State and managed care plans. (Mental health drugs are “carved out” of managed care.)

Joseph L. Fine Director Maryland Pharmacy Program DHMH, Office of Operation, Eligibility, and Pharmacy 201 West Preston Street, Room 407 Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 E-mail: [email protected] Internet address: www.dhmh.state.md.us/mma/mpap

Managed Care Organizations United Healthcare Family First Lyndwood Executive Center 6095 Marshalee Drive Elkridge, MD 21075 800/368-3400 Maryland-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Brand Name Products Contact

Medicaid Drug Rebate Contacts

Frank T. Tetkoski, P.D. Pharmacy Consultant Maryland Pharmacy Program DHMH 201 West Preston Street, Room 409 Baltimore, MD 21201 T: 410/767-1460 F: 410/333-5398 E-mail: [email protected]

Policy: Jeffrey Gruel 410/767-1455

Prior Authorization Contact Tuong A. Nguyen, P.D. Consultant Pharmacist Maryland Pharmacy Program DHMH 201 W. Preston St. Baltimore, MD 21201 T: 410/767-5701 F: 410/333-5398 E-mail: [email protected] DUR Contact Jeffrey Gruel Deputy Director DHMH Maryland Pharmacy Program 201 W. Preston Street, Room 408 Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 E-mail: [email protected]

Disputes: Barry Pope Rebate Pharmacist First Health Services Corporation Montgomery Park Business Center 1800 Washington Boulevard, Suite 420 Baltimore, MD 21230 T: 410/263-7048 F: 410/263-7062 Claims Submission Contact First Health Services Corporation Division of Claims Processing James Demery Manager, Pharmacy Services 201 W. Preston St. Baltimore, MD 21201 T: 410/767-6028 F: 410/333-5398 E-mail: [email protected] Medicare Managed Care Contact Jim Gardner Chief Division of Health Choice Management 201 W. Preston St., Room 208 Baltimore, MD 21201 410/767-1482

DUR Board

Mail Order Pharmacy Benefit

Deneen Bowlin, M.D. John Boronow, M.D., (Vice Chair) Stephen Wienner, R.Ph. Steven J. Kravet, M.D. Lori Fantry, M.D., M.P.H. Vincent Ferrari, R.Ph. (Chair) Steve A. Anifowshe, R.Ph. Elliot S. Gottlieb, R.Ph. Bernard J. Lechman, R.Ph.

None

Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578

Expanded Drug Coverage Program Joseph L. Fine 410/767-1455 Maryland Medical Advisory Committee Kevin Lindamood Cynthia Demarest Lori Doyle Mark Levi Miguel McInnis Jacquelyn Rose, M.D. Lynda E. Meade Irona Pope Virginia Keane, M.D. Frances Knoll Thomas Myers David Ward Grisele Booker Michael Douglas Maryland-4

National Pharmaceutical Council Harry S.Goodman, D.M.D. Peter Perini Charles I. Shubin, M.D. Josie Thomas Kate Tumulty, R.N. John J. Hafer Delores G. Kelley Eric M. Bromwell Robert A. Costa Shirley Nathan-Pulliam Kevin M. McGuire (ex-officio)) Pamela W. Barclay (ex-officio) Frances B. Phillips, R.N. (ex-officio)

Health and Mental Hygiene Department Officials S. Anthony McCann, Secretary Department of Health and Mental Hygiene 201 W. Preston Street Baltimore, MD 21201 T: 410/225-6505 F: 410/161-6489 E-mail: [email protected] John Folkemer Deputy Secretary for Health Care Financing Department of Health and Mental Hygiene 201 W. Preston Street Baltimore, MD 21201 T: 410/767-5806 F: 410/333-7505 E-mail: [email protected] Medical Assistance Staff Committee Members Joseph Fine, Director Maryland Pharmacy Program 201 W. Preston Street Baltimore, MD 21201 Frank Tetkoski, P.D. Services and Preauthorization Maryland Pharmacy Program 201 W. Preston Street, Room 409 Baltimore, MD 21201 Phil Cogan Preferred Drug List Maryland Pharmacy Program 201 W. Preston Street Baltimore, MD 21201

Pharmaceutical Benefits 2004 Executive Officers of State Medical and Pharmaceutical Societies Maryland State Medical Society T. Michael Preston Executive Director 1211 Cathedral Street Baltimore, MD 21201 T: 410/539-0872 F: 410/547-0915 E-mail: [email protected] Internet address: www.medchi.org Maryland Association of Osteopathic Physicians Randi Braman President 3603 Southside Drive Phoenix, MD 21131 T: 410/683-8100 F: 410/683-8200 E-mail: [email protected] Internet address: www.maops.com Maryland Pharmacists Association Howard Schiff Executive Director 650 West Lombard Street Baltimore, MD 21201 T: 410/727-0746 F: 410/727-2253 E-mail: [email protected] Internet address: www.marylandpharmacist.org Maryland Society of Health-System Pharmacists Bruce Gordon, President 8480-M Baltimore National Pike, Ste. 252 Ellicott City, MD 21042 T: 410/465-9975 F: 410/465-7073 E-mail:[email protected] Internet address: www.mshp.org Maryland State Board of Pharmacy LaVerne G. Naesea Executive Director 4201 Patterson Avenue Baltimore, MD 21215-2299 T: 410/764-4755 F: 410/358-6207 E-mail: [email protected] Internet address: www.dhmh.state.md.us/pharmacyboard

Tuong Nguyen, P.D. Maryland Pharmacy Program 201 W. Preston St. Baltimore, MD 21201

Maryland-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Association of Maryland Hospitals and Health Systems Calvin M. Pierson, President 6820 Deerpath Road Elkridge, MD 21075-6234 T: 410/379-6200 F: 410/379-8239 E-mail: [email protected] Internet address: www.mdhospitals.org Health Facilities Association of Maryland Adele Wilzack, President 7060 Oakland Mills Road, Suite M Columbia, MD 21046 T: 410/792-4390 T: 301/490-8413 F: 410/792-4617 E-mail: [email protected] Internet address: www.hfam.org

Maryland-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MASSACHUSETTS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged Blind/ Child Adult Disabled

Aged

Medically Needy (MN) Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$952,790,939

659,626

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$464,206,888 $50,116,594 $381,221,991 $9,530,411 $23,337,892

225,282 26,400 126,509 43,726 28,647

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$38,451,280 $16,299,026 $22,152,254 $0 $0

16,745 8,974 7,771 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$272,625,841 $67,368,453 $165,887,679 $36,950,055 $2,419,654 $0

220,501 29,267 49,900 136,765 4,569 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$177,506,930

197,098

2003** Expenditures Recipients $946,210,618

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

Massachusetts-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION Executive Offices of Health and Human Services, Division of Medical Assistance, Office of Medicaid.

D. PROVISIONS RELATING TO DRUGS Benefit Design

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and through both the Prescription Drug Program and physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT service if not provided by the Department of Public Health.

Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered (except in LTC facilities): disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips. Products covered with restrictions: total parenteral nutrition (prior authorization required). Products not covered: cosmetics; fertility drugs; experimental drugs; interdialytic parenteral nutrition; DESI drugs; legend vitamins not on Drug List, non-legend drugs not on Drug List; propoxyphene-containing products and products rated by the FDA as lessthan-effective.

Unit Dose: Unit dose packaging not reimbursable.

Over-the-Counter Product Coverage: Products covered with restrictions (limited OTC list-generics only- not covered in LTC facilities): allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products and topical products. Products not covered: smoking deterrent products.

Prescription Refill Limit: Prescription may be refilled, as authorized, with a limit of up to 11 refills from the filling of the original prescription

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; chemotherapy agents; contraceptives; estrogens, and thyroid agents. Prior authorization required for: growth hormones; Erythropoeitin; and selected biotech drugs. Partial coverage for: prescribed cold medications. Partial coverage with prior authorization required for: analgesic, antipyretics, and NSAIDs; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; ENT anti-inflammatory agents; hypotensive agents; misc. GI drugs; and sympathominetics (adrenergic). Therapeutic categories not covered: anoretics; prescribed smoking deterrents; weight loss or gain medications; medications to treat sexual dysfunction; experimental or investigational drugs; and less than effective drugs.

Monthly Dollar Limits: None.

Formulary/Prior Authorization Formulary: Open formulary managed through restrictions on use, prior authorization, and physician profiling. Prior Authorization: State currently has a prior authorization procedure. A recipient may file a request for a fair hearing to appeal a prior authorization decision. Prescribing or Dispensing Limitations

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.

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 (basic) plus $1.00-$2.00 additional for compounded Rx’s, effective 1/1/2004. Ingredient Reimbursement Basis: EAC = WAC + 5%.

Massachusetts-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prescription Charge Formula: Payment shall be for the lowest of:

F. STATE CONTACTS State Drug Program Administrator

1.

EAC plus dispensing fee;

2.

The usual and customary charge defined as the lowest price charged or accepted by a provider for any payor;

3.

FULP plus a dispensing fee; or

4.

MULP 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” plus prior authorization. Patient Cost Sharing: Copayment = $3.00 (Brands) and $1.00 (Generics), effective 2/1/2004. Exceptions include: −

Institutionalized patients

−

Children under age 19

−

Pregnant and postpartum women

−

Hospice care

−

Family planning items

Paul L. Jeffrey Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210-5865 E-mail: [email protected] Internet Address: www.state.ma.us/dma Prior Authorization Contact Paul L. Jeffrey 617/210-5319 DUR Contact Paul L. Jeffrey 617/210-5319 New Brand Name Products Contact Christopher T. Burke Policy Analyst Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5592 F: 617/210-5597 E-mail: [email protected]

Incentive Fee: None. Cognitive Services: Does not pay for cognitive services.

Prescription Price Updating

E. USE OF MANAGED CARE Approximately 270,000 Medicaid recipients were enrolled in MCOs in FY 2003 with another 324,000 enrolled in pre-paid health plans (PHPs) and 304,000 in PCCM.. Recipients receive pharmaceutical benefits through managed care plans. Enrollees in the PCCM program receive pharmaceutical benefits from the State. Managed Care Organization Primary Care Clinician Plan Boston Medical Center HealthNet Plan Fallon Community Health Plan Neighborhood Health Plan Network Health

First Data Bank 111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578 Medicaid Drug Rebate Contacts Martha Kessenich Rebate Analyst ACS State Healthcare 365 North Ridge Road, Suite 400 Atlanta, GA 30350 T: 800/358-2381 F: 770/730-5198 Claims Submission Contact ACS State Healthcare 365 North Ridge Road, Suite 400 Atlanta, GA 30350 T: 800/358-2381 F: 770/730-5198

Massachusetts-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Managed Care Contact

Massachusetts Osteopathic Society, Inc. William Seeglitz President P.O. Box 487 Winchester, MA 01890 781/721-9900 E-mail: [email protected]

Kate Willrich-Nordahl, Director Massachusetts Health MCO Program Department of Public Health 250 Washinton Street, 6th Floor Boston, MA 02108 T: 617/624-5693 F: 617/624-5698 E-mail: [email protected]

Massachusetts Board of Registration in Pharmacy Charles R. Young Executive Director 239 Causeway Street, Suite 500 Boston, MA 02114 T: 617/727-9953 F: 617/727-2197 E-mail: [email protected] Internet address: www.state.ma.us/reg/boards/ph

Mail Order Pharmacy Benefit None Executive Offices of Health and Human Services Ronald Preston, Secretary Executive Office of Health and Human Services One Ashburton Place, Room 1109 Boston, MA 02108 T: 617/727-0077 F: 617/727-5134 E-mail: [email protected] Internet address: www.masscares.org Beth Waldman, Director Division of Medicaid Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5690 F: 617/210-5697 E-mail: [email protected] Internet address: www.state.ma.us/dma

Massachusetts Society of Health-Systems Pharmacists Trisha LaPointe President 500 West Commings Park, Suite 3475 Woburn, MA 01801 T: 781/937-0175 F: 781/937-0176 E-mail: [email protected] Internet address: www.mashp.org

Executive Officers of State Medical and Pharmaceutical Societies

Massachusetts Hospital Association Ronald M. Hollander President Five New England Executive Park Burlington, MA 01803 T: 781/272-8000 F: 781/272-0466 E-mail: [email protected] Internet address: www.mhalink.org

Massachusetts Medical Society Corrine Broderick Executive Vice President 860 Winter Street Waltham Woods Corporate Center Waltham, MA 02451-1411 T: 781/893-4610 F: 781/893-9136 E-mail: [email protected] Internet address: www.massmed.org

Massachusetts Extended Care Federation Abraham E. Morse President 2310 Washington Street Newton Lower Falls, MA 02462 T: 617/558-0202 F : 617/558-3546 E-mail: [email protected] Internet address: www.mecf.org

Massachusetts Pharmacists Association Carmelo Cinqueonce Executive President 500 West Cummings Park, Suite 3475 Woburn, MA 01801 T: 781/933-1107 F: 781/933-1109 E-mail: [email protected]

Massachusetts-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MICHIGAN A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$674,898,273

577,785

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$307,384,075 $37,319,381 $258,120,665 $3,777,147 $8,166,882

196,929 18,461 128,992 21,894 27,582

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$38,770,065 $9,855,071 $15,916,105 $2,502,941 $10,495,948

50,815 5,560 5,625 10,303 29,327

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$39,642,975 $2,192,596 $16,721,292 $16,792,151 $3,936,936 $0

125,509 1,436 5,860 91,350 26,863 0

$289,101,158

204,532

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $758,266,989

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

Michigan-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 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.

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 (prior authorization for equipment and supplies) and interdialytic parenteral nutrition (prior authorization required for self administration). 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 (antihistamines); analgesics (payment limits, considered part of nursing home per diem reimbursement); non-H2 antagonists (payment limits, considered part of nursing home per diem reimbursement); H2 antagonist (payment limits); feminine products (payment limits); topical products; and smoking deterrent products (tablets, patches and gum-quanity limits per beneficiary per year). 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; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: anabolic steroids (prior authorization required); prescribed cold medications; and prescribed smoking deterrents (prior authorization required). Therapeutic categories not covered: anoretics.

Vaccines: Vaccines reimbursable at cost plus a fee/or vaccine replacement as part of the EPSDT service, the Children Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Closed formulary and a preferred drug list (PDL). (See www.michigan.fhsc.com for listing of drugs on the PDL.) Formulary managed through restrictions on use, prior authorization requirements, age/gender editing, and clinical editing for “first line” therapy. Prior Authorization: State currently has a formal prior authorization procedure. Beneficiaries have a right to appeal prior authorization decisions on the basis of medical necessity. Informal review of additional information can be conducted at any time. Beneficiaries also have fair hearing rights to appeal denial of coverage for an excluded product. Prescribing or Dispensing Limitations Prescription Refill Limit: None Monthly Quantity Limit: Prescribed quantities should be limited to an amount necessary to keep the recipient supplied during the therapy regimen. Quantity limits for selected pharmaceuticals (e.g., sedative hypnotics). 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: $2.50, ($2.75 for long-term care) effective Nov. 1, 2004 Ingredient Reimbursement Basis: 1-4 stores = AWP-13.5%, 5 or more stores = AWP-15.1%.

Michigan-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prescription Charge Formula: Reimbursement for legend drugs is limited to the lower of: 1.

AWP-13.5% for 1 to 4 stores & AWP-15.1% for 5 or more stores or LTC, plus dispensing fee minus patient copay, or

2.

The MAC rate, plus dispensing fee, or

3.

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. Override requires “Brand Medically Necessary” and prior authorization. Incentive Fee: None. Patient Cost Sharing: Effective Jan. 1, 2005, ambulatory recipients age 21 and older are required to pay a $3.00 copayment for brand name drugs and a $1.00 copayment for generic drugs. Effective March 1, 2005, Adult Benefit Waiver (ABW) beneficiaries are required to pay a $1.00 copayment for each prescription drug dispensed. 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 pregnancy-related 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.

Managed Care Organizations Cape Health Plan 26711 Northwestern Highway, Suite 300 Southfield, MI 48034 T: 248/386-3000 F: 888/354-2273 Internet address: www.capehealth.com Community Choice Michigan 2369 Woodlake Drive Okemos, MI 48864 T: 517/349-9922 F: 800/390-7102 Internet address: www.ccmhmo.org Great Lakes Health Plan, Inc. 17117 W. Nine Mile, Suite 1600 Southfield, MI 48075 T: 248/559-5656 F: 800/903-5253 Internet address: www.glhp.com Health Plan of Michigan, Inc. 17515 W. Nine Mile, Suite 650 Southfield, MI 48075 T: 248/557-3700 F: 888/437-0606 Internet address: www.hpmich.com HealthPlus Partners, Inc. 2050 S. Linden Road P.O. Box 1700 Flint, MI 48501-1700 T: 810/230-2132 F: 800/322-9161 Internet address: www.healthplus.com M-Caid 2301 Commonwealth Blvd. Ann Arbor, MI 48105-1573 800/527-5549 Internet address: www.mcare.org McLaren Health Plan G 3245 Beacher Road, Suite 200 Flint, MI 48532 888/327-0671 Internet address: www.mclarenhealthplan.org

E. USE OF MANAGED CARE Approximately 900,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans. Psychotropics, antidepressants, anti-mania, central nervous system stimulants, and other select classes of drugs are administered by managed care organizations but paid for by the State.

Midwest Health Plan 5050 Schaefer Road Dearborn, MI 48126 T: 313/581-3700 F: 888/654-2200 Internet address: www.midwesthealthplan.com

Michigan-3

National Pharmaceutical Council Molina Healthcare of Michigan 100 W. Big Beaver Road, Suite 600 Troy, MI 48084 T: 248/925-1700 F: 888/898-7969 Internet address: www.molinahealthcare.com OmniCare Health Plan, Inc. 1333 Gratiot Suite 400 Detroit, MI 48207 T: 313/465-1518 F: 866/711-6664 Internet address: www.omnicarehealthplan.com PHP- MM Family Care P.O. Box 30377 Lansing, MI 48909-7877 T: 517/364-8400 F: 800/661-8299 Internet address: www.phpmm.org PHP of Southwest Michigan, Inc. 106 Farmers Alley, Suite 300 Kalamazoo, MI 49007 T: 269/341-7200 F: 800/261-0084 Internet address: www.ibahealthplans.com Priority Health, Government Programs, Inc. 1231 E. Beltline, NE Grand Rapids, MI 49525-4501 T: 616/942-0954 F: 888/975-8102 Internet address: www.priority-health.com ProCare 3956 Mt. Elliot Detroit, MI 48207 T: 313/925-4607 F: 866/776-0891 Total Health Care 3011 W. Grand Blvd., Suite 1600 Detroit, MI 48202 T: 313/871-2000 F: 800/826-2862 Internet address: totalhealthcareonline.com Upper Peninsula Health Plan 228 W. Washington Street Marquette, MI 49855 T: 906/225-7500 F: 800/835-2556 Internet address: www.uphp.com

Pharmaceutical Benefits 2004

F. STATE CONTACTS State Drug Program Administrator Giovannino A. Perri, M.D. Chief Medical Consultant MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Internet address: www.michigan.gov/mdch New Brand Names Products Contact Donna Hammel Office of Medical Affairs MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Prior Authorization Contact First Health Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696 DUR Contact Debera Eggleston, M.D. MDCH- Medical Services Administration 400 S. Pine St. P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 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

Michigan-4

National Pharmaceutical Council 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 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, D.O. 1421 W. Mt. Hope Lansing, MI 48910 Prescription Price Updating First Health Services Corporation T: 877/864-9014 F: 888/603-7696 Medicaid Drug Rebate Contacts Technical: Dawn Parsons Pharmacy Consultant MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Audits: First Health Services Corporation 877/864-9014 Claims Submission Contact First Health Services Corp T: 877/864-9014 F: 888/603-7696

Pharmaceutical Benefits 2004 Medicaid Managed Care Contact Sue Moran, Chief Bureau of Medicaid Operations and Quality MDCH- Medical Services Administration 400 S. Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Disease Management Program/Initiative Contact Giovannino A. Perri, M.D. 517/335-5181 Mail Order Pharmacy Program None Elderly Expanded Drug Coverage Contact Thomas Chisnell MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Michigan Dept. of Community Health (MDCH) Janet Olszewski, Director MCDH/ Lewis Cass Building 320 South Walnut Street Lansing, MI 48913 T: 517/335-0267 F: 517-373-4288 E-mail: [email protected] Paul Reinhart, Deputy Director Michigan Department of Community Health 320 South Walnut Street Lansing, MI 48913 T: 517/241-7882 F: 517/335-5007 E-mail: [email protected]

Michigan-5

National Pharmaceutical Council 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, R.Ph. (Alternate) Addresses for all members: Medical Services Administration Michigan Department of Community Health 400 S. Pine Street Lansing, MI 48933 Michigan Pharmacy and Therapeutics Committee Robert P. Coffey, Pharm.D. Debera Hayes Eggleston, M.D. Robert Ernst, M.D. Jonathan G.A. Henry, M.D. Annette Paul, R.Ph. Giovannino A. Perri, M.D. Max Robins, D.O. Luenetta Jackson, Pharm.D. Justus Jackson, M.D. Dean Van Loo, Pharm.D. Richard Slaughter, M.Sc., FCCP Executive Officers of State Medical and Pharmaceutical Societies Michigan State Medical Society William E. Madigan, Executive Director 120 West Saginaw Street East Lansing, MI 48823 T: 517/337-1351 F: 517/337-2490 E-mail: [email protected] Internet address: www.msms.org

Pharmaceutical Benefits 2004 Michigan Osteopathic Association Dennis Paradis, Executive Director 2445 Woodlake Circle Okemos, MI 48864 T: 800/657-1556 F: 517/347-1566 E-mail: [email protected] Internet address: www.moa-do.com Michigan State Board of Pharmacy Roberta Armstrong, Chairperson Bureau of Health Services 611 W. Ottawa, First Floor P.O. Box 30670 Lansing, MI 48909-8170 517/335-0918 Internet address: www.michigan.gov/cis/ Michigan Health and Hospital Association Spencer C. Johnson, President 6215 West St. Joseph Highway Lansing, MI 48917 T: 517/323-3443 F: 517/323-0946 E-mail: [email protected] Internet address: www.mha.org Health Care Association of Michigan Reginald Carter, Ph.D. President and CEO P.O. Box 80050 Lansing, MI 48908 T: 517/627-1561 F: 517/627-3016 E-mail: [email protected] Internet address: www.hcam.org

Michigan Pharmacists Association Larry D. Wagenknecht, CEO 815 N. Washington Avenue Lansing, MI 48906-5198 T: 517/484-1466 F: 517/484-4893 E-mail: [email protected] Internet address: www.michigan pharmacists.org

Michigan-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MINNESOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged Blind/ Child Adult Disabled

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$294,838,630

190,577

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$161,712,804 $6,759,656 $147,337,336 $2,746,917 $4,868,895

84,306 4,182 50,623 15,191 14,310

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$56,712,355 $19,826,418 $35,344,455 $328,726 $1,212,756

27,809 13,434 9,576 1,389 3,410

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$1,833,878 $170,597 $451,718 $996,671 $211,724 $3,168

9,033 285 302 6,704 1,732 10

$74,579,593

69,429

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $276,731,202

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

Minnesota-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION Minnesota Department of Human Services, Health Care Management Division, 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; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: drugs used for cosmetic purposes; drugs used for hair growth; fertility drugs; appetite supressants; and experimental drugs. Products covered with limitations: sildenafil; methylphenidate (including d-methylphenidate); Adderall; pemoline; dextroamphetamine; vitamins; and cough and cold preparations. Prior authorization required for: alglucerase; Interferon Alfa N-3; Interferon Gamma-1B; Ondansetron; Granisetron; omeprazole (including s-omeprazole); sertraline 25mg and 50mg tablets; Butulinum Toxin Types A & B; valdecoxib; Esomeprazole; dolasetron; celecoxib; rofecoxib; escitalopram 10mg; citalopram 10mg and 20mg; paroxetine 10mg; modafinil 100mg; trandolapril; trandolapril/verapamil combination; quinapril; quinapril/HCTZ; amlodipine/benazepril; benazepril/HCTZ; benazepril; fosinopril; and fosinopril/HCTZ. (For a complete list of products requiring prior authorization, contact the Pharmacy Program at The Minnesota Department of Human Services, Health Care Management Division, Medical Assistance Program at http://www.dhs.state.mn.us/provider/pharm/.) Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products (antifungals covered); topical products; and smoking deterrent products. Products covered with limitations: vitamins; ocular lubricants; pediculocides; and activated charcoal and ipecac. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anticoagulants; anticonvulsants; antidepressants; anti-psychotics; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; prescribed smoking deterrents; and thyroid agents.. Prior authorization required for: analgesics, antipyretics, and NSAIDS; antibiotics; antidiabetic agents; antihistamines; antilipemic agents;

anxiolytics, sedatives; and hypnotics; cardiac drugs; hypotensive agents; misc. GI drugs; and sympathominetics (adrenergic). Therapeutic categories not covered: anoretics; DESI drugs. Coverage of Injectables: Injectable medicines reimbursable through the pharmacy benefit when dispensed by a pharmacy and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable when billed as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/ Prior Authorization Formulary: Open formulary with general exclusions, restrictions, prior authorization, and preferred products. 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 34-days 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 7/1/99. Pharmacies that dispense drugs that they package into unit packaging receive an additional $0.30 per prescription. Ingredient Reimbursement Basis: EAC = AWP11.5%. Prescription Charge Formula: Reimbursement is based on the lesser of submitted AWP minus 11.5% plus a dispensing fee, MAC plus a dispensing fee, or usual and customary. Special rules for IV admixtures.

Minnesota-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes a combination of Federal Upper Limits and Statespecific MAC on generic drugs. Override requires “dispense as written or “brand medically necessary.” Prescriber must also obtain prior authorization.

PrimeWest Health System 305 8th Avenue West Alexandria, MN T: 888/588-4420 F: 320/762-8750 UCare Minnesota P.O. Box 52 Minneapolis, MN 55440-0052 T: 612/676-6500 F: 612/676-6555

Incentive Fee: None. Patient Cost Sharing: Brand: $3.00 Generic: $1.00 Cognitive Services: State does not pay for Cognitive Services.

F. STATE CONTACTS E. USE OF MANAGED CARE

State Drug Program Administrator

Approximately 275,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans. Managed Care Organizations Itasca Medical Care Itasca Resource Center 1209 SE 2nd Ave. Grand Rapids, MN 55744-3983 T: 800/843-9536 F: 218/327-5545 Blue Plus P.O. Box 64179 St. Paul, MN 55164-0179 651/662-5200 First Plan Blue 525 South Lake Avenue Duluth, MN 55802 T: 800/635-4159 F: 218/724-9176 HealthPartners 8100 34th Avenue South P.O. Box 1309 Minneapolis, MN 55414-1309 T: 952/967-6633 Medica P.O. Box 9310 Minneapolis, MN 55440-9310 T: 952/992-3200 F: 952/992-3198

Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet address: www.dhs.state.mn.us/provider/pharm Prior Authorization Contact Mary Claire Wohletz Clinical Pharmacy Consultant Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/215-1632 F: 651/282-6744 E-mail: [email protected] Internet address: www.dhs.state.mn.us/provider/pharm DUR Contact Mary Beth Reinke, Pharm.D., M.S.A. DUR Coordinator Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected]

Metropolitan Health Plan 822 South 3rd Street, Suite 140 Minneapolis, MN 55415 T: 612/347-6308 F: 612/904-4493 Minnesota-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid DUR Board

Prescription Drug Updating

Physicians Pierre Rioux, M.D. Mayo Health Systems-Austin Behavioral Health Center 101 14th Street, N.W. Austin, MN 55912

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588/4003 Claims Submission Contact

Tim Ronnenberg, M.D. Phalen Village Clinic 1414 Maryland Avenue St. Paul, MN 55105 Christine Ziebold, M.D., Ph.D., M.P.H. Pediatrics Infection Control Pharmacy Manager Parker Hughes Clinics 2665 Long Lake Road Roseville, MN 55113 Health Care Professional Marilyn M. Ulseth, M.S., R.N., C.N.P. 2909 33rd Ave South Minneapolis, MN 55406 Pharmacists Ruth Buchmayer, R.Ph. Prime Therapeutics P.O. Box 64812 St. Paul, MN 55164 Margaret T. Schmidt, Pharm.D., M.B.A. NorthPoint Health Center 1313 Penn. Avenue North Minneapolis, MN 55411 Wendy L. St. Peter, Pharm.D. Hennepin County Medical Center Nephrology Analytical Services USRDS Coordinating Center 914 Eighth Avenue South Minneapolis, MN 55404

Dwaine Voas MMIS Unit Supervisor Minnesota Department of Human Services 800 Minnehaha Avenue St. Paul, MN 55155 Medicaid Drug Rebate Contacts Jarvis Jackson, R.Ph. Drug Rebate Coordinator Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/282-5881 F: 651/282-6744 E-mail: [email protected] Disease Management Program/Initiative Contact Mary Claire Wohtetz Clinical Pharmacist Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/215-1632 F: 651/282-6744 E-mail: [email protected] Mail Order Pharmacy Benefit None Elderly Expanded Drug Coverage Program Contact

Consumers Representative Vacant

Cody C. Wiberg, Pharm.D., R.Ph. 651/296-8515

DHS Staff Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager

Department of Human Services Officials

Mary Beth Reinke, Pharm.D., M.S.A. DUR Coordinator New Brand Names Product Contact Cody C. Wiberg, Pharm.D., R.Ph. 651/296-8515

Kevin Goodno Commissioner Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3815 T: 651/297-7515 F: 651/297-3230 E-mail: [email protected]

Minnesota-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004 DHS Staff Mary K. Woheltz, Pharm D. Clinical Pharmacist

Christine Bronson Acting Medicaid Director Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3852 T: 651/297-7515 F: 651/297-3230 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Minnesota Medical Association Robert K. Meiches Chief Executive Officer 1300 Godward Street, NE, Suite 2500 Minneapolis, MN 55413-1878 T: 612/378-1875 F: 612/378-3875 E-mail: [email protected] Internet address: www.mnmed.org

Drug Formulary Committee Gary J. Gustafson, R.Ph. Fairview Pharmacy Services 711 Kasota Avenue Minneapolis, MN Al Heaton, Pharm.D., R.Ph. Senior Director Prime Therapeutics 1020 Discovery Road, No. 100 Eagan, MN 55121

Minnesota Pharmacists Association Julie K. Johnson, R.Ph. Executive Vice-President 1935 W. County Road, B2 #450 Roseville, MN 55113 T: 651/697-1771 F: 651/697-1776 E-mail: [email protected] Internet address: www.mpha.org

Paul Johnson, M.D. HCMCS Division of General Medicine 701 Park Avenue Minneapolis, MN 55415

Minnesota Osteopathic Medical Society Colleen Jensen Executive Director P.O. Box 314 Lakeland , MN 55043-0314 T: 612/623-3268 F: 612/677-3200 Internet address: www.mndo.org

William P. Korchik, M.D. Veterans Affairs Medical Center One Veteran Drive (11L) Minneapolis, MN 55417 Ronna Linroth Manager Adult/North Clinic Services Gillette Lifetime Specialty Healthcare 555 County Road D, Suite 12 New Brighton, MN 55112 Kim Allan Macnab, M.D., Pharm.D., CCFP (EM) 714 Barton Ave, N.W. Buffalo, MN 55313 Lynne M. Schneider, R.Ph. 12910-37th Avenue North Plymouth, MN 55441 John Simon, M.D. Clinical Psychopharmacology Consultants, P.A. Riverside Park Plaza, Suite 303 701 25th Avenue South Minneapolis, MN 55454 Robert Straka, Pharm.D. University of Minnesota College of Pharmacy 7-148 Weaver-Densford Hall 308 Harvard Street, S.E. Minneapolis, MN 55455

State Board of Pharmacy David E. Holmstrom Executive Director 2829 University Avenue SE, #530 Minneapolis, MN 55414-3251 T: 612/617-2201 F: 612/617-2212 E-mail: [email protected] Internet address: www.phcybrd.state.mn.us Minnesota Hospital and Healthcare Partnership Bruce Rueben President 2550 University Avenue West, Suite 350S St. Paul, MN 55114-1900 T: 651/641-1121 F: 651/659-1477 E-mail: [email protected] Internet address: www.mnhospitals.org

Minnesota-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Minnesota Society of Health System-Pharmacists Scott Marin Executive Director 13911 Ridgedale Drive, Suite 260 Minnetonka, MN 55305 T: 952/541-9499 F: 952/541-9684 E-mail: [email protected] Internet address: www.mnshp.org Care Providers of Minnesota Rick E. Carter President & CEO 7851 Metro Parkway Suite 200 Bloomington, MN 55425 T: 612/854-2844 F: 612/854-6214 E-mail: [email protected] Internet address: www.careproviders.org

Minnesota-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MISSISSIPPI A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Skilled Nursing Home Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Blind/ Aged Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$568,084,274

526,923

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$297,248,432 $39,630,817 $219,218,827 $17,536,770 $20,862,018

240,302 20,265 105,764 72,324 41,949

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$206,384,484 $66,656,881 $88,036,351 $47,118,247 $4,573,005 $0

265,482 31,322 30,492 179,454 24,214 0

$64,451,358

21,139

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $568,007,104

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

Mississippi-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 weight loss drugs; fertility drugs; vitamins and minerals (except prenatal); and DESI drugs.

C. ADMINISTRATION Division of Medicaid, Office of the Governor.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; and total parenteral nutrition. Prior authorization required for: brand name multisource products; Sandimmune; oral erectile dysfunction agents; enteral feeding products; nutritional products; immunosuppressant agents; Clozaril (must be prescribed by Board Certified or Board Eligible Psychiatrist); * Xenical, Benzodiazepines, NSAD, Protropin and Humatrope; * all Antihemophilic Factors including VIII and IX; * Synagis; Enbrel; Brand SR opioid agonists; Neurontin; and all Home IV drug therapies. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and interdialytic parenteral nutrition. * 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 with restrictions (i.e., must be on limited formulary, requires a prescription, and counts against monthly service limits): allergy, asthma, and sinus products (Benadryl); analgesics (ASA, generic Tylenol); cough and cold preparations (generic Robitussin); digestive products (non-H2 antagonist); feminine products; topical products; smoking deterrent products; certain vitamins (prenatal and dialysis). Products not covered: H2 antagonists. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamines; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; estrogens; growth hormones; hypotensive agents; misc.; GI drugs; prescribed smoking deterrents, antilipemic agents (PA required for xenical); sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs. Partial coverage for: prescribed cold medications. Products not covered: anoretics;

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians’ offices. Unit Dose: Unit dose packaging is reimbursable. Vaccines: Vaccines reimbursable as part of the Vaccine for Children Program. LTC reimbursed in cost reports. POS only for adult non-LTC beneficiaries. Counts against monthly Rx limits. Formulary/Prior Authorization Formulary: Open formulary with preferred drug list (PDL). General exclusions include: 1.

Drugs used for anorexia or weight gain.

2.

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).

3.

Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are covered).

4.

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.

5.

Barbiturates (except amobarbital, butabarbital, mephobarbital, pentobarbital, phenobarbital, secobarbital, which are covered).

6.

Benzodiazepines (except Klonopin, Lorazapam, Diazepam and Temazepam which are covered).

7.

DESI drugs (those drugs that are designated less than effective by the FDA).

Additional techniques to manage the PDL include restrictions on use, prior authorization, and preferred products. Prior Authorization: State currently has a prior authorization procedure. A written request (including medical justification for beneficiaries under age 21) must be made within 30 days of denial to appeal a prior authorization decision. Review and determination made by clinical specialists within 3 days of receipt. All parties notified in writing within 24 hours of decision.

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Prescribing or Dispensing Limitations

E. USE OF MANAGED CARE

Prescription Refill Limit: Limited to 11 scripts per year. 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. Two additional prescriptions per month may be allowed with prior authorization. Beneficiaries under age 21 years old or in long term care facilities are exempt from monthly prescription limits. Drug Utilization Review PRODUR system implemented in 1993. State has a 12 member DUR Board that meets quarterly. Pharmacy Payment and Patient Cost Sharing

No Medicaid recipients receive health benefits through MCOs.

F. STATE CONTACTS State Drug Program Administrator Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: www.dom.state.ms.us Division of Medicaid Official

Dispensing Fee: $3.91 (effective 5/1/02). IV mixtures can receive up to a $30 per liter dispensing fee. Ingredient Reimbursement Basis: EAC = AWP12%, effective July 1, 1990. Prescription Charge Formula: Reimbursement for legend drugs will be at the lessor of AWP-12% plus a dispensing fee or usual and customary charge. OTC drugs will be paid at lessor of AWP plus a dispensing fee, usual and customary price, or estimated shelf price plus a dispense fee. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” or prior authorization (e.g., brand name multi-source prior authorization form showing allergic Rx, ADR, or failure to respond) for brand multi-source drugs.

Warren A. Jones, M.D., Executive Director Division of Medicaid Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 T: 601/359-6050 F: 601/359-6048 E-mail: [email protected] Prior Authorization Contact Judith P. Clark, R.Ph. 601/359-5253 DUR Contact Judith P. Clark, R.Ph. 601/359-5253 Mississippi DUR Board

Incentive Fee: None.

Lee Montgomery, M.D. Premier Family Practice 602 South Adams Fulton, MS 38843

Patient Cost Sharing: Tiered copayment of $1.00$3.00. $1.00 - preferred generic $2.00 - preferred brand $3.00 - non-preferred brand

Tim Alford, M.D. (Chair) Kosciusko Medicaid Clinic Highway 12 Kosciusko, MS 39090

Cognitive Services: Pays for disease management services for diabetes, hyperlipidemia, asthma, and coagulatory disorders (effective 8/1/98). Pays $20 for average 30-minute encounter.

John R. Mitchell, M.D. Tupelo Family Medicine Residency Center 1665 South Green Street Tupelo, MS 38804 Cynthia Undesser, M.D. P.O. Box 5102 Brandon, MS 39047

Mississippi-3

National Pharmaceutical Council Andrea Phillips, M.D. Phillips Medical Services P.O. Box 21214 Jackson, MS 39289 Rudy Runnels, M.D. Medical and Surgical Clinic 376 A Simpson Highway 149 Magee, MS 39114 Joe McGuffee, R.Ph. McGuffee Drugs 102 North Main Street Mendenhall, MS 39114

Pharmaceutical Benefits 2004 Medicaid Drug Rebate Contact Robert Reedy, C.Ph.T. DRAMS Business Analyst ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/206-2936 F: 601/206-3119 E-mail: [email protected] Claims Submission Contact Robert Reedy, C.Ph.T. ACS State Healthcare T: 601/206-2936

D. Montez Carter, Pharm.D. P.O. Box 1414 Greenwood, MS 38935

Disease Management/Patient Education Programs

Leigh Ann Ramsey, Pharm.D. 231 Winged Foot Circle Jackson, MS 39211

Disease/Medical State: Asthma Program Name: Asthma Disease Management (eff. 2/03) Program Manager: Mckesson

Billy R. Brown, Pharm.D. 2825 Glen Derry Street Jackson, MS 39212 Clarence DuBose, R.Ph. (Vice-Chair) Medi-Mart Pharmacy 3737 Main Street Moss Point, MS 39563 Randy Calvert, R.Ph. 655 Duling Avenue Jackson, MS 39216 New Brand Names Product Contact Judith P. Clark, R.Ph. 601/359-5253 Prescription Price Updating Terri R. Kirby, R.Ph. Pharmacist Divison of Medicaid 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected]

Disease/Medical State: Diabetes Program Name: Diabetes Disease Management (eff. 2/03) Program Manager: Mckesson Disease/Medical State: Hypertension Program Name: Hypertension Disease Management (eff. 2/03) Program Manager: Mckesson Disease Management/Patient Education Contact Alicia K. Crowder, R.N., M.P.H. Director of Medical Services Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5243 F: 601/359-5252 E-mail: [email protected] Mail Order Pharmacy Program None Pharmacy and Therapeutics Committee Craig Dawkins, M.D. 1213 Broad Avenue, Suite 210 Gulfport, MS 39501 Jennifer Gholson, M.D. 110 Franklinton Street Tylertown, MS 39667

Mississippi-4

National Pharmaceutical Council Michael L. O’Dell, M.D. (Vice-Chair) Director, Family Medicine Residency Program North Mississippi Medical Center 1665 South Green Street Tupelo, MS 38804 Gary Davis, M.D. 571 East Beasley Road, Suite D Jackson, MS 39206 Raymond Wynn, M.D. Singing River Hospital System Director, The Regional Cancer Center 2809 Denny Avenue Pascagoula, MS 39581 Betsy Commings, C.F.N.P 1740 McClain Street Greenville, MS 38701 Pearl Wales, Pharm.D. 164 Tithelo Road Canton, MS 39046 David Hudson, R.Ph. 389 NW Depot Street Durant, MS 39063 Todd Barrett, R.Ph. Covenant Pharmacy 2506 Lakeland Drive, Suite 101 Flowood, MS 39232 Jeff Jones, R.Ph. Carthage Discount Drugs 602 Highway 16E Carthage, MS 39051-4212 Larry Calvert, R.Ph. (Chair) 720 Sarazen Drive Gulfport, MS 39507 Executive Officers of State Medical and Pharmaceutical Societies Mississippi State Medical Association William F. Roberts Executive Director P.O. Box 2548 Ridgeland, MS 39158-2548 601/853-6733 E-mail: [email protected] Internet address: www.msmaonline.com

Pharmaceutical Benefits 2004 Mississippi Pharmacists Association Bo Dalton, R.Ph. Executive Director 341 Edgewood Terrace Drive Jackson, MS 39206-6217 601/981-0416 E-mail: [email protected] Internet address: www.mspharm.org Mississippi State Board of Pharmacy Leland “Mac” McDivitt Executive Director 204 Key Drive, Suite D Madison, MS 39110 T: 601/605-5388 F: 601/605-9546 E-mail: [email protected] Internet address: www.mbp.state.ms.us Mississippi Osteopathic Medical Association Jeffrey J. LeBoeuf Executive Director P.O. Box 16890 Jackson, MS 39236 T: 601/366-3105 F: 601/366-2868 E-mail: [email protected] Internet address: www.moma-net.org Mississippi Hospital Association Sam W. Cameron President/CEO P.O. Box 16444 6425 Lakeover Road Jackson, MS 39236-6444 T: 800/289-8884 F: 601/368-3200 E-mail: [email protected] Internet address: www.mhanet.org Mississippi Society of Health-System Pharmacists Dianna McGowan, R.Ph. Association Manager 328 Dover Lane Madison, MS 39110 T: 601/856-9273 F: 601/856-8539 E-mail: [email protected] Internet address: www.pharmd.org/mshp Mississippi Health Care Association Vanessa P. Henderson Executive Director 114 Marketridge Drive Ridgeland, MS 39157 T: 601/956-3472 F: 601/977-0273 E-mail: [email protected] Internet address: www.mshca.com Mississippi-5

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Pharmaceutical Benefits 2004

MISSOURI A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Blind/ Aged Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$799,910,014

493,230

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$356,695,975 $51,673,954 $225,953,649 $35,102,211 $43,966,161

275,059 18,903 66,602 110,002 79,552

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$35,427,693 $7,218,295 $16,527,657 $9,869,502 $1,812,239 $0

47,905 4,168 4,142 27,036 12,559 0

$407,786,346

170,266

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $941,522,305

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION Division of Medical Services, Missouri Department of Social Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Categories or drugs that are covered: prescribed insulin; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products covered with restrictions (single source supplies): disposable needles and syringe combinations used for insulin; blood glucose test strips. Limited coverage (limited to OTC formulary) for: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonists); and topical products. Prior authorization required for: amphetamines; barbiturates; Isotretinoin; Orlistat; and Retinoic Acid. Products not covered: cosmetics; fertility drugs; experimental drugs; H2 antagonists; smoking deterrent products; feminine products; hair growth products; Halazepam; Prazepam; Estazolam; Quazepam; and non-legend products.

Formulary: Open formulary with preferred drug list. PDL managed through exclusions and restrictions, including preferred products, physician profiling, prior authorization, therapeutic substitution, clinical edits, and step therapy. Prior Authorization: State currently has a prior authorization procedure and a Drug Prior Authorization Committee composed of 9 members who meet quarterly. Fair hearing process to appeal prior authorization decisions. Prescribing or Dispensing Limitations Prescription Refill Limit: None 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. Dose Limit: Prescriptions for the following must be dispensed for at least 200 units per prescriptions: Acetaminophen 5 gr. Prenatal vitamins must be dispensed in a quantity of at least 30. Drug Utilization Review

Therapeutic Catogory Coverage: Therapeutic categories covered: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; antipsychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anxiolytics, sedatives, and hypnotics; prescribed cold medications; growth hormones; and GI drugs. Partial coverage for: anabolic steroids. Categories not covered: anoretics; prescribed smoking deterrents. (For additional information on products and/or category coverage, see the pharmacy provider bulletin at www.medicaid.state.mo.us.) Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care settings, and extended care facilities.

PRODUR system implemented in 1993. State currently has a 13 member DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.09 (out-of-state), $8.04 (instate), $8.19 (long-term care pharmacies). Ingredient Reimbursement Rate: EAC = AWP10.43% or WAC+10%. Prescription Charge Formula: 1.

Method of reimbursement payment is based on acquisition cost plus a dispensing fee 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-10.43% or the WAC+10%. The majority of drugs listed are based on AWP. The method of pricing will be taken from the NDC number.

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. 1,067 drugs are listed on the Statespecific MAC list. Override requires prior authorization and a MedWatch form.

FirstGuard Health Plan 4001 Blue Parkway, Suite 300 Kansas City, MO 64130 816/922-7250 Family Health Partners Health Plan 215 W. Pershing Road, 6th Floor P.O. Box 411806 Kansas City, MO 64108 816/855-1888

Incentive Fee: None. Patient Cost Sharing: Variable tiered copayment: Drug Ingredient Cost

Copayment

$0.00 to $10.00

$0.50

$10.01 to $25.00

$1.00

$25.01 or more

$2.00

Missouri Care Health Plan 2404 Forum Boulevard Columbia, MO 65203 573/441-2100

F. STATE CONTACTS

($5.00 copayment for certain 1115 waiver populations (see Pharmacy Bulletin).)

State Drug Program Administrator

Copayment retained by pharmacist. Cognitive Services: Payment for cognitive services is provided to qualified pharmacies who enroll to provide asthma, diabetes, heart failure, and depression education.

E. USE OF MANAGED CARE Approximately 417,000 Medicaid recipients are enrolled in managed care organizations in 2003. All receive pharmacy services through managed care. Protease inhibitors are carved out of managed care. Managed Care Organizations Healthcare USA 10 South Broadway, Suite 1200 St. Louis, MO 63102 800/213-7792 Blue Cross and Blue Shield of Kansas City P.O. Box 419169 2301 Main St., 3rd Floor Kansas City, MO 64108 816/395-2119 Mercy Health Plan 14528 S. Outer 40 Road, Suite 300 Chesterfield, MO 63017 314/214-8010

George L. Oestreich, Pharm.D., M.P.A. Pharmacy Program Director Department of Social Services Division of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected] Internet address: www.dss.mo.gov/dms Social Services Department Officials Steve Renne, Acting Director Department of Social Services Broadway State Office Building 221 West High Street P.O. Box 1527 Jefferson City, MO 65102 T: 573/751-4815 F: 573/751-3203 E-mail: [email protected] Michael Ditmore, M.D., Interim Director Department of Social Services Division of Medical Services 615 Howerton Court, P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6922 F: 573/751-6564 E-mail: [email protected]

Community Care Plus Health Plan 10123 Corporate Square Drive St. Louis, MO 63112 800/875-0679

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New Brand Name Products Contact

DUR Contact

Rhonda A. Driver Clinical Pharmacist Department of Social Services Division of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102- 6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected]

Tisha A. Pomering DUR Coordinator Division of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected] DUR Board

Prior Authorization Contact Rhonda A. Driver 573/751-6961 Pharmacy Advisory Group Matt Carlise, R.Ph. St. Peters, MO Gene Forrester, R.Ph. Columbia, MO Curtis Hartin, R.Ph. St. Louis, MO Ed Powers, R.Ph. Macon, MO Steve Hartwig, R.Ph. Marshall, MO Jim Harlan, R.Ph. Poplar Bluff, MO Barb Hauck, R.Ph. Deerfield, IL Christie Beisner, R.Ph. Nevada, MO John Fester, R.Ph. Steelville, MO Janice Steiger, R.Ph. Florissant, MO Kevin James, R.Ph. Bentonville, AR

John W. Newcomer, M.D. (Chair) Stacy Mangum, Pharm.D. Jacquelyn Garrett, M.D. Joy S. Gronstedt, D.O. Joseph M. Yasso, D.O. Harold Lurie, M.D. Karla Dwyer, R.Ph. Susan Abdel-Rahman, Pharm.D. Peggy Wanner-Barjenbrunch, M.D. Sandra Bollinger, Pharm.D. Stephen Calloway, R.Ph. Robert Dale Potter, R.N. Drug Prior Authorization Committee Patrick J. Bryant, Pharm.D. Kansas City, MO Joseph Parks, M.D. Jefferson City, MO Gene Forrester, R.Ph. Columbia, MO Henry Petry, D.O. Edina, MO Jay R. Bryant-Wimp, R.Ph. Columbia, MO Lorraine C. Brown, D.O. Lebanon , MO Conrad S. Balcer, D.O. Jefferson City, MO Karen Norris, Pharm.D. (alternate) Kansas City, MO Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 650/588-5454 F: 650/872-4510

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National Pharmaceutical Council Medicaid Drug Rebate Contact Vickie L. Harper Medicaid Unit Supervisor Division of Medicaid Services Drug Rebate Unit 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/526-5664 F: 573/522-4650 E-mail: [email protected] Claims Submission Contact Diane Twehous Account Manager Infocrossing Health Care Services, Inc. 905 Weathered Rock Road Jefferson City, MO 65109 573/635-2434 Medicaid Managed Care Contact Michael Ditmore, M.D. Interim Director 573/751-6922 Mail Order Pharmacy Program None Disease Management/ Patient Education Programs Disease Medical States: Asthma Cardiovascular Disease Depression Diabetes Program Manager: Jennifer Cornelious Program Sponsor: State of Missouri Disease Management Initiatives Contact George Oestreich, Pharm.D., M.P.A. 573/781-6961 Pharmacy Subcommittee Roster Bill Fitzpatrick, R.Ph. St. Louis, MO Philip A. Bangert, R.Ph. Florissant, MO Tom Beetem, R.Ph., Chairman Holts Summit, MO Robert D. Hurley, R.Ph. Florissant, MO

Pharmaceutical Benefits 2004 Craig Leonard, R.Ph. Lee’s Summit, MO 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 T: 573/636-5151 F: 573/636-8552 E-mail: [email protected] Internet address: www.momed.net/momed/index.htm Missouri Pharmacy Association Ron Fitzwater Chief Executive Officer 211 East Capitol Avenue Jefferson City, MO 65101-3001 T: 573/636-7522 F: 573-636-7485 E-mail: [email protected] Internet address: www.morx.com Missouri Assoc. of Osteopathic Physicians/Surgeons, Inc. Bonnie M. Bowles Executive Director 1423 Randy Lane Jefferson City, MO 65102 T: 573/634-3415 F: 573/634-5635 E-mail: [email protected] Internet address: www.maops.com Missouri State Board of Pharmacy Kevin E. Kinkade Executive Director 3605 Missouri Boulevard P.O. Box 62 Jefferson City, MO 65102 T: 573/751-0091 F: 573/526-3464 E-mail: [email protected] Internet address: www. pr.mo.gov/pharmacists.asp Missouri Hospital Association Marc Smith President 4712 Country Club Drive P.O. Box 60 Jefferson City, MO 65102-0060 T: 573/893-3700 F: 573/893-2809 E-mail: [email protected] Internet address: www.mhanet.com Missouri-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

MONTANA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$77,980,883

67,365

$79,771,831

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$37,487,485 $3,002,578 $28,824,343 $2,079,303 $3,581,261

28,190 1,524 10,729 9,751 6,186

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$22,256,552 $12,864,890 $9,380,602 $10,732 $328

7,821 5,336 2,449 34 2

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$2,541,402 $14 $0 $2,084,695 $399,668 $57,025

13,561 1 0 11,322 2,183 55

$15,695,444

17,793

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION Department of Public Health and Human Services, Health Resources Division, Medicaid Services Bureau

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: legend drugs, prescribed insulin; fertility drugs; syringe combinations used for insulin; certain prescribed over-the-counter products, vaccines except children 18 and under and clients with Medicare Part B coverage; compounded prescriptions; contraceptive supplies and devices. Products not covered: cosmetics; experimental drugs; disposable needles used for insulin, blood glucose test strips; and urine ketone test strips. Prior authorization required for: total parenteral nutrition; interdialytic parenteral nutrition; non-steroidal antiinflammatory drugs; all single source NSAIDs; Celebrex, Vioxx; disease-modifying anti-rheumatic drugs (Arava, Enbrel, Remicade); growth hormones; single-source benzodiazepines; gastrointestinal drugs (including H2 antagonists, proton pump inhibitors, Carafate and Cytotec); migraine headache drugs for certain monthly quantities on Imitrex, Maxalt, Zomig, Migranal, Amerge; weight reduction drugs (Fastin, Ionamin, Meridia, Xenical); smoking-cessation drugs; Toradoloral; Dipyridamole; Aggrenox; Trental, Pletal; Ambien and Sonata; Viagra; Thalomid; Zyvox; Tretinoin; Zoloft; Hismanal; Bextra; Kineret; Stadol; Isoetherine; and Isoproterenol.

smoking deterrents and growth hormones. Therapeutic categories not covered: anoretics; prescribed cold medications. Coverage of Injectables: Injectable medicines reimbursable through the physician payment when used in home health care and extended care facilities, and physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT service, the Children Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary with a preferred drug list. Formulary managed through exclusion of products based on contracting issues, restrictions on use, prior authorization preferred products, and physician profiling. Drugs classified as less-thaneffective (LTE) by the FDA are not covered. Drugs with no manufacturer rebate are not covered. 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: None Monthly Quantity Limit: 34-day supply. May have quantity limits on certain medications selected by the DUR Board.

Over-the-Counter Product Coverage: Products covered (i.e., when prescribed): allergy, asthma, and sinus products (Claritin OTC only); insulin; laxatives; head lice treatments; H2 antagonists; GI products; bronchosaline; and smoking deterrent products (prior authorization required). Products not covered: analgesics; cold and cough preparations; non-H2 antagonists; feminine products; and topical products.

Drug Utilization Review PRODUR system implemented in September 1994. State DUR Board meets monthly. Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; antipsychotics; anxiolytics, sedatves, 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: antihistamines; analgesics, antipyretics, and NSAIDs; prescribed

Dispensing Fee: $2.00-$4.70; effective 7/1/02. Pharmacies submit documentation showing their costs. Dispensing fee is based on their cost up to a maximum of $4.70. Pharmacies that do not submit documentation receive a dispensing fee of $2.00. Ingredient Reimbursement Basis: EAC = AWP15%. Prescription Charge Formula: The lower of EAC, the Federal MAC (plus a dispensing fee), or the provider usual and customary charge.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Prior Authorization Contact

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Necessary” or “Brand Required” on the prescription. Incentive Fee: None. Patient Cost Sharing: Copayment of $1.00 - $5.00. Recipient pays 5% of Medicaid allowable cost between $1.00 and $5.00. $5.00 copayment cap per prescription. $25.00 copayment cap per month.

Mark Eichler, R.Ph., FASCP Pharmacy Programs Director Mountain-Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 T: 406/457-5818 F: 406/443-7014 E-mail: [email protected] DUR Contact

Cognitive Services: Does not pay for cognitive services.

Mark Eichler, R.Ph., FASCP T: 406/457-5818

E. USE OF MANAGED CARE Montana DUR Board Does not use MCO’s to provide services to Medicaid recipients.

Mark Eichler, R.Ph., FASCP DUR Coordinator

F. STATE CONTACTS

Lee Ann Bradley, Pharm.D. Sherrill Brown, Pharm.D. Bill Burton, R.Ph. Carla Cobb, Pharm.D. Jim Crichton, M.D. Lori Fitzgerald, Pharm.D. V. Lee Harrison, M.D. Stephen S. Nagy, M.D. Richard Sargent, M.D.

State Drug Program Administrator Dan Peterson Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau 1400 Broadway P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected] Internet address: www.mtmedicaid.org

New Brand Name Products Contact Dan Peterson 406/444-2738 Prescription Price Updating

Public Health and Human Services Officials Dr. Robert E. Wynia, Director Department of Public Health and Human Services 111 N. Sanders, Room 301 P.O. Box 4210 Helena, MT 59604-4210 T:406/444-5622 F: 406/444-1970 E-mail: [email protected] John Chappuis Medicaid Director Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4084 F: 406/444-1861 E-mail: [email protected]

First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578 Medicaid Drug Rebate Contacts Betty DeVaney, Drug Rebate Coordinator Department of Public Health & Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2591 T: 406/444-3457 F: 406/444-1861 E-mail: [email protected]

Montana-3

National Pharmaceutical Council Claims Submission Contact Brett Jakovac, Executive Account Manager ACS, State Healthcare 34 N. Last Chance Gulch, Suite 200 Helena, MT 59601 T: 406/457-9555 F: 406/442-2819 E-mail: [email protected] Medicaid Managed Care Contact Niki Scoffield, Program Officer Dept. of Public Health and Human Services Medicaid Services Bureau 1400 Broadway P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-4148 F: 406/444-1861 E-mail: [email protected]

Pharmaceutical Benefits 2004 Montana State Board of Pharmacy Rebecca Deschamps, R.Ph. Executive Director P.O. Box 200513 301 South Park, 4th Floor Helena, MT 59620-0513 T: 406/841-2371 F: 406/841-2305 E-mail: [email protected] Internet address: discoveringmontana.com/dli/bsd/license/bsd_board s/pha_board/board_page.asp Montana Osteopathic Medical Association Carmen Bell Executive Director 1600 2nd Avenue, SW, Suite 120 Minot, ND 58701 701/852-8789 E-mail: [email protected] Internet Address: www.mtoma.org

Mail Order Pharmacy Benefit None Executive Officers of State Medical and Pharmaceutical Societies Montana Medical Association G. Brian Zins Executive Vice President and CEO 2021 11th Avenue, Suite 1 Helena, MT 59601-4890 T: 406/443-4000 F: 406/443-4042 E-mail: [email protected] Internet address: www.mmaoffice.com

Association of Montana Health Care Providers Dick Brown Sr. Vice President/Executive Director P.O. Box 5119 1720 Ninth Avenue Helena, MT 59601 406/442-1911 E-mail: [email protected] Internet address: www.mtha.org

Montana Pharmacy Association Jim E. Smith Executive Director P.O. Box 1569 34 West 6th Avenue, Suite 2E Helena, MT 59601-5074 T: 406/449-3843 F: 406/443-1592 E-mail: [email protected] Internet address: www.rxmt.org/services.htm

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Pharmaceutical Benefits 2004

NEBRASKA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

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‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

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‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

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‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$196,526,107

194,889

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$69,279,614 $9,843,626 $49,388,569 $4,534,213 $5,513,206

48,501 3,983 15,517 19,350 9,651

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$48,643,279 $29,632,049 $6,684,567 $2,260,713 $10,065,950

33,380 9,808 1,527 6,761 15,284

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$65,092,537 $15,871,572 $29,727,730 $18,756,687 $694,614 $41,934

90,997 6,505 8,077 71,241 5,144 30

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$13,510,677

22,011

2003** Expenditures Recipients $197,518,471

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2003 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division. Source: CMS, MSIS Report, FY 2002 and Nebraska Medicaid Statistical Information System, FY 2003 Note: Nebraska estimates 2004 drug expenditures to be approximately $216.5 million and the number of Medicaid drug recipients to be 192,000.

Nebraska-1

197,704

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Vaccines: Vaccines reimbursable by Medicaid for individuals under 21 years of age as part of EPSDT services, through the Children’s Health Insurance Program, and through the Vaccines for Children Program.

C. ADMINISTRATION State Department of Health and Human Services, Finance and Support, Medicaid Division.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: legend drugs, compound prescriptions, prescribed insulin with prior approval (i.e., must be medically necessary on pre-filled syringes). Products covered under the supplier program: disposable needles used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: DESI drugs, drugs for weight control; cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: methadone; IV infusions; and protein replacement supplements. Over-the-Counter Product Coverage: Products covered: (must be prescribed and subject to rebate) allergy, asthma, and sinus products; analgesics; topical products; vitamin/mineral supplements; eye/ear products; cough and cold preparations; digestive products; and feminine products. Products not covered: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anticoagulants; anticonvulsants; antilipemic agents; anti-psychotics; cardiac drugs; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); antibiotics; anti-depressants; antidiabetic agents; and thyroid agents. Prior authorization required for: 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, RSVIG); and drugs for sexual dysfunction (e.g., Sildenafil, Alprostadil). Partial coverage (PA required) for: analgesics, antipyretics, NSAIDs; antihistamines; anxiolytics, sedatives, and hypnotics; chemotherapy agents; growth hormones; and misc. GI drugs. Therapeutic categories not covered: anabolic steroids; anorectics; and prescribed smoking deterrents.

Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary managed through restrictions on use and prior authorization. General exclusions include: 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 (ICF/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 or website.

Coverage of Injectables: Injectables reimbursable through the Pharmacy program when used in home health care and extended care facilities, and through physician payment when used in physician offices.

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Pharmaceutical Benefits 2004

Prior Authorization: State currently has a formal prior authorization procedure. Prescriber must submit a letter of medical necessity with documentation. 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.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. More than 1,500 drugs are listed on the State-specific MAC list. Override requires a “Brand Medically Necessary” form signed by the physician.

Prescribing or Dispensing Limitations

Additional Pharmacy Payments: Additional payments for tablet splitting (effective 2000)

Incentive Fee: None. Patient Cost Sharing: Copayment = $2.00.

Prescription Refill Limit: As authorized by the prescribing physician. For controlled substances, maximum 5 refills every 6 months.

E. USE OF MANAGED CARE

Monthly Quantity Limit: 90-day supply or 100 dosage units, whichever is greater. 31-days for injectables.

Approximately 65,000 unduplicated Medicaid recipients were enrolled in managed care in 2003. Recipient enrolled in MCOs receive pharmaceutical services through the State.

Drug Utilization Review Managed Care Organizations

PRODUR system implemented in April 1995. State currently has a DUR Board that meets 10 times each year.

Share Advantage United Healthcare of the Midland 2717 North 118th Circle Omaha, NE 68164

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.27 - $5.00. The Nebraska Department of Health and Human Services assigns a dispensing fee to each individual pharmacy based on location, services, volume, and other third-party participation. The fee is calculated from information obtained through the Department’s Prescription Survey.

Primary Care + Blue Cross/Blue Shield of Nebraska P.O. Box 241739 Omaha, NE 68124 Magellan Behavioral Health P.O. Box 82047 Lincoln, NE 68501

Ingredient Reimbursement Basis: EAC = AWP 11%.

F. STATE OFFICIALS

Prescription Charge Formula: Lower of:

State Drug Program Administrator

1.

Product cost (EAC, SMAC, or FUL) plus a dispensing fee, or

2.

The usual and customary price to the general public.

Dyke Anderson, R.Ph Pharmacy Consultant Department of Health and Human Services Finance and Support /Medicaid Division 301 Centennial Mall South, 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected]

Listed OTCs are reimbursed at the lower of: 1.

Product cost (EAC, SMAC, or FUL) plus a dispensing fee,

2.

The usual and customary shelf price to the general public, or

3.

Product cost (EAC, SMAC, or FUL) plus a 50% mark-up.

Nebraska-3

National Pharmaceutical Council Health and Human Services Department Officials Richard P. Nelson, Director Department of Health and Human Services Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-8566 F: 402/471-9449 E-mail: [email protected] Mary Steiner, Interim Administrator Medicaid Division Department of Health and Human Services Finance and Support P.O. Box 95007 301 Centennial Mall South, 5th Floor Lincoln, NE 68509-5007 T: 402/471-9567 F: 402/471-9092 E-mail: [email protected] Prior Authorization Contacts Dyke Anderson, R.Ph. 402/471-9379 Barbara Mart Pharmacy Consultant Health and Human Services 301 Centennial Mall South 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9301 F: 402/471-9092 E-mail: [email protected] DUR Contact Beth Wilson, R.Ph. DUR Director Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected] Nebraska DUR Board Pharmacist Members: Kevin Borcher, R.Ph. Elissa Carney, R.Ph. Patty Gollner, R.Ph. David Hutsell, R.Ph. John Franklin, R.Ph. Kim Hamik, R.Ph. Shannon Nelson, R.Ph. Phillip Vuchetich, R.Ph.

Pharmaceutical Benefits 2004 Physician Members: Kay Anderson, M.D. Fred Ayers, M.D. Kirk Muffly, M.D. Thomas B. Murray, M.D. Sam Perry, M.D. New Brand Name Products Contact Dyke Anderson, R.Ph. 402/471-9379 Prescription Price Updating Dyke Anderson, R.Ph. 402/471-9379 Medicaid Drug Rebate Contacts Technical Karen Jaques Accountant II Health and Human Services – Finance and Support 301 Centennial Mall South 5th Floor – NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9397 F: 402/471-7783 E-mail: [email protected] Policy Dyke Anderson, R.Ph. 402/471-9379 Claims Submission Contact Barbara Pavolony Account Manager ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8536 F: 770/730-5198 E-mail: [email protected] Medicaid Managed Care Contact David Cygan Managed Care Program Administrator HHSS-Finance & Support-Medicaid 301 Centennial Mall South P.O. Box 95026 Lincoln, NE 68509 T: 402/471-9050 F: 402/471-9092 E-mail: [email protected]

Nebraska-4

National Pharmaceutical Council Mail Order Pharmacy Program None Medical 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 Joni Cover, J.D. Executive Vice President Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68502 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 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 Sandy Johnson Executive Secretary Nebraska Medical Association First Bank Bldg., Suite 1512 Lincoln, NE 68508

Pharmaceutical Benefits 2004 Pat Snyder Executive Director Nebraska Health Care Association 421 South 9th Street, Suite 137 Lincoln, NE 68508 James Walker, D.D.S. 1640 South 70th, Suite 200 Lincoln, NE 68506 Executive Officers of State Medical and Pharmaceutical Societies Nebraska Medical Association Sandra Johnson Executive Vice President 233 S. 13th Street, Suite 1512 Lincoln, NE 68508-2091 402/474-4472 E-mail: [email protected] Internet address: www.nebmed.org Nebraska Pharmacists Association Joni Cover, J.D. Executive Vice President 6221 South 58th, Suite A Lincoln, NE 68516-3679 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected] Internet address: www.npharm.org Nebraska Assn. of Osteopathic Physicians & Surgeons (Inactive) Nebraska State Board of Pharmacy Becky Wisell Section Administrator, Pharmacist Licensure P.O. Box 94986 Lincoln, NE 68509 T: 402/471-2118 F: 402/471-3577 E-mail: [email protected] Internet address: www.hhs.state.ne.us/medical/pharm/ Nebraska Hospital Association Laura J. Redoutey, FACHE President 1640 L Street, Suite D Lincoln, NE 68508-2509 T: 402/458-4900 F: 402/475-4091 E-mail: [email protected] Internet address: www.nhanet.org

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Pharmaceutical Benefits 2004

Nebraska-6

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Pharmaceutical Benefits 2004

Nevada-0

National Pharmaceutical Council

Pharmaceutical Benefits 2004 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

NEVADA2 A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Source: CMS, MSIS Report Medically (MN)Report, FY FY 2002Needy and CMS-64 2003 Blind/ Blind/ Child Adult Aged Child Adult Disabled Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

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Nursing Facility Services

‹

‹

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Physician Services

‹

‹

‹

‹

Dental Services

‹

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‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$90,134,969

71,950

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$64,869,022 $13,073,373 $49,568,652 $953,980 $1,273,017

34,682 6,228 17,472 6,473 4,509

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCC Women

$2,687,912 $163,078 $423,871 $834,644 $1,266,319 $0

11,667 204 329 5,694 5,440 $0

$22,578,035

25,601

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2 The State of Nevada did not respond to the 2004 NPC

Survey. Using CMS data and other source materials, we have, to the extent possible, updated the profile and the tables in other sections of the Compilation. Users should contact the Nevada Medicaid Program to assess the accuracy and currency of the information included.

Nevada-1

2003** Expenditures Recipients $106,821,075

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Vaccines: Vaccines reimbursable at cost plus an administration fee ($3.83) as part of the EPSDT service.

C. ADMINISTRATION Division of Health Care Financing and Policy of the Department of Human Resources.

Unit Dose: Unit dose packaging reimbursable.

D. PROVISIONS RELATING TO DRUGS

Formulary/Prior Authorization

Benefit Design

Formulary: Open formulary. General exclusions include:

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 under DME: total parental nutrition; interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; and smoking deterrent products. Products covered with restrictions: topical products. OTC drugs are reimbursed at EAC+$4.76 or the usual and customary amount, whichever is less, and require prior authorization. Products not covered: feminine products. Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, and 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; hypotensive agents; misc. GI products; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: CNS stimulants; Hemapopoiletic; PPIs; Cox2 inhibitors; erectile dysfunction medications; duragisic patches; HCG; Gonadotropin, Gonadotropin releasing hormone analog; Erythropoetin; Interferon; IV antibiotic; Methylpenidate, Peomoline; vitamins; and Remicade. Partial coverage for: growth hormones (prior authorization required); estrogens; and anabolic steroids. Therapeutic categories not covered: anorectics; amphetamine combinations; radiopague and radiographic products; DESI drugs; yohimbine; and drugs not participating in the drug rebate program. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians’ office

1. 2. 3. 4. 5.

6.

Agents used for cosmetic purposes or hair growth. Yohimbine (e.g., Yocon). Radiopaque agents (e.g., Telepaque, Hypaque, Barium Sulfate). 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: State currently has a prior authorization procedure with appeals process. Prior authorization procedure screening for individual drugs. Drugs requiring PA include: 1. Amphetamine (e.g., Dexedrine) 2. Chorionic Gonadotropin (HCG) 3. Dipyridamole (e.g., Persantine) 4. Erythropoietin (e.g., Epogen, Procrit) 5. Gonadotropin releasing hormone analog (e.g., Lupron, Zoladex) 6. Growth hormone (e.g., Protropin, Nutropin) 7. Interferon (all combinations manufactured by recombinant DNA technology) 8. Intravenous antibiotic therapy 9. Methylphenidate (e.g., Ritalin) 10. Non-legend pharmaceuticals 11. Nutritional supplements or replacements 12. Pemoline (e.g., Cylert) 13. Pulmozyme 14. Vitamins, vitamin/mineral combinations or hematinics Prescribing or Dispensing Limitations Monthly Quantity Limit: The maximum dispensable quantity is limited to a 34-day supply. Maintenance medications limited to a 100-day supply. Monthly Quantity Limit: 5 refills within 6 months for controlled drugs. Up to 11 refills for noncontrolled drugs.

Nevada-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Drug Utilization Review

F. STATE CONTACTS

State currently has a DUR Board with a quarterly review by a PRODUR contractor. PRODUR system implemented in 2003.

State Drug Program Administrator

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.76, effective 10/1/98. IV dispensing fee is $16.80 for first ingredient; $5.60 for other ingredients. Ingredient Reimbursement Basis: EAC = AWP15%.

Dionne Coston, R.N., Medical Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 Email: [email protected] Internet address: www.dhcfp.state.nv.us Human Resources Department Officials

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. Maximum Allowable Cost: State imposes Statespecific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: None. Cognitive Services: Does not pay for cognitive services.

Michael J. Willden, Director Department of Human Resources State Capital Complex 505 East King Street, Room 600 Carson City, NV 89710 T: 775/684-4000 F: 775/684-4010 E-mail: [email protected] Charles Duarte, Administrator Division of Health Care Financing and Policy 1100 E. Williams Street, Suite 116 Carson City, NV 89710 T: 775/684-3676 F: 775/684-8792 E-mail: [email protected]

E. USE OF MANAGED CARE

Prior Authorization Contact

Approximately 75,000 Medicaid recipients are enrolled in MCOs in 2003; all receive pharmacy benefits through their managed care plan.

Dionne Coston, R.N. 775/684-3775

Managed Care Organizations Health Plan of Nevada P.O. Box 15645 Las Vegas, NV 89114 702/242-7317 NevadaCare, Inc. 10600 W. Charleston Blvd. Las Vegas, NV 89135 T: 702/304-5500 F: 702/474-7592

Steve Espy, R.Ph., Director of Drug Utilization Health Information Design, Inc. 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531 DUR Contact Dionne Coston, R.N. 775/684-3775 DUR Board Joseph W. Johnson, M.D. Steven W. Parker, M.D. David England, R.Ph., Pharm.D. (Chair) Lori Winchell, R.N.P. Keith W. MacDonald, Pharm.D. Amy H. Schwartz Marjorie Uhalde, M.D., Ph.D.

Nevada-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Brand Name Products Contact

Pharmacy and Therapeutics Committee

Dionne Coston, R.N. 775/684-3775

Steven L. Phillips, M.D. (Chair) Diana L. Bond, R.Ph. Judy Britt, Pharm.D. Linda Flynn, R.Ph. Alan Greenberg, M.D. Carl Heard, M.D. Robert L. Horne, M.D. Larry L. Pinson, Pharm.D. Susan L. Pintar, M.D. Thomas H. Wiser, Pharm.D.

Prescription Price Updating First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578 Medicaid Drug Rebate Contacts Technical: Anita Sheard, 775/684-3749 Policy: Dionne Coston, R.N., 775/684-3755 Rebate: Anita Sheard, 775/684-3749 Claims Submission Contact First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 800/884-3238

Executive Officers of State Medical and Pharmaceutical Societies Nevada State Medical Association Lawrence P. Matheis Executive Director 3660 Baker Lane, Suite 101 Reno, NV 89509 T: 775/825-6788 F: 775/825-3202 E-mail: [email protected] Internet address: www.nsmadocs.org

Medicaid Managed Care Contact Hilary Jones, R.N. Medicaid Services Specialist III 1100 E. Williams Street, Suite 204 Carson City, NV 89701 775/684-3697 E-mail: [email protected] Mail Order Pharmacy Program None Physician-Administered Drug Program Contact Coleen Lawrence, 775-684-3744 Medical Care Advisory Committee Trudy Larson, M.D. (Chair) Mr. Paul Boyar (LTC Administrator) Patricia Craddock, D.D.S. Ms. Jessie Harris Mr. Keith MacDonald, Pharm.D. Mr. Ken Richardson (Admnistrator, Health Care Clinic) Ms. Linda Sheldon (Advocate for Children) Bradford Lee, M.D. (Nevada State Health Officer)

Nevada Pharmacy Alliance Mary Grear, R.Ph. Executive Vice President c/o Nevada College of Pharmacy 5740 S. Eastern Avenue, Suite 24C Las Vegas, NV 89119 T: 702/259-3449 F: 702/259-3521 E-mail: [email protected] Internet address: www.nvphall.org Nevada Osteopathic Medical Association Denise Selleck Davis Executive Director 405 Max Court, Suite K Henderson, NV 89015 T: 702/434-7112 F: 702/434-7110 E-mail: [email protected] Internet address: www.nevadaosteopathic.com Nevada State Board of Pharmacy Keith W. MacDonald, R.Ph. Executive Secretary 555 Double Eagle Court, Suite 1100 Reno, NV 89511-8991 T: 775/850-1440 F: 775/850-1444 E-mail: [email protected] Internet address: www.state.nv.gov/pharmacy

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Pharmaceutical Benefits 2004

Nevada Hospital Association Bill M. Welch President and CEO 5250 Neil Road Suite 302 Reno, NV 89502 T: 775/827-0184 F: 775/827-0190 E-mail: [email protected] Internet address: www.nvha.net

Nevada-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Nevada-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004 **2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

NEW HAMPSHIRE

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

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$98,836,636

78,861

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$27,161,385 $3,424,175 $19,092,652 $1,763,556 $2,881,002

19,253 1,431 5,671 7,911 4,240

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$24,082,471 $10,981,139 $10,425,563 $463,065 $2,212,704

9,223 4,380 2,472 935 1,436

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$8,422,399 $441,811 $600,362 $7,006,717 $373,509 $0

30,040 287 327 27,509 1,917 0

$39,170,381

20,345

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

Nevada-7

2003** Expenditures Recipients $112,948,647

National Pharmaceutical Council

Pharmaceutical Benefits 2004 providers for routine vaccines, although an administration fee is allowed.

C. ADMINISTRATION Office of Medicaid, Business and Policy; Department of Health and Human Services.

Unit Dose: Unit dose packaging reimbursable.

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. Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (including H2 antagonists); feminine products smoking deterrents; and topical products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anticoagulants; anticonvulsants; chemotherapy agents; prescribed cold medications; contraceptives; estrogens; growth hormones; thyroid agents; and prescribed smoking deterrents. Therapeutic categories/products requiring prior authorization: analgesics, antipyretcs; and NSAIDs*; anorectics; antibiotics; antidepressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; ENT anti-inflammatory agents; hypotensive agents; misc. GI drugs*; sympathominetics (adrenergic); erectile dyfunction products; PPIs; Cox IIs; CNS stimulants; antifungals for nail fungus; leukotrine modifiers; glaucoma agents; triptans; anti-emetics; Alzheimer’s agents; and rheumatoid arthritis agents. *Brand approval override required for NSAIDs, controlled substances, and GI drugs for which there are therapeutically equivalent (A-rated) generics available. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home healthcare and extended care facilities, and through physician payment when used in physicians’ 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

Formulary/Prior Authorization Formulary: States maintain a formulary with a preferred drug list. General exclusions include cosmetic agents for hair growth, experimental and fertility drugs. Management of formulary includes prior authorization and quantity limits on certain products (e.g., anti-emetics, anti-migraine agents, etc.). Prior Authorization: State currently has a formal prior authorization procedure with an associated grievance and appeal procedure. Prescribing or Dispensing Limitations Monthly Quantity Limit: Limited to 30-day supply Maintenance Medications: Limited to 90-day Supply Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in July 1995. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $1.75, effective 1/24/2004. Ingredient Reimbursement Basis: EAC = AWP16%. Prescription Charge Formula: Lesser of usual and customary charge or AWP-16%, Federal Upper Limit; State MAC; or DOJ pricing, plus a dispensing fee. Special rules for Blood Factor products on the DOJ price list. 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 – Generics: $1.00; Brand: $2.00, effective 3/1/04. 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.

New Hampshire-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE None as of June 2003.

F. STATE CONTACTS

Medicaid DUR Board Paul S. Collins, M.D. Mark Henschke, D.O. Emory Kaplan, M.D. Steve Lawrence, M.D. Thomas Mellman, M.D. Elizabeth Gower, R.Ph. Helen Pervanas, R.Ph. Michael Smith, R.Ph. John Zinka, R.Ph.

State Drug Program Administrator Margaret A. Clifford Pharmacy Administrator Office of Medicaid Business and Policy 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4210 F: 603/271-8701 E-mail: [email protected] Internet address: www.dhhs.state.nh.gov/dhhs/medicaidprogram

New Brand Name Products Contact

Department of Health and Human Services Officials

Prescription Price Updating

John A. Stephen Commissioner Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-4331 F: 603/271-4912 E-mail: [email protected]

Lise C. Farrand, R.Ph. Pharmaceautical Services Specialist Office of Medicaid Business and Policy 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected]

Sherrill Bryant Plan Administrator First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected] Medicaid Drug Rebate Contacts

Stephen Norton Director Office of Health Planning & Medicaid Office of the Commissioner 129 Pleasant Street Concord, NH 03301-6521 T: 603/271-3676 F: 603/271-8431 E-mail: [email protected]

John Cox Rebate Pharmacist First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965/7647 E-mail: [email protected]

DUR Contact

Claims Submission Contact

Robert Coppola Clinical Manager First Health Services Corporation 17 Chenell Drive Concord, NH 03301 T: 603/224-2083 F: 603/224-6690 E-mail: [email protected]

Sherrill Bryant 800/884-2822 Medicaid Managed Care Contact Margaret A. Clifford 603/271-4210 Mail Order Pharmacy Benefit None

New Hampshire-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Disease Management/Patient Education Contact Doris Lotz, M.D. Medicaid Medical Director Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-8166 F: 603/271-8701 E-mail: [email protected] Pharmacy & Therapeutics Advisory Committee William Kassler, M.D., M.P.H. Stephen Bartels, M.D. Doris Lotz, M.D. Bryan King, M.D. Steven Paris, M.D. Richard Lafleur, M.D. Eric Pollak, M.D., M.P.H.Lenny Parker, R.Ph. Margaret Clifford, R.Ph. Roger Hebert, R.Ph. Paul Santos, Pharm.D. Robert Lenza, R.Ph.

New Hampshire State Board of Pharmacy Paul G. Boisseau, R.Ph. Executive Secretary 57 Regional Drive Concord, NH 03301-8518 T: 603/271-2350 F: 603/271-2856 E-mail: [email protected] Internet address: www.state.nh.us/pharmacy New Hampshire Hospital Association Michael J. Hill, C.H.E. President 125 Airport Road Concord, NH 03301-7300 T: 603/225-0900 F: 603/225/4346 E-mail: [email protected] Internet address: www.nhha.org

Executive Officers of State Medical and Pharmaceutical Services New Hampshire Medical Society Palmer P. Jones Executive Vice President 7 N. State Street Concord, NH 03301-4018 T: 603/224-1909 F: 603/226-2432 E-mail: [email protected] Internet address: www.nhms.org New Hampshire Pharmacists Association David Minnis Executive Director 2 Eagle Square, Suite 400 Concord, NH 03301 T: 603/229-0292 F: 603/224-7769 E-mail: [email protected] Internet address: www.nhpharmacists.org New Hampshire Osteopathic Association, Inc. Robert Soucy, D.O. President 7 North State Street Concord, NH 03301 603/224-1909 E-mail: [email protected] Internet address: www.nhosteopath.org

New Hampshire-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEW JERSEY A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures

Recipients

TOTAL

$686,301,522

296,059

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$363,069,902 $72,311,029 $285,795,677 $2,049,951 $2,913,245

139,560 28,986 85,000 14,902 10,672

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$10,351,402 $9,122,951 $1,223,455 $4,996 $0

3,657 3,389 254 14 0

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$111,545,421 $34,813,603 $73,422,788 $2,790,853 $469,454 $48,723

57,258 13,901 16,669 21,063 5,587 38

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$201,334,797

95,584

2003** Expenditures Recipients $766,995,569

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

1 The State of New Jersey did not respond to the 2002 or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid program to assess the accuracy and currency of the information included.

New Jersey-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

**2003 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2002 and CMS-64 Report, FY 2003.

New Jersey-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

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

Formulary: Open formulary. General exclusions include experimental drugs, cosmetics, fertility drugs, DESI drugs, and drugs for which FFP is not available (OBRA '90).

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, and DESI drugs. Prior authorization required for: methadone; IV infusions; and protein replacement supplements. Over-the-Counter Product Coverage: Products covered: digestive products (non-H2 antagonists); smoking deterrent products (inhalers or nasal spray); contraceptive devices and supplies; and family planning supplies (e.g., pregnancy test kits). Products covered with restrictions (for children under age 21 only): allergy, asthma, and sinus products; analgesics; topical products; and cough and cold preparations. Products not covered: digestive products; (H2 antagonists); feminine products; contraceptives; inhalation drugs; and antacids. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; ENT anti-inflammatory agents; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: anorectics (for ADD); contraceptives; growth hormones; and misc. GI drugs. Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and through physician payment when used in home health care, extended care facilities, and physician offices. Vaccines: Vaccines reimbursable at AWP as part of the Vaccines for Children Program.

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization is implemented by DUR edit criteria, not by therapeutic category. 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: Original, 34-day supply. Refills, 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. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.73 for legend drugs. Additional add-ons per/Rx shall be given to pharmacy providers who provide the following: 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.

Ingredient Reimbursement Basis: EAC = AWP12.5%. AAC for injectables, effective 5/1/00. Prescription Charge Formula: “Maximum Allowable Cost,” or Average Wholesale Price12.5% (reduction from AWP is pharmacy specific) plus a dispensing fee or the provider’s usual and customary charge, whichever is lower. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Dispense as Written” or “Medically Necessary.” Incentive Fee: None.

Unit Dose: Unit dose packaging reimbursable in long-term care facilities only, not in retail settings (unless u/d is only way item is packaged).

Patient Cost Sharing: None.

New Jersey-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Department of Human Services Officials

Cognitive Services: Does not pay for cognative services.

E. USE OF MANAGED CARE Approximately 640,000 Medicaid recipients received pharmacy benefits through managed care in 2003. Beneficiaries receive pharmaceutical benefits through the State and through MCOs. Mental health drugs and prescriptions for the aged, blind, and disabled (ABD) population are carved out of managed care. Managed Care Organizations AMERIGROUP New Jersey, Inc 399 Thornall Street, 9th Floor Edison, NJ 08837 800/600-4441

James M. Davy, Commissioner Department of Human Services Capitol Place One CN-700, 5th Floor P.O. Box 700 Trenton, NJ 08625 T: 609/292-3717 F: 609/292-3824 E-mail: [email protected] Ann Clemency Kohler, Director Division of Medical Assistance and Health Services Department of Human Services P.O. Box 712 Trenton, NJ 08625-0712 T: 609/588-2600 F: 609/588-3583 E-mail: [email protected] DUR Contact

Health Net of New Jersey, Inc. CNA Building 3501 State Highway 66 Neptune, NJ 07754 800/555-2604

Kaye Morrow Assistant Director Department of Human Services Division of Medical Assistance and Health Services Office of Provider Relations P.O. Box 712 Trenton, NJ 08619 T: 609/631-2396 F: 609/588-3889 E-mail: [email protected]

AmeriChoice of New Jersey, Inc. Two Gateway Center, 13th Floor Newark, NJ 07102 800/941-4647 Horizon NJ Health 210 Silvia Street Trenton, NJ 08628 800/765-4325

Medicaid DUR Board Christopher A. Cella, R.Ph. Judith Martinez Rodriguez, R.Ph. Joseph Nicholas Micale, M.D. Rochelle Dallago, R. Ph. Linda Gooen, Pharm D., R.Ph. Eileen Moynihan, M.D. David Ethan Swee, M.D.

University Health Plans, Inc. 550 Broad Street, 17th Floor Newark, NJ 07102 800/564-6847

Prior Authorization Contact

F. STATE CONTACTS State Drug Program Administrator Joseph B. Martinez, Chief Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services Office of Utilization Management P.O. Box 712 Trenton, NJ 08619 T: 609/588-2774 F: 609/588-3889 E-mail: [email protected] Internet address: www.state.nj.us

Marion Pardes Director First Health Services Corporation College Road Plainsboro, NJ 08536 T: 609/919-1897 F: 609/919-9465 E-mail: [email protected] New Brand Name Products Contact Joseph B. Martinez T: 609/588-2774

New Jersey-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Executive Officers of State Medical and Pharmaceutical Societies

Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 415/588-5454

Medical Society of New Jersey Michael T. Kornett Executive Director 2 Princess Road Lawrenceville, NJ 08648-2302 T: 609/896-1766 F: 609/896-1368 E-mail: [email protected] Internet address: www.msnj.org

Medicaid Drug Rebate Contacts Technical: Daniel Upright, 609/588-4611 Policy: Joseph B. Martinez, 609/588-2774 Claims Submission Contact Edward J. Vaccaro, R. Ph. Assistant Director Office of Utilization Management Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, NJ 08619 T: 609/588-3475 F: 609/588-3889 E-mail: [email protected] Medicaid Managed Care Contact Jill Simone, M.D. Director Managed Health Care Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712 Trenton, NJ 08619 T: 609/588-2705 F: 609/588-2774 E-mail: [email protected] Mail Order Benefit Program None Elderly Expanded Drug Coverage Contact Wade Epps, Director Department of Health and Senior Services 12 Quakerbridge Plaza Mercerville, NJ 08619 T: 609/588-7640 F: 609/631-4667 E-mail: [email protected]

New Jersey Pharmacists Association Joseph V. Roney, R.Ph. Chief Executive Officer 760 Alexander Road, P.O. Box 1 Princeton, NJ 08543-0001 T: 609/275-4246 F: 609/275-4066 E-mail: [email protected] Internet address: www.njpharma.org New Jersey Association of Osteopathic Physicians & Surgeons Robert W. Bowen Executive Director 1 Distribution Way, Suite 201 Monmouth Junction, NJ 08852 T: 732/940-9000 F: 732/940-8899 E-mail: [email protected] Internet address: www.njosteo.com New Jersey State Board of Pharmacy Remi Erdos Executive Director P.O. Box 45013 Newark, NJ 07101 973/504-6450 E-mail: [email protected] Internet address: www.state.nj.us/lps/ca/brief/pharm.htm New Jersey Hospital Association Gary S. Carter, FACHE President & CEO 760 Alexander Road, P.O. Box 1 Princeton, NJ 08543-0001 609/275-4000 E-mail: [email protected] Internet address: www.njha.com

New Jersey-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEW MEXICO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Blind/ Aged Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003* Expenditures Recipients

TOTAL

$92,674,018

122,098

$86,408,362

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$11,574,166 $2,231,875 $8,861,075 $167,821 $313,385

24,286 5,200 12,384 3,257 3,445

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$667,225 $41,483 $165,963 $430,430 $29,349 $0

8,009 132 254 7,110 513 0

$80,432,627

89,803

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

New Mexico-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and physician payment when used in physician offices, home health care, and extended care facilities.

Human Services Department (HSD), Medical Assistance Division.

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. Prior authorization required for: amphetamines and stimulants for ADD (adults only); nutritional supplements; and drugs used to treat impotence. 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; hormones; stimulants; drugs classified by FDA as “ineffective;” hypnotic drugs (barbiturates); and drugs without Medicaid rebate participation agreement. Over-the-Counter Product Coverage: OTC products covered when a) they may be the drug of choice for common medical conditions or b) when they are an appropriate and therapeutic alternative to prescription drugs. Products covered: insulin; antacids for active gastric and duodenal ulcers; infant vitamin drops for up to 1 year; Salicylates and acetaminophen; vitamins; iron; minerals; and pediculocides; laxatives, stool softeners, calcium, nicotine replacement, ibuprofen, antihistamines, decongestants, expectorants, cough suppressants, anti-candida, and antifungals. Products covered with restriction: topical products (specific therapeutic categories). Products not covered: personal care items (i.e., over-the-counter shampoo and soap); feminine products. Therapeutic Category Coverage: Products Covered: anabolic steroids; analgesics, antipyretics, and NSAIDs, antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents, antihistamines; antilipemic agents; antipsychotics; anxyolitics, 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; and thyroid agents. Prior authorization required: anoretics; sympathominetics (adrenergic); and drugs used to treat impotence.

Vaccines: Vaccines reimbursable as part of the EPSDT service, the Children’s Health Insurance Program, the Vaccine for Children Program,and various Department of Health Programs. Unit Dose: Does not reimburse for unit dose packaging. Formulary/Prior Authorization Formulary: Open formulary with preferred drug list (PDL). PDL managed through restrictions on use, prior authorization, and therapeutic “step” requirements. Prior Authorization: State currently has a formal prior authorization procedure screening for drug classes with right of fair hearing to appeal a prior authorization decision. Prescribing or Dispensing Limitations Monthly Quantity Limit: 34-day supply maximum, excluding birth control pills (1 year) and maintain drugs (90 days). Number of refills must conform to applicable State and Federal laws. Drug Utilization Review PRODUR system implemented in October 1993. State currently has a DUR Board that meets at between 1-4 times per year. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.65, effective 6/12/02. Ingredient Reimbursement Basis: EAC = AWP14%. 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. Override “Brand Necessary” or “Brand Medically Necessary.” Also prescriber is not prohibited from generic substitution and, if due to drug shortage, requesting reimbursement at the brand level.

New Mexico-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Medicaid Drug Rebate Contact

Incentive Fee: None. Patient Cost Sharing: No copayment, except $5.00 for CHIP clients and working disabled clients. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 250,000 Medicaid recipients enrolled in are MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans.

Sherry Montoya, Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7777 F: 505/827-3196 E-mail: [email protected] New Brand Name Products Contact Neal Solomon, M.P.H., R.Ph. 505/827-3174 Prescription Price Updating Contact

F. STATE CONTACTS State Drug Program Administrator Neal Solomon, M.P.H., R.Ph. Pharmacist, Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3196 E-mail: [email protected] DUR Contact Neal Solomon, M.P.H., R.Ph. 505/827-3174 DUR Board Denise Cuellar, Pharm.D. Greg D’Armour, Pharm.D. Gregory Toney, R.Ph., Ph.C. John Piper, Pharm.D. John Lauriello, M.D. Gayle Chacon, M.D. John Seibel, M.D. Judy Romero, Pharm.D. Manual Archuleta, M.D. Prior Authorization Contact Cynthia Wilson Pharmacy Program Manager Human Services Department Medical Assistance Division P.O. Box 2345 Santa Fe, NM 87504-2345 T: 505/827-3174 F: 505/827-3196 E-mail: [email protected]

First DataBank 111 Bayhill Drive, Suite 350 San Bruno, CA 94066 800/633-3453 Claims Submission ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8592 F: 770/730-5198 Medicaid Managed Care Contact Alana Reeves, Chief Contract Administration Bureau Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3131 F: 505/827-3185 E-mail: [email protected] Mail Order Pharmacy Program None Human Services Department Officials Pamela Hyde, J.D. Secretary New Mexico Department of Human Services P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7750 F: 505/827-6286 E-mail: [email protected] Internet address: www.state.nm.us/hsd

New Mexico-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Lila Maples, R.N. 2769 Villa Venado Santa Fe, NM 87505

Carolyn Ingram Director Medicaid Assistance Division New Mexico Department of Human Services P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3106 F: 505/827-3185 E-mail: [email protected]

Clarice Pick, D.D.S 1405 Luisa Street Suite #2 Santa Fe, NM 87505 Richard L. Ragel, D.O. 1010 Bridge Boulevard, SW, Suite D Albuquerque, NM 87105-3734

Medical Advisory Committee Members Linda Sechovec Executive Director NM Health Care 6400 Uptown Boulevard, NE, Suite 520-W Albuquerque, NM 87110

Kathy Minoli, C.F.N.P. 1835 Solano, NE Albuquerque, NM 87110 Mary Lou Edward 16 Applewood Lane, N.W. Albuquerque, NM 87107 505/898-5103

Yvette Ramirez Ammerman Policy Analyst New Mexico Primary Care Association 2309 Renard, S.E., Suite 209 Albuquerque, NM 87106

Richard Honsinger, M.S. Los Alamos Medical Center Los Alamos, NM 87544

Chris Isengard Executive Director Developmental Disabilities Planning Council 435 St. Michael’s Drive, Bldg. D Santa Fe, NM 87501

Maureen Boshier New Mexico Hospital Association 2121 Osuna Road NE Albuquerque, NM 87113

Michelle Lujan-Grisham New Mexico State Agency on Aging 228 East Palace Avenue Santa FE, NM 87501 Sam Cata, Commissioner Office of Indian Affairs 224 E. Palace Avenue Santa FE, NM 87501

Joie Glen Executive Director New Mexico Association for Home Care 3200 Carlisle N.E., Suite 115 Albuquerque, NM 87110 Bert Umland, M.D. Division of Family Practice UNM Medical Center Albuquerque, NM 87131 505/277-2165

Loyola Burgess 1801 Dorothy Street, NE Albuquerque, NM 87112 Walace Begay, Co-Chairman Pueblo Health Council/All Indian Pueblo Council P.O. Box 56 New Laguna, NM 87038 Rosalyn Curtis Director of the Navajo Nation Division of Health P.O. Box 1390 Window Rock, AZ 86515

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 T: 505/828-0237 F: 505/828-0336 E-mail: [email protected] Internet address: www.nmms.org

New Mexico-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Mexico Pharmaceutical Association R. Dale Tinker Executive Director 4800 Zuni, SE Albuquerque, NM 87108-2898 T: 505/265-8729 F: 505/255-8476 E-mail: [email protected] Internet address: www.nm-pharmacy.com New Mexico Osteopathic Medical Association Elizabeth “Betty” Barrett Executive Director P.O. Box 53098 Albuquerque, NM 87153-3098 T: 505/332-2146 F: 505/332-4861 E-mail: [email protected] Internet address: www.nmoma.org New Mexico State Board of Pharmacy Bill Harvey, R.Ph. Executive Director/Chief Drug Inspector 5200 Oakland, NE, Suite A Albuquerque, NM 87113 T: 505/222-9830 F: 505/222-9845 E-mail: [email protected] Internet address: www.state.nm.us/pharmacy New Mexico Hospitals and Health Systems Association Jeff Dye President and CEO 2121 Osuna Road, NE Albuquerque, NM 87113 T: 505/343-0010 F: 505/343-0012 E-mail: [email protected] Internet address: www.nmhhsa.org

New Mexico-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Mexico-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEW YORK A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$3,413,404,507

2,567,595

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$2,125,736,518 $372,043,201 $1,586,923,061 $62,747,562 $104,022,694

989,129 143,685 452,780 277,409 115,255

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$881,847,140 $227,546,353 $415,602,060 $99,410,347 $139,288,380

1,030,821 111,929 109,328 453,643 355,921

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$44,803,433 $0 $0 $44,035,613 $767,820 $0

221,363 0 0 215,136 6,227 0

$361,017,416

326,282

TOTAL OTHER EXPENDITURES/ RECIPIENTS*

2003** Expenditures Recipients $4,218,811,815

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

New York-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION State Department of Health, Office of Medicaid Management.

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. Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; smoking deterrent products (max. 2 courses of treatment/year); and topical products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; 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; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories partially covered: prescribed cold medication and misc. GI drugs. Therapeutic categories requiring prior authorization: antibiotics (zyvox only); second generation antihistamines; growth hormones; (serostim) medical/surgical supplies; orthopedic shoes; compression stockings; and some DME items. Therapeutic categories not covered: anorectics and agents used for hair growth. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care facilities and through physician payment when used in physician offices. In extended care facilities reimbursement for non-self administered injectable medicines is included in the facility rate. No special coverage policies exist for self-administered injectable medicines.

Formulary: Open formulary. Utilization managed through restrictions on use, prior authorization, and quantity limits. General exclusions: New York State follows OBRA '90 guidelines in the reimbursement of prescription drugs. Prior Authorization: State currently has a formal prior authorization procedure and a Pharmacy and Therapeutics Committee that meets quarterly. Although there is no formal method for appealing a prior authorization decision, the ordering prescriber may call the voice interactive system until the system issues a prior authorization number. All requests are approved. Beginning in November 2002, all brand name drugs with A-rated generics require prior authorization. Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of 5 refills within 6 months. Also, annual limits on number of prescriptions and prescription and nonprescription drugs without an override. Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in March 1995. State currently has a DUR Board which meets bimonthly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.50 for brand name drugs, $4.50 for generic drugs. Effective 8/1/98. Ingredient Reimbursement Basis: EAC = AWP12.75% for brand name drugs and AWP-16.5% for generics (effective 10/1/04). Prescription Charge Formula: 1.

Payment for multiple source drugs must not exceed the aggregate of the specified upper limit set by the Federal Centers for Medicare and Medicaid Services (CMS), plus a dispensing fee, for a particular drug; and

2.

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

3.

The billing pharmacy's usual and customary price charged to the general public.

Vaccines: Vaccines are reimbursable under the EPSDT service, CHIP, and the Vaccines for Children program. Unit Dose: Unit dose packaging not reimbursable. New York-2

National Pharmaceutical Council Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Must get prior authorization for most brand name products. (see www.health.state.ny.us/nysdoh/medicaid/ ptcommittee/mandatorggen.htm) Incentive Fee: $1.00 for dispensing a lower cost multi- source product. 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 2.1 million Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through the State. Health Maintenance Organizations − − − − − − − − − − − − − − − − − − − − − − − − − − − − − −

ABC Health Plan Affinity Health Plan AmeriChoice of New York Broome MAX Capitol District Physicians’ Health Plan Care Plus Center Care/Manhattan PHSP Community Choice HP of Westchester Community Premier Plus Excellus Health Plan Fidelis/NYS Catholic Health Plan GHI HMO HealthFirst PHPS Health Insurance Plan of Greater New York Health Plus PHPS HealthNow/BCBS-WNY/Community Blue HealthNow/Blue Shield of NENY HealthSource/Hudson Health Plan Independent Health Association Managed Health Manhattan PHSP/CenterCare MetroPlus Health Plan MVP Health Plan Neighborhood Health Providers NYPS Select Health NYP Community Health Plan NYS Catholic Health Plan PCMP Preferred Care SCHC Total Care/Syracuse PHSP

Pharmaceutical Benefits 2004 − − − − − − −

Southern Tier St. Barnabas/Partners in Health Suffolk Health Plan United Healthcare Plan of NY, Inc. Univera Community Health VidaCare, Inc. Wellcare of New York

F. STATE CONTACTS State Drug Program Administrator Mark-Richard A. Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Office of Medicaid Management NYS Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Internet address: www.health.state.ny.us Pharmacy Advisory Committee Kandyce Daley, R.Ph. Patricia Donato, R.Ph. Steven Giroux, R.Ph. Thomas Golden, R.Ph. John Navarra, R.Ph. (Chairman) Dilip Patel, R.Ph. Mohammed Saleh, R.Ph. John Westerman, R.Ph. Formulary Contact Mark-Richard A. Butt, M.S., R.Ph. 518/474-9219 Prior Authorization Contact Linda J. Jones Assistant Director Bureau of Program Guidance NYS Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]

New York-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pharmacy and Therapeutics Committee

Medicaid Drug Rebate Contacts

Roxanne Hall Richardson, R.Ph. Maria Amodio-Groton, Pharm.D. Andrew G. Flynn, R.Ph., C.G.P. William P. Scheer, R.Ph. Carl R. Reed, R.Ph., M.B.A. Judy K. Shaw, M.S., A.C.R.N., ANP-C Marc A. Johnson, M.D. Scott C. Bello, M.D. Steven E. Barnes, D.O. Aaron Satloff, M.D. Glenn A. Martin, M.D.

Audits: Thomas E. Howe Director, Audit Unit NYS Department of Health Corning Tower, Room 1336 Empire State Plaza Albany, NY 12237 T: 518/473-3920 F: 518/486-1405

DUR Contact Lydia J. Kosinski, R.Ph., Manager Recipient Activitiest and Utilization Review Office of Medicaid Management NYS Department of Health 800 North Pearl Street Albany, NY 12204 T: 518/474-6866 F: 518/473-5332 E-mail: [email protected]

Disputes: Joseph A. Maiello Pharmacy Rebate Manager Office of Medicaid Management NYS Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Policy: Mark-Richard A. Butt, M.S., R.Ph. 518/474-9219

DUR Committee

Claims Submission Contact

Physicians Richard S. Blum, M.D. Ronald J. Dougherty, M.D. David F. Lehmann, M.D. Jill Braverman-Panza, M.D., R.Ph.

eMedNY Computer Sciences Corporation (CSC) Attn: eMedNY Webmaster One CSC Way Rensselaer, NY 12144 800/343-9000 E-mail: [email protected]

Pharmacists Sidney Falow, R.Ph. John Gotowko, R.Ph., M.S., M.B.A. Marc L. Speert, R.Ph. Frank Barone, R.Ph. James R. Suhrbier, R.Ph. New Brand Name Products Contact Mark-Richard A. Butt, M.S., R.Ph. 518/474-9219 Prescription Price Updating Carl T. Cioppa, Pharm,D. Pharmacy Operations Manager NYS Dept. of Health Office of Medicaid Management 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]

Medicaid Managed Care Contact Elizabeth Macfarlane, Director Bureau of Managed Care Planning Office of Managed Care NYS Department of Health Room 1927, Corning Tower Empire State Plaza Albany, NY 12237-0064 T: 518/473-0122 F: 518/474-5886 E-mail: [email protected] Disease Management/Patient Education Programs Disease/Medical State: AIDS/HIV Program Name: Aids Intervention Management Program Program Manager: Guthrie Birkhead Program Sponser: AIDS Institute, NYSDOH

New York-4

National Pharmaceutical Council Disease/Medical State: Asthma Program Name: NYS Asthma Grant Program Manager: Patricia Waniewski Program Sponser: Division of Family Health, NYSDOH Disease/Medical State: Diabetes Program Name: Diabetes Prevention and Control Program Program Manager: Maureen Spence Program Sponser: Bureau of Chronic Disease Services, NYSDOH Disease/Medical State: Smoking Cessation Program Name: Smokers’ Quit Line Program Manager: [email protected] Program Sponsor: Roswell Park and NYSDOH Disease/Medical State: Cardiovascular Disease Program Name: Healthy Heart Program Program Manager: [email protected] Program Sponser: NYDOH Disease Management Program/Initiative Contacts Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance Office of Medicaid Management NYS Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Mail Order Pharmacy Program None Expanded Drug Program Contact Julie Naglieri Director NYS Department of Health Program Elderly Prescription Insurance Coverage (EPIC) 1 Corporate Plaza, Suite 101 260 Washington Avenue Albany, NY 12203 T: 518/452-6828 F: 518/452-6882 E-mail: [email protected] Internet address: www.health.state.ny.us/nysdoh/epic

Pharmaceutical Benefits 2004 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 T: 518/474-2011 F: 518/474-5450 E-mail: [email protected] 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 T: 518/474-3018 F: 518/486-6852 E-mail: [email protected] Title XIX Medical Care Advisory Committee Ruben P. Cowart, D.D.S., (Chairman) John Angerosa, M.D. Steven E. Barnes, D.O. Russel N. Cecil, M.D. David Cerniglia, D.C. Stoner E. Horey, M.D. Mary K. Lashomb Norman R. Loomis, M.D. Hugo M. Morales, M.D., P.C. Tanton Mustapha, M.D. Leon Nadrowski, M.D. Dennis P. Norfleet, M.D. Elena Padilla, Ph.D. Carl P. Sahler, M.D., Ph.D. Robert A. Schwartz, M.D. Gavin Setzen, M.D. Kathleen Benson Smith Patricia Stevens, Deputy Commissioner, NYS Office of Temporary and Disability Assistance (DSS Representative) Roger W. Trifthauser, D.D.S., M.S.

New York-5

National Pharmaceutical Council Executive Officers of State Medical and Pharmaceutical Societies Medical Society of the State of New York William R. Abrams Executive Vice President 420 Lakeville Road P.O. Box 5404 Lake Success, NY 11042-5404 T: 516/488-6100 F: 516-488-6136 E-mail: [email protected] Internet address: www.mssny.org

Pharmaceutical Benefits 2004 Greater New York Hospital Association Kenneth E. Raske President 555 W. 57th Street 15th Floor New York, NY 10019 T: 212/246-7100 F: 212/262-6350 E-mail: [email protected] Internet address: www.gnyha.org

Pharmasists Society for the State of New York Craig M. Burridge, M.S., CAE Executive Director 210 Washington Avenue Extension Albany, NY 12203-5335 T: 518/869-6595 F: 518/464-0618 E-mail: [email protected] Internet address: www.pssny.org/index_new.htm New York State Osteopathic Medical Society, Inc. Martin Diamond, D.O. Interim Executive Director 1855 Broadway, Suite 1102A New York, NY 10023 T: 800/841-4131 F: 312/202-8224 E-mail: [email protected] Internet address: www.nysoms.org New York State Board of Pharmacy Lawrence H. Mokhiber Executive Secretary Office of the Professions Division of Professional Licensing Services 89 Washington Avenue, Second Floor W Albany, NY 12234-1000 T: 518/474-3817 F: 518/473-6995 E-mail: [email protected] Internet address: www.nysed.gov/prof/pharm.htm Healthcare Association of New York State Daniel Sisto President One Empire Drive Rensselaer, NY 12114 T: 518/431-7600 F: 518/431-7915 E-mail: [email protected] Internet address: www.hanys.org

New York-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NORTH CAROLINA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures TOTAL

Recipients

$1,069,140,895

949,795

$603,557,480 $158,697,938 $340,911,000 $32,488,999 $71,459,543

450,000 63,887 130,730 132,601 122,782

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$69,821,479 $47,950,356 $18,071,505 $276,567 $3,523,051

28,176 16,850 6,202 789 4,335

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$370,773,038 $148,954,057 $147,615,329 $68,217,052 $5,986,600 $0

421,345 61,023 53,941 272,181 34,200 0

$24,988,898

50,274

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS

2003** Expenditures Recipients $1,291,263,155

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

North Carolina-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Prior Authorization: Formal prior authorization process can be found at: ww.ncmedicaidpbm.com. A prescriber’s written justification is required to appeal a prior authorization decision.

C. ADMINISTRATION Division of Medical Assistance, Department of Health and Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations used for insulin; blood glucose test strips; total parenteral nutrition; interdialytic parenteral nutrition; OTC drugs not listed on the selected coverage list; and those products/categories mentioned below under “Therapeutic Category Coverage” section.

Prescribing or Dispensing Limitations Monthly Quantity Limit: 34-day supply maximum. Except birth control tablets and hormonal replacement therapy dial packs: 3 months; maintenance non-controlled medications, tied with the FUL and/or SMAC after a prior successful fill may receive a 3 month supply upon the prescribers discretion. Monthly Prescription Limit: Six prescriptions per month per recipient. Prescription Dollar Limits: None.

Over-the-Counter Product Coverage: North Carolina covers a select list of OTC products. (See www.dhhs.state.nc.us/dma/mp/mpindex.htm for a complete list of covered OTC products.)

Drug Utilization Review

Therapeutic Category Coverage: North Carolina provides coverage for all therapeutic categories except anoretics; products used for cosmetic purposes; fertility drugs; diaphragms; IV fluids (Dextrose 500ml or greater) and irrigations fluids used in an inpatient facility; drugs on the DESI list; any drug manufactured by a company who has not signed the Federal rebate agreement; and experimental drugs. Prior authorization required for: analgesics, antipyretics, and NSAIDs; drugs used to treat ADHD; Procrit/Epogen; Neupogen; Aransep; OxyContin; Growth Hormones;Provigil; Rebetron; Vioxx; Celebrex; Bextra; Botox; Mybloc; Zyban, Nicotrol, Nicotine Patch; Synagis; and RespiGam. (See www.ncmedicaidpbm.com for additional information.)

Pharmacy Payment and Patient Cost Sharing

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facility, and through physician payment when used in physician offices.

Unit Dose: Unit dose packaging not reimbursable.

Formulary: Open formulary.

Dispensing Fee: B: $4.00; G: $5.60, effective 2002. Ingredient Reimbursement Basis: EAC = AWP10%. Prescription Charge Formula: The lowest price of AWP minus 10%, State MAC or Federal MAC plus a dispensing fee or usual and customary, whichever is lowest. 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 as well as State-specific maximum allowable cost (MAC) limits generic drugs. 433 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary” written on the face of the prescription by the prescriber. Incentive Fee: $1.60 to dispense a lower cost multisource product.

Vaccines: Vaccines reimbursable as part of the ESPDT service and The Vaccines for Children Program.

Formulary/Prior Authorization

PRODUR system implemented in May 1996. State currently has a DUR Board with a quarterly review.

Patient Cost Sharing: $1.00 copayment/Rx (includes refills) for generic prescriptions; $3.00 copayment/Rx for brand name prescriptions. Cognitive Services: Does not pay for cognitive services.

North Carolina-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Approximately 11,500 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through the State. Managed Care Organizations SouthCare/Coventry 2815 Coliseum Center Drive Suite 550 Charlotte, NC 28217 800/350-6294

Members at Large Sandy Newton Gina Upchurch New Brand Name Products Contact Tom D’Andrea, R.Ph., M.B.A. 919/855-4300 Prescription Price Updating Tom D’Andrea, R.Ph., M.B.A. 919/855-4300 Medicaid Drug Rebate Contact

F. STATE CONTACTS State Drug Program Administrator Tom D’Andrea, R.Ph., M.B.A. Chief of Pharmacy and Ancillary Services Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma Prior Authorization Contact Tom D’Andrea, R.Ph., M.B.A. 919/855-4300 DUR Contact Melissa Weeks, R.Ph., Pharm.D. Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected] Medicaid Drug Utilization Review Board Physicians: Edward Treadwell, M.D. Steve Wegner, M.D. Pharmacists: Joseph S. Moose, R.Ph., Pharm. D. Al Lockramy Wayne Creech, R. Ph. Martha Jones, Pharm. D. Thomas Thutt

Audits: Tom D’Andrea, R.Ph., M.B.A. 919/855-4300 Rebate Disputes: Sharon Greeson, R.Ph. Pharmacy Program Manager EDS 4905 Waters Edge Drive Raleigh, NC 27606 T: 919/816-4475 F: 919/816-4399 E-mail: [email protected] Claims Submission Contact Sharon Greeson, R.Ph. 919/816-4475 Medicaid Managed Care Contact Jeffrey Simms Assistant Director- Managed Care Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27613 919/647-8170 Mail Order Pharmacy Program None Department of Human Resources Officials Carmen Hooker Odom Secretary Department of Health and Human Services 2001 Mail Service Center 101 Blair Drive Raleigh, NC 27699-2001 T: 919/733-4534 F: 919/715-4645 E-mail: [email protected]

North Carolina-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004 North Carolina Hospital Association William A. Pulley President P.O. Box 4449 Cary, NC 27519-4449 T: 919/677-2400 F: 919/677-4200 E-mail: [email protected] Internet address:

Mark Benton, Interim Director Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/855-4100 F: 919/733-6608 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies North Carolina Medical Society Robert W. Seligson, M.B.A., CAE Executive Vice President and CEO P.O. Box 27167 Raleigh, NC 27611-7167 T: 919/833-3836 F: 919/833-2023 E-mail: [email protected] Internet address: www.ncmedsoc.org North Carolina Association of Pharmacists Fred Eckel Executive Director 109 Church Street Chapel Hill, NC 27516-2502 T: 919/967-2237 F: 919/968-9430 E-mail: [email protected] Internet address: www.ncpharmacists.org North Carolina Osteopathic Medical Association Jeffrey J. LeBoeuf Executive Director 8311 Brier Creek Parkway Raleigh, NC 27617 T: 888/626-6248 F: 910/763-4666 E-mail: [email protected] Internet address: www.ncoma.org North Carolina State Board of Pharmacy David R. Work Executive Director P.O. Box 4560 Chapel Hill, NC 27515-4560 T: 919/942-4454 F: 919/967-5757 E-mail: [email protected] Internet address: www.ncbop.org

North Carolina-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NORTH DAKOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$51,749,961

44,428

$56,960,417

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$24,615,037 $4,732,778 $14,828,540 $1,914,375 $3,139,344

22,125 1,868 5,185 9,228 5,844

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

$22,863,537 $14,650,825 $7,382,657 $377,862 $452,193

9,804 5,748 2,254 1,083 719

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

$367,360 $7,319 $6,279 $335,504 $18,258 $0

1,758 32 22 1,549 155 0

$3,904,027

10,741

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

North Dakota-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION

Formulary: Open formulary

North Dakota Department of Human 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 total parenteral nutrition. Products not covered: cosmetics; fertility drugs; urine ketone test strips; interdialytic parenteral nutrition; drugs used for hair growth; prescription vitamins (except prenatal vitamins); and DESI drugs. Prior authorization required for: nutritional supplements; and orlistat. Over-the-Counter Product Coverage: Products covered: antacids; analgesics; iron supplements; digestive products; and anti-ulcer medications. Products covered with restriction: allergy, asthma, and sinus products (loratadine only); and topical products (artificial tears only); smoking deterrent products (lifetime limits). Products not covered: cough and cold preparations; feminine products. Therapeutic Category Coverage: Categories covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticouvulsants; anti-depressants; antidiabetic agents; 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, sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterents (partial coverage). Prior authorization required for: brand name NSAIDs, anoretics (orlistat); antihistamines; and PPIs. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, and extended care facilities, and through both the Prescription drug program and physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of the EPSDT service.

Prior Authorization: State currently has a formal prior authorization procedure. Beneficiary can request a fair hearing to appeal a prior authorization decision. Prescribing or Dispensing Limitations Prescription Refill Limit: 5 refills per script. Monthly Quantity Limit: 34-day supply. Monthly Dollar Limits: None. Drug Utilization Review PRODUR system implemented in July 1996. State has a DUR Board that meets quarterly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.60 for generic, $4.60 for brand effective 8/1/03. Ingredient Reimbursement Basis: EAC = AWP10%. 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 as well as State-specific limits on generic drugs. Override requires “Dispense As Written.” Incentive Fee: None. Patient Cost Sharing: $3.00 (brand-name drugs) Cognitive Services: Does not pay for cognitive services

E. USE OF MANAGED CARE Approximately 3,500 Medicaid recipients were enrolled in managed care organizations in 2003. Recipients enrolled in MCO’s receive pharmacy benefits through the State.

Unit Dose: Unit dose packaging not reimbursable.

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F. STATE CONTACTS

Claims Submission Contact

State Drug Program Administrator

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected] Internet address: www.state.nd.us/humanservices Prior Authorization Contact

Medicaid Managed Care Contact Tom Solberg, Administrator Managed Care ND Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismark, ND 58505-0261 T: 701/328-1884 F: 701/328-1544 E-mail: [email protected]

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Disease Management Program/Initiative Contact

DUR Contact

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Mail Order Pharmacy Benefit Program

DUR Board

Department of Human Services Officials

Carrie Sorenson, Pharm.D. Patricia Churchill, R.Ph. Leann Ness, Pharm.D. Greg Pfister, Pharm.D. John Savageau, R.Ph. Robert Treitline, RPh Kamille Sherman, MD Cheryl Huber, M.D. Norman Byers, M.D. Albert Samuelson, M.D. Jay Huber, M.D. Gary Betting, M.D. Brendan K. Joyce, Pharm.D., R.Ph. Scott Setzepfandt, R.Ph.

Carol K. Olson Executive Director ND Dept. of Human Services 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-2538 F: 701/328-1545 E-mail: [email protected]

None

New Brand Name Products Contact

Dave Zentner, Director Division of Medical Services 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0261 T: 701/328-2321 F: 701/328-1544 E-mail: [email protected]

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Medical Care Advisory Committee

Prescription Price Updating Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023 Medicaid Drug Rebate Contact Brendan K. Joyce, Pharm.D., R.Ph. 701/328-4023

Terry Dwelle, M.D. Lynn Blakeman Alison Fallgater, D.D.S. Amy Fleck, O.D. Howard Anderson, R.Ph. Terry Johnson, M.D. David Peske Gary Betting, M.D.

North Dakota-3

National Pharmaceutical Council Pharmacy Advisory Committee Robert L. Treitline (Chair) Dickinson, ND Anton P. Welder, R.Ph. Bismarck, ND Doreen M. Beiswanger, R.Ph. Valley City, ND David L. Just, R.Ph. Beulah, ND David J. Olig, R.Ph. Fargo, ND DuWayne Schlittenhard, R.Ph. Fargo, ND

Pharmaceutical Benefits 2004 North Dakota State Board of Pharmacy Howard C. Anderson Executive Director P. O. Box 1354 Bismarck, ND 5802-1354 T: 701/328-9535 F: 701/328-9536 E-mail: [email protected] Internet address: www.nodakpharmacy.com North Dakota Healthcare Association Arnold R. Thomas, President P.O. Box 7340 1622 E. Interstate Avenue Bismarck, ND 58503 T: 701/224-9732 F: 701/224-9529 E-mail: [email protected] Internet address: www.ndha.org

Mary Beth Reinke, R.Ph. Fargo, ND Cindy Yeager, R.Ph. Fargo, ND Executive Officers of State Medical and Pharmaceutical Societies North Dakota Medical Association Bruce Levi Executive Vice President P.O. Box 1198 Bismarck, ND 58502-1198 T: 701/223-9475 F: 701/223-9476 E-mail: [email protected] Internet address: www.ndmed.com North Dakota State Osteopathic Association Carmen Christianson Bell President Director 1600 2nd Avenue, SW, Suite 20 Minot, ND 58701 701/852-8798 E-mail: [email protected] Internet address: www.ndoma.org North Dakota Pharmacists Association Patricia A. Hill Executive Vice President 1661 Capitol Way, Suite 102 Bismarck, ND 58501-2195 T: 701/258-4968 F: 701/258-9312 E-mail: [email protected] Internet address: www.nodakpharmacy.net North Dakota-4

National Pharmaceutical Council

Pharmaceutical Benefits 2004

OHIO A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Aged

Medically Needy (MN) Blind/ Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures TOTAL

Recipients

$1,330,569,382

997,246

$636,705,938 $98,218,659 $510,976,291 $13,850,390 $13,660,598

287,972 33,902 171,277 59,837 22,956

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$47,855,411 $2,277,564 $5,780,069 $36,005,788 $3,791,990 $0

164,830 1,878 3,194 138,564 21,194 0

$646,008,033

544,444

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $1,520,147,470

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

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C. ADMINISTRATION

Approved Drug List (ADL)/Prior Authorization

Ohio Department of Job and Family Services, Bureau of Health Plan Policy.

ADL: Closed ADL of preferred products with approximately 28,000 NDC-specific trade and generic drugs. Products excluded include obesity, fertility, and experimental drugs. ADL managed by excluding products based on contracting issues, restrictions on use, and prior authorization.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: most drugs including prescribed insulin. Products not covered: cosmetics; fertility drugs; obesity drugs; experimental drugs. Prior authorization required for some drugs including these examples: Ceredase; Cerebyx; Cerezyme; Clorazepates; Depo-Provera; Enbrel; immunoglobulins; Lioresal Intrathecal; Lodosyn; Nascobal; Orgaran; Oxandrin Panretin; Periostat; Priftin; Prolastin; Proleukin; Provigil; Psoralens; Remicade; Rituxan; Stimate; Synagis; and Targretin. Products covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parentaral nutrition (PA required); and interdialytic parenteral nutrition (PA required).

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization is needed for certain individual drugs (see examples above) A beneficiary may appeal a prior authorization decision and be granted an administrative hearing. Manufactures may also request reconsideration for an excluded product. Prescribing or Dispensing Limitations Monthly Dollar Limits: None Monthly Quanity Limits: None Quanity Limit per Prescription: 34-day supply. 102day supply for chronic maintenance medications.

OTC Coverage: Selective coverage for: allergy, asthma, and sinus products; analgesics; feminine products; smoking deterrent products; cough and cold preparations; digestive products; topical products; laxatives; antacids; and vitamins and minerals.

Prescription Refill Limit: 5 refills per script. Drug Utilization Review PRODUR system implemented through POS in Feb 2000. State currently has a DUR Board with quarterly review.

Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, and NSAIDS; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anbabolic steroids; antihistamines; cardiac drugs; prescribed cold medications; growth hormones; hypotensive agents; misc. GI drugs; and prescribed smoking deterrents. Therapeutic categories not covered: anorectics; innovator multi-source drugs; selected high-risk drugs (e.g., Accutane); and drugs used in special settings (e.g., outpatient hospital).

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.70, effective 7/1/98. ($0.50 fee for flu vaccine.) Ingredient Reimbursement Basis: EAC = WAC+9% (eff. 5/1/02). Prescription Reimbursement Formula: Reimbursement for legend drugs and selected OTC products based on the lowest of: 1.

2. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians offices.

3.

Provider’s submitted charge, which should reflect usual and customary charge to the general public; WAC+9% 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 + 9% plus a dispensing fee, or MAC if applicable. Special reimbursement for Blood Factors 8 and 9.

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires prior authorization. Ohio-2

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F. STATE CONTACTS

Incentive Fee: None.

State Program Drug Administrator Patient Cost Sharing: $3.00 (for prior authorized drugs)

Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Ohio Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected] Internet address: www.jfs.ohio.gov

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 435,000 Medicaid recipients were enrolled in managed care in 2003. All received pharmacy services through managed care plans.

New Brand Name Products Contact

Managed Care Organizations

Robert P. Reid, R.Ph. 614/466-6420

Buckeye Community Health Plan 175 South Third Street Suite 1200 Columbus, OH 43215 866/246-4356

Prior Authorization Contacts Drugs: Robert P. Reid, R.Ph. 614/466-6420

Dayton Area Health Plan (CareSource) One South Main Street Suite 900 Dayton, OH 45402 937/224-3300

DME/Nutritions: Bonnie Brownlee 614/466-6065 DUR Contact Jeff Corzine DUR Administrator 255 East State Street Columbus, OH 43215 T: 614/466-9689 F: 614/-466-2866

PrimeTime Medical Insurance Company (MediPlan) P.O. Box 6907 Canton, OH 44706 330/451-0934

DUR Board

Paramount Care, Inc. P.O. Box 928 Toledo, OH 43697-0928 419/887-2550

Thomas E. Gretter, M.D. Timothy Garner, M.D. Jacob F. Palomaki, M.D. Beth T. Tranen, D.O. Rob Kubasak, R.Ph. Sue Eastman, R.Ph. Jill Orn, R.Ph. Donald Sullivan, Ph.D., R.Ph.

QualChoice Health Plan 6000 Parkland Boulevard Cleveland, OH 44124 440/460-0093

Prescription Price Updating

SummaCare P.O. Box 3620 Akron, OH 44309 330/996-8410

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578 Medicaid Drug Rebate Contacts Robert P. Reid, R.Ph. 614/466-6420

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Department of Job and Family Services Officials

Claims Submission Contact First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7696

Barbara Riley, Director Ohio Department of Job and Family Services 30 East Broad Street, 32nd Floor Columbus, OH 43215-3414 T: 614/466-6282 F: 614/466-2815 E-mail: [email protected]

Medicaid Managed Care Contact John Barley Bureau of Managed Health Care Ohio Department of Job and Family Services 255 E. Main Street Columbus, OH 43215 614/466-4693

Barbara C. Edwards, Deputy Director Ohio Health Plans Ohio Department of Job and Family Services 30 East Broad Street, 31st Floor Columbus, OH 43215-3414 T: 614/466-0140 F: 614/752-3986 E-mail: [email protected]

Mail Order Pharmacy Benefit State has mail order providers. Recipients free to select mail order pharmacy of their choosing. Pharmacy and Therapeutics Committee

Medical Care Advisory Committee

Robert P. Reid, R.Ph., Chairman Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43266-0423

Jerry Friedman, (Chair) Cindy Norwood Ed Lentz Hubert Wirtz Robert Logan Eugene King, J.D. Pamela Morris Frank Giganti Walter Clark, M.D. Sam Chapman Robert Staib Jack Cera Art Schlesinger Randall Garland William Sawyer, M.D. Lolita M. McDavid, M.D., M.P.A. Maureen Mitchell, R.N., Ed.D. Sherri Morgan, M.D., M.P.H. Christopher Moore Nancy Lee Kathleen Anderson Katherine Kuck Donna Skoda, M.S., R.D., L.D. Clifford Deveny, M.D. Randy Runyon Brian Tilow

Suzanne Eastman, R.Ph., M.S. 3922 North Cliff Lane Cincinnati, OH 43220 Michael Alexander, D.O. 3219 Sullivant Avenue Columbus, OH 43204 Ruth E. Purdy, D.O. 4830 Slate Run Court Columbus, OH 43220 Susan Baker, APN 2288 Kings Corners East Lexington, OH 44904 Mary Jo Welker, M.D. 2231 North High Street Columbus, OH 43201 Jennifer Christner, M.D. 2262 Parkwood Toledo, OH 43620 Sandra Hrometz, R.Ph, Ph.D. 740 E. College Avenue Bluffton, OH 43209 Tammie J. Stroup, R.Ph. 30 E. Broad Street, 27th Floor Columbus, OH 43215-3414

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Pharmaceutical Benefits 2004

Executive Officers of State Medical and Pharmaceutical Societies Ohio State Medical Association Brent Mulgrew Executive Director 3401 Mill Run Drive Hilliard, OH 43026 T: 800/766-6762 F: 614/527-6763 E-mail: [email protected] Internet address: www.osma.org Ohio Pharmacists Association Ernest E. Boyd Executive Director 6037 Frantz Road, Suite 106 Dublin, OH 43017 T: 614/798-0037 F: 614/798-0978 E-mail: [email protected] Internet address: www.ohiopharmacists.org Ohio Osteopathic Association Jon F. Wills Executive Director 53 W. 3rd Avenue P.O. Box 8130 Columbus, OH 43201 T: 614/299-2107 F: 614/294-0457 E-mail: [email protected] Internet address: www.ooanet.org Ohio State Board of Pharmacy William T. Winsley Executive Director 77 S. High Street, Room 1702 Columbus, OH 43215-6126 T: 614/466-4143 F: 614/752-4836 E-mail: [email protected] Interent address: www.state.oh.us/pharmacy/ Ohio Hospital Association James Castle President and CEO 155 E. Broad Street, 15th Floor Columbus, OH 43215-3620 T: 614/221-7614 F: 614/221-4771 E-mail: [email protected] Internet address: www.ohanet.org

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Pharmaceutical Benefits 2004

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

OKLAHOMA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy

Medically Needy (MN)

Aged

Blind/ Disabled

Child

Adult

Aged

Blind/ Disabled

Child

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$267,549,002

276,111

$93,374,439 $26,963,385 $64,994,426 $791,061 $625,567

64,654 22,887 37,378 3,079 1,310

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$386,198 $16,944 $195,575 $104,496 $69,183

607 40 148 220 199

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$35,945,183 $124,949 $195,087 $33,687,481 $1,937,666 $0

148,226 217 211 132,437 15,361 0

$137,843,182

62,624

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $301,294,000

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

1

Note: As of January 1, 2004, (after the survey was conducted) the Oklahoma Medicaid program, according to its website, underwent changes regarding managed care. These changes will be reflected in the 2004 compilation. Please contact the State for information on the changes in managed care.

Oklahoma-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Oklahoma-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Formulary/Prior Authorization

Oklahoma Health Care Authority.

Formulary: Open formulary with the preferred drug list (PDL). PDL managed through restrictions on use, prior authorization, therapeutic substitution, use of preferred products, and step therapy.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered (DME benefit): 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, not reimbursed through pharmacy program). Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: birth control products. Products covered with restrictions: allergy, asthma, and sinus products (Claritin OTC only for children < 21 years. PA required for adults. Rx required for all ages.); digestive products (non-H2 antagonists-Prilosec OTC only, Rx required); smoking deterrent products (PA and Rx required). Products not covered: analgesics; cough and cold preparations; H2 antagonists; feminine products; topical products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anoretics (partial coverage); analgesics, antipyretics, NSAIDs; antihistamine drugs (partial coverage); anxiolytics, sedatives, and hypnotics; cardiac drugs; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents (partial coverage) stimulants for ADHD; clopidigrel; and montelukast. Therapeutic categories not covered: anabolic steroids; and prescribed cold medications. OBRA ’90 drugs identified as "coverage optional." Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and physician payment when used in home health care and extended care facilities, and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of EPSDT services and the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Prior Authorization: State currently has a formal prior authorization procedure. Grievance process exists for appeal of prior authorization decisions or coverage of an excluded product to the agency’s Administrative Law Judge. Recipient must present compelling reason to obtain coverage. Prescription or Dispensing Limitations Prescription Refills: None Monthly Quantity Limits: Six prescriptions per month/recipient, including a maximum of three brand name scripts. ICF-MR, Medicaid children, and nursing home recipients are allowed unlimited orders. Clients on Home and Community Based Waivers and DDSD Waivers are also allowed an unlimited number of prescriptions each month. Quantity Limit per Prescription: Greater of 34-day supply or 100 units. Drug Utilization Review PRODUR system implemented in 2000. State currently has a DUR Board with a monthly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.15, effective 10/95. Ingredient Reimbursement Basis: EAC = AWP12.0%. 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 as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary” and prior authorization (effective 12/04). Currently, 917 drugs on MAC list. 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.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE

Medicaid Drug Rebate Contact

Approximately 185,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive benefits through both the State and managed care plans. Effective 1/1/2004, there will be no fully capitated managed care plans in Oklahoma. The Primary Care/Care Management System will remain in place.

Tom P. Simonson Drug Rebate Manager Oklahoma Healthcare Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7327 F: 405/530-3236 E-mail: [email protected]

F. STATE CONTACTS State Drug Program Administrator Nancy Nesser, D.Ph., J.D. Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7325 F: 405/530-3235 E-mail: [email protected] Internet address: www.ohca.state.ok.us Prior Authorization Contact Ronald Graham, D.Ph. Manager, Operations/DUR University of Oklahoma, College of Pharmacy P.O. Box 26901 Oklahoma City, OK 73109 T: 405/271-6614 F: 405/271-2615 E-mail: [email protected] DUR Contact Ronald Graham, D.Ph. 405/271-6614 Medicaid DUR Board Dick Robinson, D.Ph. (Vice-Chair) Dorothy Gourley, D.Ph. Cliff Meece, D.Ph. Greg Tarasoff, M.D. Cathy E. Hollen, D.Ph. Brent Bell, D.O., D.Ph. Thomas Whitsett, M.D. (Chair) Dan McNeill, Ph.D., PA-C James Swaim, D.Ph. Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 800/633-3453 Internet address: www.firstdatabank.com

New Brand Name Products Contact Rodney Ramsey Drug Reference Coordinator Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7492 F: 405/530-7119 E-mail: [email protected] Claims Submission Contact EDS 2401 N.W. 23rd Street, Suite 11 Oklahoma City, OK 73107 405/416-6794 Medicare Managed Care Contact Melinda Jones Senior Compliance Analyst Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105-9901 T: 405/522-7125 F: 405/530-3281 E-mail: [email protected] Mail Order Pharmacy Program Oklahoma has a mail order pharmacy option. Pharmacy must be a contracted provider. Disease Management Program/Initiative Contact Alex Easton Pharmacy Operations Manager Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7453 F: 405/522-3238 E-mail: [email protected]

Oklahoma-4

National Pharmaceutical Council Oklahoma Health Care Authority Officials Michael Fogarty, J.D. Chief Executive Officer Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7300 F: 405/522-7187 E-mail: [email protected] Lynn Mitchell, M.D., M.P.H. Medicaid Director Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/530-7365 F: 405/530-3218 E-mail: [email protected] Oklahoma Health Care Authority Board Charles Ed McFall (Chair) Wayne Hoffman (Vice Chair) George Miller Anne M. Roberts Lyle Roggow Medical Advisory Committee Steven A. Crawford, M.D. (Chair) Dan McNeil, Ph.D. (Vice Chair) E. Edward Beckham, Ph.D. Bruce Bennett Steve Buck Tanya Case Terry Cline, Ph.D. Mike Crutcher, M.D. Sherry Davis, A.R.N.P. Steve Goforth Michael Grim, Ph.D. Stanley E. Grogg, D.O. Howard Hendrick Jo Hill Ragina Holiman, M.S., C.N.S. Craig Jones Richard Langerman, D.O. Greg Machtolff, D.D.S. Kelli McNeal James Murtaugh, D.D.S. Ann S. Owen, Ph.D. J. Daniel Post, D.C. Jerry Unruh Steven Walker, D.P.M. Gara Wilsie, D.Ph. Travis Yadon, O.D.

Pharmaceutical Benefits 2004 Executive Officers of State Medical, Pharmaceutical, and Osteopathic Societies Oklahoma State Medical Association Brian O. Foy, Executive Director 601 NW Grand Boulevard Oklahoma City, OK 73118 T: 405/843-9571 F: 405/842-1834 E-mail: [email protected] Internet address: www.osmaonline.org Oklahoma Pharmacists Association Phil Woodward, Ph.D., Executive Director P.O. Box 18731 Oklahoma City, OK 73154 T: 405/528-3338 F: 405/528-1417 E-mail: [email protected] Internet address: www.opha.com Oklahoma Osteopathic Association Lynette C. McLain Executive Director 4848 N. Lincoln Boulevard Oklahoma City, OK 73105 T: 405/528-4848 F: 405/528-6102 E-mail: [email protected] Internet address: www.okosteo.org Oklahoma State Board of Pharmacy Bryan Potter Executive Director 4545 N. Lincoln Boulevard, Suite 112 Oklahoma City, OK 73105-3488 T: 405/521-3815 F: 405/521-3758 E-mail: [email protected] Internet address: www.pharmacy.state.ok.us Oklahoma Hospital Association Craig W. Jones President 4000 Lincoln Boulevard Oklahoma City, OK 73105 T: 405/427-9537 F: 405/424-4507 E-mail: [email protected] Internet address: www.okoha.com

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

OREGON A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$269,936,847

242,865

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$101,222,484 $12,149,831 $80,475,039 $1,687,922 $6,909,692

67,680 8,646 33,840 12,138 13,056

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$39,179,280 $6,131,229 $33,048,051 $0 $0

8,559 2,149 6,410 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$6,445,727 $491,212 $1,097,160 $4,123,226 $734,129 $0

38,728 402 576 32,729 5,021 0

$123,089,356

127,898

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $262,335,388

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION

Formulary: Open formulary with a preferred drug list (PDL). PDL managed through physician profiling.

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 Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Prior authorization required for: isotretinon; acute anti-ulcer drugs; cosmetics; total parenteral nutrition; interdialytic parenteral nutrition; retinoic acid; nasal inhalers; coal tar preparations; and topical testosterone. Products not covered: cosmetics; fertility drugs; experimental drugs.

Prescribing or Dispensing Limitations 34-day supply. (Limits on initial prescription for chronic medications to 15 days to prevent wasting if drug is changed due to intolerance, side effects, etc.) Therapy duration limits on selected drugs. Drug Utilization Review PRODUR system implemented in March 1994. State currently has a DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; and topical products. Products not covered: topical products (cosmetics, acne medications, and psoriasis products).

Dispensing Fee: effective 2/1/03.

Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; antidepressants; antidiabetic drugs; antilipemic agents; antipsychotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (andrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: anabolic steroids; anoretics; anticonvulsants; antihistamine drugs; anxiolytics, sedatives, and hypnotics; ENT anti-inflammatory agents; growth hormones; misc. GI drugs; antifungals; legend laxatives; oral nutrionals; topical antibiotics; topical antivirals; weight reduction drugs; and any other drug products for which the only indication is for a non-funded condition. (The Oregon Health Plan coverages are limited to conditions which appear on the HSC prioritized list.) Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physician offices, home health care, and extended care facilities.

1)

$3.50 (retail);

2)

$3.91 (institutional/SNF: providers operating a True or Modified Dose Delivery System).

Ingredient Reimbursement Basis: EAC = AWP-15% (Retail), AWP-11% (Institutional) Prescription Charge Formula: Estimated acquisition cost (EAC) defined as the lesser of: (1) AWP-15% (2) Federal Upper Limits for multiple source drugs or (3) State MAC, or (4) the usual and customary charge plus a dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits on generic drugs. Override requires or “Brand Medically Necessary” plus documentation of patient intolerance to generic. Incentive Fee: None. Patient Cost Sharing: $2.00 (generic); $3.00 (brand) Cognitive Services: Does not pay for cognitive services.

Vaccines: Vaccines reimbursable by Medicaid as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE Approximately 241,000 Medicaid Recipients were enrolled in MCOs in FY 2003. Recipients enrolled in MCOs receive pharmaceutical benefits through managed care plans. Mental health drugs are carved out of managed care. Care Oregon, Inc 522 SW Fifth Avenue, Suite 200 Portland, OR 97204 800/224-4840 Cascade Comprehensive Care, Inc. 900 Main Street, Suite A P.O. Box 217 Klamath Falls, OR 97601-0368 541/883-2947 Central Oregon Independent Health Services, Inc. 2650 NE Courtney Drive P.O. Box 5729 Bend, OR 97708-5729 800/431-4155 Doctors of The Oregon Coast South (DOCS) 750 Central, Suite 202 P.O. Box 1096 Coos Bay, OR 97420 541/269-7400 Douglas County IPA 500 SE Cass, Suite 210 Roseburg, OR 97470 541/672-1685

Mid Rogue IPA Health Plan 820 NE 7th Street Grants Pass, OR 97526 541/471-4106 Oregon Health Management Services 1051 NE 6th Street, Suite 2C Grants Pass, OR 97526 541/ 471-4208 Providence Health Assurance 1235 NE 47th, Suite 220 Portland, OR 97213-2196 800/ 898-8174 Tuality Health Alliance 335 SE 8th Avenue P.O. Box 925 Hillsboro, OR 97123-0925 800/681-1901

F. STATE CONTACTS State Drug Program Administrator Thomas Drawbaugh Pharmacy Program Manager Office of Medical Assistance Programs (OMAP) Department of Human Resources 500 Summer Street, NE, E-35 Salem, OR 97301-1077 T: 503/945-6492 F: 503/373-7689 E-mail: [email protected] Internet address: www.dhs.state.or.us/healthplan Prior Authorization Contact

Family Care, Inc 2121 SW Broadway, Suite 300 Portland, OR 97201 800/458-9518 Intercommunity Health Network, Inc 3600 NW Samaritan Drive Corvallis, OR 97330 800/757-5114

Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected] DUR Contact

Lane Individual Practice Association, Inc. (LIPA) 1500 Valley Rive Drive, Suite 370 Eugene, OR 97401 541/485-2155 Marion Polk Community Health Plan 198 Commercial Street, SE, Suite 240 Salem, OR 97301 503/584-2150

Kathy L. Ketchum, R.Ph., M.P.A.: H.A. 503/494-1589 Medicaid DUR Board Rickland G. Asai, D.M.D. Maggie Bennington-Davis, M.D. Sherry Barrett, R.Ph. Patrick Bowman, R.Ph. George R. Gerding, R.Ph. Dean Haxby, Pharm.D. Robert Ingle, Jr., M.D., M.P.H. Gregory Johnson, M.D. (Chair)

Oregon-3

National Pharmaceutical Council J. Allen Johnson, M.D. Raymond S. Lee, D.O. John Muench, M.D., M.P.H. Kevin Russell, R.Ph. New Brand Name Products Contact Kathy L. Ketchum, R.Ph., M.P.A.: H.A. 503/494-1589 Prescription Price Updating Jim Rowland Account Manager First Health Services Corporation 925 Commercial Street Salem, OR 97302 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected] Medicaid Drug Rebate Contacts Jim Rowland 503/391-1980 Claims Submission Contact Jim Rowland 503/391-1980

Pharmaceutical Benefits 2004 Mail Order Pharmacy Program State has a mail order pharmacy program. All noninstitutionalized beneficiaries are entitled to participate. Office of Medical Assistance Officials Gary Weeks Director Department of Human Services 500 Summer Street, NE, E-15 Salem, OR 97301 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] Barney H. Speight Administrator Office of Medical Assistance Programs Department of Human Services 500 Summer Street, NE, E-49 Salem, OR 97301 T: 503/373-7689 F: 503/373-7823 E-mail: [email protected] Title XIX Medical Care Advisory Committees

Joyce Riggi Delivery Systems Unit Manager Office of Medical Assistance Programs 500 Summer Street, NE, E-35 Salem, OR 97310 T: 503/945-6497 F: 503/947-5221 E-mail: [email protected]

Elizabeth Byers Bruce Bliatout Donna Crawford Rosemari Davis Michael Garland John Hogan Kelley Kaiser Noel Larson, D.M.D. Amy Malone Rick Wopat, M.D.

Disease Management Program/Initiative Contact

Pharmacy Advisory Task Force

Medicaid Managed Care Contact

Chris Barber Case Management Coordinator Office of Medical Assistance Programs 500 Summer Street, NE, E-35 Salem, OR 97301 T: 503/945-6588 F: 503/373-7689 E-mail: [email protected] Disease Management/Patient Education Programs Disease States/Medical Conditions: asthma, cardiovascular disease, diabetes Program Name: Care Enhance Program Manager: McKesson

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.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Executive Officers of State Medical and Pharmaceutical Associations Oregon Medical Association John C. Moorhead President 5210 SW Corbett Street Portland, OR 97239-3897 T: 503/226-1555 F: 503/241-7148 E-mail: [email protected] Internet address: www.theoma.org Oregon State Pharmacy Association Tom Holt, CEO 29702-B Town Center Loop West Wilsonville, OR 97070-6481 T: 503/582-9055 F: 503/582-9046 E-mail: [email protected] Internet address: www.oregonpharmacists.com Osteopathic Physicians and Surgeons of Oregon Jeff Heatherington Executive Director 2121 SW Broadway, Suite 300 Portland, OR 97201 T: 503/222-2779 F: 503/222-2392 E-mail: [email protected] Internet address: www.opso.com Oregon State Board of Pharmacy Gary A. Schnabel Executive Director State Office Bldg., Room 425 800 NE Oregon Street Portland, OR 97232 T: 503/731-4032 F: 503/731-4067 E-mail: [email protected] Internet address: www.pharmacy.state.or.us Oregon Association of Hospitals and Health Systems Ken Rutledge President 4000 Kruse Way Place Building 2, Suite 100 Lake Oswego, OR 97035-2543 T: 503/636-2204 F: 503/636-8310 E-mail: [email protected] Internet address: www.oahhs.org

Oregon-5

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Oregon-6

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PENNSYLVANIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002

2003**

Expenditures

Recipients

Expenditures

TOTAL

$719,243,402

464,848

$791,053,653

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$289,159,044 $63,502,096 $204,581,556 $8,207,666 $12,867,726

163,053 25,125 76,620 37,962 23,346

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$78,820,915 $69,435,876 $5,799,806 $2,269,641 $1,315,592

36,294 23,554 1,375 6,755 4,610

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$150,197,883 $47,969,716 $80,402,609 $19,935,060 $1,410,384 $480,114

158,264 19,213 36,860 92,408 9,614 169

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$201,065,560

107,237

Recipients

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

Pennsylvania-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

C. ADMINISTRATION

Vaccines for Children Program, the EPSDT Program, and the Pharmacy Services Program.

Office of Medical Assistance Programs, Department of Public Welfare.

Unit Dose: Unit dose packaging not reimbursable. 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; 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; scabicides containing permethrin; oral electrolytes; and smoking deterrent products. Products covered with restrictions: 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: emollients and digestive products (nonH2 antagonists). Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterrent products; prescribed cold medications. Prior authorization required for: Cox-2s; erectile dysfunction products; Oxycodone/ Oxycontin; and Brand Medically Necessary drugs. Therapeutic categories not covered: anorectics (unless for treatment of hyperkinesis or narcolepsy); hair restoration products; drugs prescribed for obesity; appetite control products; vitamins (with some exceptions); and products from companies not participating in the rebate program. 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 at AWP-10% as part of the Children Health Insurance Program, the

Formulary: Open formulary. 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-rated generics, H2 antagonists used >90 days, and drugs for erectile dysfunction. Also, Oxycontin prescriptions with doses in excess of 3 tablets per day, or being on more than 2 different strengths concurrently and COX-2 drugs if the patient is taking another NSAID, the prescribed dose is higher than the FDA recommended dose, or the patient is under 70 years of age and is not taking an anticoagulant. State hearing and appeals process available to appeal a prior authorization decision. Prescribing or Dispensing Limitations Quantity Limit: 34-day supply or 100 units, whichever is greater. Refill Limit: Up to 5 within 6 months. Monthly Prescription Limit: 6 Drug Utilization Review PRODUR system implemented in June 1993. DUR Board has 10 members and meets quarterly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.00 ($5.00 for compounds), 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 plus 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. 225 drugs (not including different strengths on package sizes) are listed on the Statespecific MAC list. Override requires “Brand

Pennsylvania-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medically Necessary” or “Brand Necessary,” plus prior authorization. Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00; $2.00 for General Assistance. 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: − − − − − − − − −

Anticonvulsants Antidiabetic agents Antiglaucoma agents Antihypertensive agents Antineoplastic agents Antiparkinson agents Cardiovascular preparations HIV/AIDS specific drugs Psychotherapeutic agents

F. STATE CONTACTS State Drug Program Administrator

E. USE OF MANAGED CARE Approximately 1.3 million unduplicated Medicaid recipients were enrolled in managed care in 2003. All receive pharmacy services, depending on their category of assistance, through managed care.

AmeriHealth HMO/Mercy Health Plan 200 Stevens Drive Philadelphia, PA 19113 215/937-8200 Keystone Mercy Healthplan 200 Stevens Drive, Suite 900 Philadelphia, PA 19113-1570 215/937-8200 Americhoice of PA The Wanamaker Building 100 Penn Square East, Suite 900 Philadelphia, PA 19107 215/835-4602 Health Partners of Philadelphia 833 Chestnut Street, Suite 900 Philadelphia, PA 19107 215/849-9606 Three Rivers Health Plans/MedPlus+ 300 Oxford Drive Monroeville, PA 15146 412/858-4000

Gateway Health Plan U.S. Steel Tower, Floor 41 600 Grant Street Pittsburgh, PA 15219 412/255-4640 Ion Health, Inc. 1527 East Lake Road Erie, PA 16511 814/874-3098

Cognitive Services: Does not pay for cognitive services.

Managed Care Organizations

UPMC Health Plan, Inc. One Chatham Center 112 Washington Place, Suite 800 Pittsburgh, PA 15219 412/454-7640

Terri Cathers Director of Pharmacy Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6195 F: 717/705-8391 E-mail:[email protected] Internet address: www.dpw.state.pa.us/omap Welfare Department Officials Estelle B. Richman Secretary Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-2600 F: 717/772-2062 E-mail: [email protected] David S. Feinberg Deputy Secretary for Medical Assistance Programs Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-1870 F: 717/787-4639 E-mail: [email protected] Prior Authorization Contact Terri Cathers 717/772-6195

Pennsylvania-3

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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 (All contacts 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., R.Ph. 1514 Scenery Ridge Drive Pittsburgh, PA 15241 Marshall P. Burnside, R.Ph. 6000 Bell Road Harrisburg, PA 17111

Medicaid Managed Care Contact Patricia S. Jacobs Director Bureau of Managed Care Operations Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6300 F: 717/772-6328 Disease Management Program/ Initative Contact Joanie Morgan Project Manager Access Plus Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 Mail Order Pharmacy Program None

Michael A. Zemaitis, Ph.D., R.Ph. 133 Shadowlawn Drive Pittsburgh, PA 15261 Robert L. Mayer, Jr., Pharm.D., R.Ph. 5814 Elmer Street Pittsburgh, PA 15232 Keith Burkhart, M.D. 206 Mine Road Hershey, PA 17033 Jeffrey P. Staab, M.D., M.S. 5 Heritage Lane Phoenixville, PA 19460-4607

Expanded Drug Coverage Program Contact Thomas M. Snedden, Director PACE Program PA Department of Aging 555 Walnut Street, 5th Floor. Harrisburg, PA 17101 T: 717/787-7313 F: 717/772-2730 Medical Assistance Advisory Committee Christine Allen American PACE Exchange 215 Stoneway Lane Merion Station, PA 19066-1819

New Brand Name Products Contact Terri Cathers 717/772-6195 Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 800/633-3453 Medicaid Drug Rebate Contacts

Shirley Beer Armstrong County Low Income Rights Organization 251 Briar Hill Road Kittanning, PA 16201 Kent D. W. Bream, M.D. Department of Family Practice University of Pennsylvania 2 Gates, HUP, 3400 Spruce Street Philadelphia, PA 19104

Terri Cathers 717/772-6195

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Louise Brookins Philadelphia State Welfare Rights Organization 1231 N. Franklin Street Philadelphia, PA 19122

Yvette Long Philadelphia Welfare Rights Organization 1231 North Franklin Street Philadelphia, PA 19122

Michael D. Chambers County Commissioners Association of Pennsylvania 17 North Front Street Harrisburg, PA 17101

Donald McCoy (Chair) Pennsylvania Medical Society 777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820

Barbara Coffin Pennsylvania Association of Area Agencies on Aging Berks County Office of Aging County Services Center 633 Court Street Reading, PA 19601-4303 Jonna L. Stefano Delaware County Office of Behavioral Health 20 South 69th Street, 3rd Floor Upper Darby, PA 19802

Russ McDaid PA Association of Non-Profit Homes for the Aging 1100 Bent Creek Boulevard Mechanicsburg, PA 17050 Eugene McGuire, D.D.S. PA Dental Association 1575 Pond Road, Suite 105 Allentown, PA 18104

Henry R. Fiumelli Executive Director Pennsylvania Forum for Primary Health Care 1035 Mumma Road, Suite 1 Wormleysburg, PA 17043

Anne R. McHugh Hospital and Healthsystem Association of Pennsylvania 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600

Vickie Hoak (Vice-Chair) Pennsylvania Homecare Association 20 Erford Road, Suite 115 Lemoyne, PA 17043

Donna McNonagle Philadelphia Coordinated Health Care 123 South Broad Street, 22nd Floor Philadelphia, PA 19109

Dolores Hodgkiss Managed Care Association of Pennsylvania 240 North Third Street, Suite 501 Harrisburg, PA 17101

Thomas Peifer Hospital and Health System Association of Pennsylvania 4750 Lindle Road Harrisburg, PA 17105

Michelle Jones Healthy Start, Inc. 400 North Lexington Street Pittsburgh, PA 15208

Mary Ellen Rehrman 10 Bertolet School Road Spring City, PA 19475

Coleen Kayden PA Pharmacists Association 508 North Third Street Harrisburg, PA 17101

Margery Lynn Wasko, M.D. Hamilton Health Center, Inc. 1821 Fulton Street Harrisburg, PA 17110

George Kimes Pennsylvania Community Providers Association 2400 Park Drive Harrisburg, PA 17110

Ivonne Bucher - Ex-Officio Member Department of Aging Office of Community Services and Advocacy 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

Carol Lavoritano AmeriChoice The Wanamaker Building 100 Penn Square East, Suite 900 Philadelphia, PA 19107

Brian Ebersole - Ex-Officio Member Pennsylvania Department of Health Room 808, Health and Welfare Building Harrisburg, PA 17120

Pennsylvania-5

National Pharmaceutical Council Executive Officers of State Medical and Pharmaceutical Associations Pennsylvania Medical Society Roger F. Mecum Executive Vice President 777 E. Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820 T: 717/558-7750 F: 717/558-7840 E-mail: [email protected] Internet address: www.pamedsoc.org

Pharmaceutical Benefits 2004 The Hospital and Healthsystem Association of Pennsylvania Carolyn F. Scanlan President and CEO 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 T: 717/564-9200 F: 717/561-5334 E-mail: [email protected] Internet address: www.haponline.org

Pennsylvania Pharmacists Association Patricia A. Epple, CAE Executive Director 508 North Third Street Harrisburg, PA 17101-1199 T: 717/234-6151 F: 717/236-1618 E-mail: [email protected] Internet address: www.papharmacists.com Pennsylvania Osteopathic Medical Association Mario E.J. Lanni Executive Director 1330 Eisenhower Boulevard Harrisburg, PA 17111-2395 T: 717/939-9318 F: 717/939-7255 E-mail: [email protected] Internet address: www.poma.org Pennsylvania Podiatry Association Michael Q. Davis Executive Director 757 Poplar Church Road Camp Hill, PA 17011 717/763-7665 Pennsylvania State Board of Pharmacy Melanie Zimmerman Executive Secretary P.O. Box 2649 Harrisburg, PA 17105-2649 T: 717/783-7156 F: 717/787-7769 E-mail: [email protected] Internet address: www.dos.state.pa.us/bpoa/cwp/view.asp

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

RHODE ISLAND A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Blind/ Aged Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expended Recipients TOTAL

$126,331,040

53,729

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$75,903,018 $8,594,928 $67,160,656 $34,974 $112,460

29,656 4,365 24,010 516 765

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$10,071,564 $6,921,415 $3,149,477 $0 $672

3,728 3,002 723 0 3

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$614,107 $134,738 $291,154 $40,337 $34,272 $113,606

1,266 107 138 662 228 131

$39,742,351

19,079

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expended Recipients $140,686,626

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

Rhode Island-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION

D. PROVISIONS RELATING TO DRUGS

Formulary: No formulary. Prior prescription drug use authorization is used to manage appeal process to appeal prior authorization decisions and exclusion of specific products.

Benefit Design

Prescribing or Dispensing Limitations

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; urine ketone test strips. Products covered under DME: blood glucose test strips; total parenteral nutrition (prior authorization required); and interdialytic parenteral nutrition (prior authorization required). Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs.

Prescription Refill Limit: Refills to a maximum of 5 are allowed.

Rhode Island Department Human Services.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics (acetaminophen); cough and cold preparations (guifenisin, diphenhydramine, chlorpheniramine); feminine products; topical products; (antibiotics only); antacids; and laxatives. Products not covered: digestive products; smoking deterrent products. Therapeutic Category Coverage: Products covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents, 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: analgesics, antipyretics, and NSAIDs; anoretics; antihistamines; growth hormones; PPIs; Provigil; CNS stimulants; Tracleer; Remodulin; Flolan; Xolair; erectile dysfunction products; and Cox 2 inhibitors. Partial coverage for: prescribed smoking deterrents. Therapeutic categories not covered: products for hair growth. Coverage of Injectables: Injectable medicines reimbursable under the Prescription Drug Program when used in home health care, extended care facilities, and physician offices. Vaccines: Limited coverage under the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Monthly Quantity Limit: One month’s supply for non-maintenance drugs. One inhaler per fill. 8 tablets per month for erectile dysfunctions medication. 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. State has a DUR Board that meets quarterly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.40 (ambulatory) and $2.85 (longterm care), effective 1987. 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 5 percent, the usual and customary charge to the general public, or the allowable cost plus the professional fee for service.

Maximum Allowable Cost: State does not impose Upper Limits on generic drugs. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

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E. USE OF MANAGED CARE

Medicaid Managed Care Contact

Approximated 135,000 Medicaid recipients were enrolled in managed care in 2003. Managed care recipients receive pharmaceutical benefits through managed care plans. Managed Care Organizations

Tricia Leddy, Administrator Department of Human Services 600 New London Avenue Cranston, RI 02919 401/462-2127 E-mail: [email protected]

−

Mail Order Pharmacy Program

− −

United Healthcare of New England Coordinated Health Partners, Inc. Neighborhood Health Plan of Rhode Island

None Department of Human Services Officials

F. STATE CONTACTS State Drug Program Administrator Paula J. Avarista, R.Ph., M.B.A. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6836 E-mail: [email protected] Internet address: www.dhs.state.ri.us DUR Contact Paula J. Avarista, R.Ph., M.B.A. 401/462-6390 Rhode Island DUR Board Raymond Maxim, M.D. Edward Westrick, M.D., Ph.D. Richard Wagner, M.D. Steve Kogut, Ph.D., M.B.A. Tara Higgins, R.Ph. John Zevzavadjian R.Ph. Ellen Mauro, R.N, M.P.H. New Brand Name Products Contact Paula J. Avarista, R.Ph., M.B.A. 401/462-6390 Prescription Price Updating Paula J. Avarista, R.Ph., M.B.A. 401/462-6390 Medicaid Drug Rebate Contacts Helen Vaughn Analyst EDS 1471 Elmwood Avenue Cranston, RI 02910 401/784-3879

Jane A. Hayward Director Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-2121 F: 401/462-3677 E-mail: [email protected] John C. Young Associate Director Health Care Quality, Financing, and Purchasing Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-3575 F: 401/462-6338 E-mail: [email protected] Executive Officers of State Medical and Pharmaceutical Societies Rhode Island Medical Society Newell E. Warde, Executive Director 235 Promenade Street, Suite 500 Providence, RI 02908 T: 401/331-3207 F: 401/751-8050 E-mail: [email protected] Internet address: www.rimed.org Rhode Island Society of Osteopathic Physicians and Surgeons/Northeast Osteopathic Consortion Donald J. Halpin, Executive Director P.O. Box 487 Winchester, MA 01800 T: 781/721-9900 T: 800/454-9663 E-mail: [email protected]

Claims Submission Contact EDS, 401/784-3879

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Rhode Island Pharmacists Association Jack Hutson Executive Director 1643 Warwick Avenue PMB 113 Warwick, RI 02889 T: 401/737-2600 F: 401/737-0959 E-mail: [email protected] Internet address: www.ripharmacists.org Rhode Island State Board of Pharmacy Catherine A. Cordy Board Administrator 3 Capitol Hill, Room 205 Providence, RI 02908-5097 T: 401/222-2837 F: 401/222-2158 E-mail: [email protected] Internet address: www.healthri.org//hsr/professions/pharmacy.php Hospital Association of Rhode Island Edward J. Quinlan, President 880 Butler Drive, Suite One Providence, RI 02906 T: 401/274-1647 F: 401/274-1838 E-mail: [email protected] Internet address: www.hari.org

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SOUTH CAROLINA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Blind/ Aged Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$456,976,916

576,136

$559,618,608

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$221,186,878 $51,109,927 $131,758,033 $14,462,767 $23,856,151

214,690 29,073 72,534 62,082 51,001

$257,211,722 $53,002,997 $157,058,050 $16,940,364 $30,210,311

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child 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 Child Adult BCCA Women

$145,547,570 $42,051,973 $53,686,499 $47,895,973 $1,852,433 $60,692

255,510 24,724 23,236 194,169 13,315 66

$177,510,401 $47,343,069 $66,311,073 $59,918,715 $3,937,544 N/A

N/A

$90,242,468

105,936

$124,896,485

TOTAL OTHER EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2003 data provided by the South Carolina Department of Health and Human Services. 2003 data on number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2002, and South Carolina Medicaid Statistical Information System, FY 2003.

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C. ADMINISTRATION

3.

South Carolina Department of Health & Human Services.

4.

D. PROVISIONS RELATING TO DRUGS

5.

Benefit Design Drug Benefit Product Coverage: Products covered: most rebated legend generic drugs; prescribed insulin, and disposable needles and syringe combinations used for insulin. Products covered as DME: blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic nutrition. Products not covered: pharmaceutical for cosmetics purposes or hair growth; fertility drugs; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Within program guidelines and limitations, the Medicaid program covers all rebated OTC medications and their generic equivalents. Products not covered: brand name products for which equivalent generics are available. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines are reimbursable through the Medicaid Physician Services Program when used in physicians’ offices. Injectables are reimbursable through the Pharmacy Services Program when used at home, through home health care, or in long-term care facilities.

6.

7. 8. 9. 10. 11. 12. 13.

Immunizing agents. (except for influenza, pneumococall, and hepatitis-B vaccines where certain criteria are met) Pharmaceuticals determined by the FDA to be less than effective and identical, related, or similar drugs (Referred to as “DESI” drugs). Injectable pharmaceuticals administered by the practitioner in the office, in a clinic, or in a mental health center . Products used as flushes to maintain potency of indwelling peripheral or central venipuncture devices. Devices and supplies (e.g., diabetic supplies, infusion supplies, etc.) Fertility products. Pharmaceuticals which are not rebated. Nutritional supplements Oral hydration therapies for adults. Pharmaceuticals used for cosmetic purposes or hair growth. Anti- hemophilia factor.

Prior Authorization: State currently has a prior authorization program. A preferred drug list (PDL) was implemented in calendar year 2004. Consideration of additional therapeutic classes is ongoing. Beneficiaries can request a fair hearing and exception to policy in order to appeal a prior authorization decision. The prescriber must obtain prior authorization for Medicaid coverage of the following products: 1. 2.

Non- preferred drugs. Brand name products (excluding certain narrow, therapeutic index drugs) for which there are A-rated, therapeutically equivalent, less costly generics available. 3. COX-2 inhibitors for patients < age 60. 4. Erectile dysfunction products. 5. OxyContin® (when maximum quantity limitation is exceeded). 6. Panretin®. 7. Proton pump inhibitors (patients age 12 and younger may receive Prevacid without PA). 8. Growth hormone products 9. Targretin®. 10. Xenical®.

Vaccines: Vaccines are reimbursable based on CDC price as part of the Vaccines for Children Program (age under 21).

Prescribing or Dispensing Limitations

Unit Dose: Unit dose packaging is reimbursable.

Prescription Refill Limit: The prescriber authorizes the number of refills.

Formulary/Prior Authorization Formulary: Open formulary; certain drug classifications excluded. General Exclusions: 1. 2.

Weight control products. (except for lipase inhibitors) Investigational pharmaceuticals or products. South Carolina-2

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Monthly Quantity Limit: Children (birth to age 21) are allowed unlimited prescriptions per month. Beneficiaries over the age of 21 are limited to a maximum of four prescriptions per month; however, pharmacists may override the monthly prescription limit for adult Medicaid beneficiaries if the prescription meets certain specified override criteria.

Patricia Marquis, Chief Operating Officer P.O. Box 40024 Charleston, SC 29403 843/569-1759

Quantity Limit per Prescription: 34-day supply per prescription. Maximum quantity limitations have been established for certain pharmaceuticals.

Better Health Care Plans Dan Gallagher Vice President and Executive Director 250 Berryhill Road, Suite 514 Columbia, SC 29210 803/798-8210

Monthly Dollar Limit: None.

F. STATE CONTACTS

Drug Utilization Review

State Drug Program Administrator

PRODUR system implemented November 2000. State currently has a DUR Panel with a monthly review.

James M. Assey, R.Ph., Division Director Division of Pharmaceutical Services and DME S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected] Internet address: www.dhhs.state.sc.us

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 maximum allowable costs (MAC) on additional drugs. Override requires “Brand Medically Necessary,” handwritten certification by the prescriber, and prior authorization. Incentive Fee: None.

Prior Authorization Contact Caroline Y. Sojourner, R.Ph., Dept. 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: 803/255-8353 E-mail: [email protected] DUR Contact Caroline Y. Sojourner, R.Ph. 803/898-2876 DUR Panel

Patient Cost Sharing: $3.00 co-payment per prescription for most adult beneficiaries, unless otherwise accepted. SilverxCard beneficiaries are subject to a three- tiered co-payment schedule: $10 for generic drugs, $15 for brand name drugs, and $21 for drugs requiring prior authorization.

Gwendolyn C. Galphin, M.D. F. Joseph Hodge, R.Ph. Henry Rose, R.Ph. Leslie M. Stuck, M.D. Caroline Sojourner, R.Ph. New Brand Name Products Contact

Cognitive Services: Does not pay for cognitive services.

James M. Assey, R.Ph. 803/898-2876

E. USE OF MANAGED CARE

Prescription Price Updating

Approximately 74,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans.

First DataBank, 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

Managed Care Organizations Select Health of South Carolina, Inc.

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Medicaid Drug Rebate Contacts

Pharmacy and Therapeutics Committee

Technical: Rod Davis, 803/898-2610 Policy: James Assey, 803/898-2876 DUR & PA: Caroline Sojourner, 803/898-2876 Disputes: Laurel Kennerly, 803/898-2954

J. Kevin Baugh, M.D. Edward M. Behling, M.D. Gregory V. Browning, M.D. Matthew K. Cline, M.D. Joseph A. Horvath, M.D. Albert Humphrey, M.D. Kelly W. Jones, Pharm.D. Jerome E. Kurent, M.D. Robin Kelley LaCroix, M.D. James M. Lindsey, M.D. Thomas R. Phillips, R.Ph. Deborah J. Tapley, R.Ph., M.B.A. George E. “Ed” Vess. Pharm.D. Harry H. Wright, M.D.

Claims Submission Contact Rod Davis Deputy Director of Information Technology S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2610 E-mail: [email protected] Managed Care Contact

Medical Care Advisory Council

Bruce Harbaugh Department of Managed Care Reimbursement Programs S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2618 E-mail: [email protected] Mail Order Drug Program None, however, mail order pharmacies may enroll. Disease Management Program/Initiative Contact Beverly Hamilton Division of Care Management S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-4502 E-mail: [email protected] South Carolina Department of Health and Human Services Officials Robert Kerr, Director S. C. Department of Health & Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected]

Ms. Valerie Aiken Mr. John P. Barber Ms. Susan B. Berkowitz Ms. Lesly A. Bowers Dr. Gloria Bonali Mr. Bruce Carlson Mr. Tommy Cockrell Charles P. Darby, M.D. C. Warren Derrick, M.D. Ana DeFede, Ph.D. James M. DuRant, Jr., M.D. C. Morrison Farish, M.D. Mr. Ron Fitzwater Ms. Laura Fowler Ms. Connie Ginsberg Dr. Barbara Haight Jerome E. Kurent, M.D. Mr. Rudy Long Ms. Amy McDonald Mr. J.J. McLawhorn Albert D. Mims, M.D. Dr. Linda S. Moore Mr. John A. Morris J. Michael Ross, R.Ph. Sabra Slaughter, Ph.D. Mr. Lewis Stephens Ms. Cindy White Ms. Deborah Williamson Dr. Constance Yearling Dr. Foster H. Young, Jr. Mr. Hal Zorn

Melanie Giese, Chief Bureau of Health Services 803/898-2870 Caroline Y. Sojourner, R.Ph., Department Head Department of Pharmacy Services 803/898-2876

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Executive Officers of State Medical and Pharmaceutical Societies South Carolina Medical Association Todd K. Atwater, Chief Executive Officer 132 West Park Boulevard P.O. Box 11188 Columbia, SC 29210 T: 803/798-6207, Ext. 490 F: 803/772-6783 E-mail: [email protected] Internet address: www.scmanet.org South Carolina Osteopathic Medical Society Valerie Smith Southeast Regional Manager P.O. Box 433 Red Bay, AL 35585 866/356-4481 E-mail: [email protected] Internet address: www.scoms.org South Carolina Pharmacy Association James R. Bracewell, Executive Vice President 1350 Browning Road Columbia, SC 29210-6903 T: 803/354-9977 F: 803/354-9207 E-mail: [email protected] Internet address: www.scrx.org/scrx South Carolina State Board of Pharmacy Lee Ann F. Bundrick, Administrator Kingstree Building 110 Centerview Drive, Suite 306 Columbia, SC 29210 T: 803/896-4700 F: 803/896-4596 E-mail: [email protected] Internet address: www.llr.state.sc.us/pol/pharmacy South Carolina Hospital Association J. Thornton Kirby, President 1000 Center Point Road Columbia, SC 29210-5802 T: 803/796-3080 F: 803/796-2938 E-mail: [email protected] Internet address: www.scha.org

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SOUTH DAKOTA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Blind/ Child Adult Aged Disabled

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Aged Blind/ Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$63,654,623

64,948

$71,223,108

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$32,400,063 $3,687,941 $24,972,780 $1,514,094 $2,225,248

22,529 1,793 8,898 7,211 4,627

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$6,304,155 $38,283 $110,,665 $5,678,563 $464,812 $11,832

25,351 62 99 22,699 2,481 10

$24,950,405

17,068

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

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Pharmaceutical Benefits 2004 Prior Authorization: State currently has no formal prior authorization procedure.

C. ADMINISTRATION Department of Social Services, Office of Medical Services.

D. PROVISIONS RELATING TO DRUGS

Prescribing or Dispensing Limitations Prescription Dollar Limit: None.

Benefit Design

Refill Limit: None

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. Prior authorization required for: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; experimental drugs; and drugs for impotence.

Monthly Quantity Limit: Varies by drug.

Over-the-Counter Product Coverage: Product covered with restrictions: allergy, asthma, and sinus products (OTC loratadine only) and digestive products (non-H2 antagonists-OTC omeprazole only). Products not covered: analgesics; cough and cold preparations; digestive products; (H2 antagonists); feminine products; topical products; and smoking deterrents.

Dispensing Fee: $4.75 to $5.55 (with unit dose fee applied), effective 7/1/1991

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; anoretics; 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); prescribed cold medications and thyroid agents. Prior authorization required for: growth hormones. Partial coverage for: prescribed smoking deterrents. Therapeutic categories not covered: nutritional supplements; clozapine.

1. 2.

Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and physician payment when used in physician offices, home health care, and extended care facilities.

Monthly Prescription Limit: None Drug Utilization Review PRODUR system implemented in 1996. Pharmacy Payment and Patient Cost Sharing

Ingredient Reimbursement Basis: EAC = AWP10.5%. Prescription Charge Formula: Payment is the lower of: 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 as well as State-specific limits on generic drugs. Approximately 1,000 drugs are listed on the State-specific MAC list. Override requires “Brand Necessary” or “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.

Vaccines: Vaccines reimbursable with HCPC code as part of EPSDT services, The Children’s Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary.

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F. STATE CONTACTS State Drug Program Administrator Mark E. Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3498 F: 605/773-5246 E-mail: [email protected] Internet Address : www.state.sd.us/social/medical/index.htm

Pharmaceutical Benefits 2004 Disease Management Program/Initiative Contact Mark Petersen, R.Ph. 605/773-3495 South Dakota Medicaid Agency Officials James Ellenbecker Secretary Department of Social Services 700 Governors Drive Pierre, SD 57501-2291 T: 605/773-3165 F: 605/773-4855 E-mail: [email protected]

Prior Authorization Contact Mark E. Petersen, R.Ph. 605/773-3498 DUR Contact Teddi Martell Rebate Coordinator Department of Social Services 700 Governors Drive Pierre, SD 57501 605/773-3653 E-mail: [email protected]

Larry Iverson Division Director Medical Services Department of Social Services 700 Governors Drive Pierre, SD 57501-2291 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected] Medical Advisory Committee

New Brand Name Products Contact

Paul Engbrecht, Chairman Marion, SD

Mark E. Petersen, R.Ph. 605/773-3498

John Jones, Vice Chairman Pierre, SD

Prescription Price Updating Mark E. Petersen, R.Ph. 605/773-3498 Medicaid Drug Rebate Contact Teddi Martell 605/773-3653 Claims Submission Contact Meredith Heerman Claims Processing Administrator Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

Jud Bergan, O.D. Madison, SD 57042 Sheryl Petersen Pierre, SD James D. M. Russell Pierre, SD Herb McClellan, Jr., D.D.S. Mobridge, SD Lynn Greff Rapid City, SD Stephen Schroeder, M.D. Miller, SD Michelle Miller Sioux Falls, SD A.A. Lampert, M.D. Rapid City, SD

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Pharmaceutical Benefits 2004

Executive Officers of State Medical and Pharmaceutical Societies South Dakota State Medical Association L. Paul Jensen Chief Executive Officer 1323 South Minnesota Avenue Sioux Falls, SD 57105 T: 605/336-1965 F: 605/336-0270 E-mail: [email protected] Internet address: www.sdsma.org South Dakota Osteopathic Association David A. Lauer, D.O. Secretary-Treasurer P.O. Box 247 Sturgis, SD 57785 T: 605/347-3616 F: 605/347-4713 South Dakota Pharmacists Association Sue Schaefer Executive Director 320 East Capitol P.O. Box 518 Pierre, SD 57501-0518 T: 605/224-2338 F: 605/224-1280 E-mail: [email protected] Internet address: www.sdpha.org South Dakota State Board of Pharmacy Dennis M. Jones Executive Secretary 4305 S. Louise Avenue, Suite 104 Sioux Falls, SD 57106 T: 605/362-2737 F: 605/362-2738 E-mail: [email protected] Internet address: www.state.sd.us/dcr/pharmacy South Dakota Association of Healthcare Organizations David R. Hewett President and CEO 3708 Brooks Place, Suite 1 Sioux Falls, SD 57106 T: 605/361-2281 F: 605/361-5175 E-mail: [email protected] Internet address: www.sdaho.org

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Pharmaceutical Benefits 2004

TENNESSEE -- TennCare On January 1, 1994, Tennessee made history by withdrawing from the Medicaid Program and implementing an innovative new health care reform plan called TennCare. In order to implement TennCare, Tennessee was granted a Section 1115 demonstration waiver by the Federal government. TennCare replaced the existing Medicaid Program with a program of managed health care. TennCare receives about 66 percent of its annual budget from the Federal government. Approximately one-third of the TennCare budget consists of State funds. 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.

demonstration project ended December 31, 1998. HCFA approved a waiver extension for three years beginning January 1, 1999 through December 31, 2001. On July 1, 2002, Tennessee reached a new five-year agreement with the federal government to continue TennCare.

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. 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 $5 and $10 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 Medicaid-eligible or who are uninsurable. Current enrollment (1/23/04) is approximately 1.3 million of which 1 million are Medicaid eligibles and 300,000 are in the uninsured/uninsurable categories.

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.

The State of Tennessee was granted approval by the Health Care Financing Administration (now CMS) 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

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. 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 is financed by pooling current Federal, State, and local expenditures for indigent health care. Pooled resources totaled $5.5 billion in FY 2001. 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. ELIGIBILITY FOR TENNCARE COVERAGE The current federal waiver separates TennCare into Two products: TennCare Medicaid and TennCare Standard. Tenncare Medicaid is a continuation of the basic TennCare Medicaid program with a few minor changes in benefits. TennCare Medicaid adds a new eligibility category: woman under 65 who have been screened by The Centers for Disease Control and are in need of treatment for breast or cervical cancer.

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TennCare Standard is similar to a commercial HMO package. People eligible for TennCare standard are adults below the 100 percent of the federal poverty level, children below 200 percent of the poverty level, and people who are “medically eligible” a new term to describe what the state previously referred to as “uninsurables.” The difference is that “Medical eligibility” will be determined by a State-appointed health insurance underwriter. Under the previous TennCare system, a denial letter from an insurance company defined “uninsurability.” The five-year waiver that TennCare began on July 1, 2002 also includes an annual “open enrollment” period, which would allow people who are uninsured or medically eligible above poverty to enroll in TennCare. The current fiscal year’s budget does not allow for an open enrollment period, at least through the end of the current fiscal year, June 30, 2003. However, if an applicant is both below 100 percent of the poverty level and medically eligible, enrollment will be allowed at any time during the year. Persons wanting to apply for TennCare must visit the local Tennessee Department of Human Services (DHS) office. There is a local DHS office in every Tennessee County. For the applicants' convenience, DHS will make a copy of the application, date stamp it, and process the application. Recent Proposed Changes to TennCare The TennCare program is currently undergoing a major restructuring as a result of rapidly escalating program costs, Tennessee, during 2004, developed a plan to restructure TennCare in a manner that would allow the State to maintain coverage while reining in the unstainable increase in program costs. In September 2004, Tennessee submitted a proposal to CMS to amend the TennCare program. While continuing to engage in decisions with various stakeholders regarding the proposed changes, numerous legal objections and possible law suits have made it more difficult to implement many of the proposed changes. While still hoping to implement many of the reforms that were previously announced, because of the rapidly deteriorating budget outlook, the State has had to contemplate more drastic reform measures in order to stabilize the program. The proposed revisions, which the State has submitted to CMS for approval, are designed to reduce TennCare enrollment trim benefits without returning to a traditional Medicaid program. The State’s objective is to maintain current levels of coverage for the more than 600,000 children who rely on the TennCare program for their care.

Accordingly, the State has proposed terminating coverage for the adult demonstration population as well as for the adult non-pregnant Medically Needy population. As a result, approximately 396,000 Medicaid eligible adults will retain a “reasonable” level of coverage while another 323,000 adults who are not elegible for Medicaid but who are covered under TennCare via a Federal waiver will lose coverage. In addition, some types of coverage would be eliminated and certain limits or restrictions will be imposed on other programs, including pharmacy. Managed care organizations participating in TennCare would be asked to assume greater financial risk. The TennCare Plan amendments are being reviewed by CMS.

A. ADMINISTRATION Tennessee Department of Finance and Administration, Bureau of TennCare

B. PROVISIONS RELATING TO DRUGS Benefit Design Pharmacy services are provided by the managed care organizations. Within Federal and State guidelines, each individual managed care and pharmacy benefit management organization makes formulary/drug decisions. 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, experimental drugs; smoking cessation products, experimental drugs; and OTCs). Starting in July 1, 2003 all eligible products dispensed through ambulatory pharmacies are invoiced through the CMS rebate program. Formulary/Prior Authorization Formulary: Preferred Drug List (PDL) was phased in from October 15th through December 15th in 3 phases (see http://tennessee.fhsc.com). The PDL is managed through preferred products and prior authorization. Prior Authorization: State currently has a formal prior authorization procedure. Recipient may appeal coverage and prior authorization decisions to the TennCare Solutions Unit.

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Pharmacy Payment and Patient Cost Sharing

1420 Centerpoint Boulevard Knoxville, TN 37932 T: 800/705-5248 F: 865-470-7404

Prescription Dollar Limit: None Monthly Quantity Limit: 31-day supply Refill Limit: up to one year for non-controlled prescriptions 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.

TennCare Select 801 Pine Street Chattanooga, TN 37402-2555 T: 800/276-1978 F: 423/752-6790 Windsor Health Plan of Tennessee 215 Centerview Drive, Suite 300 Brentwood, TN 37027 T: 615/782-7878 F: 615/782-7812

D. STATE CONTACTS C. USE OF MANAGED CARE

State Drug Program Administrator

1.4 million Medicaid recipients and the uninsured/uninsurable are enrolled in MCOs through the TennCare program. All receive pharmacy benefits through managed care.

Jeffrey G. Stockard, D.Ph. Associate Pharmacy Director Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-3107 F: 615/253-5481 E-mail: [email protected] Internet address: www.tennessee.gov/tenncare

Managed Care Organizations Better Health Plans 890 Willow Tree Circle Cordova, TN 38018 T: 800/600-9007 F: 901/737-1420 BlueCare 801 Pine Street Chattanooga, TN 37402-2555 T: 800/468-9736 F: 423-752-6790 John Deere Health Plan Executive Tower I, Suite 400 408 N. Cedar Bluff Road Knoxville, TN 37923 T: 800/832-1539 F: 865/690-1941 TLC Family Care Healthplan 1407 Union Avenue, Suite 200 Memphis, TN 38104 T: 800/473-6523 F: 901/725-2846

TennCare Pharmacy Information Line 800/816-1680 TennCare Officials Gina Lodge, Commissioner Department of Human Services 400 Deaderick Street, 15th Floor Nashville, TN 37248-0001 T: 615/313-4700 F 615/741-4165 E-mail: [email protected] Manny Martins, Deputy Commissioner Bureau of TennCare Department of Finance and Administration 729 Church Street Nashville, TN 37247-6501 T: 615/741-5346 F: 615/741-0882 E-mail: [email protected]

OmniCare Health Plan, Inc. 1991 Corporate Avenue, 5th Floor Memphis, TN 38132 T: 800/346-0034 F: 901/348-2212 PHP TennCare

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Marry-Anne Rudolph, Director Medicaid Policy Unit 400 Deaderick Street, 12th Floor Nashville, TN 37248 T: 615/313-4873 F: 615/313-6639 E-mail: [email protected]

TennCare Pharmacy Advisory Board

Prior Authorization Contact

Diane Todd Pace, Ph.D., R.N., F.N.P. Cordova , TN

Jeffrey G. Stockard, D.Ph. 615/532-3107 DUR Contact Jeffrey G. Stockard, D.Ph. 615/532-3107 TennCare DUR Advisory Board Physician Member: Tracy Doering, M.D. Nashville, TN

James Powers, M.D. (Chairman) Nashville, TN Alan Corley, Pharm.D. (Vice Chairman) Greenville, TN

Edward Capparelli, M.D. Newport, TN James King, M.D. Selmer, TN Lisa D’Souza, J.D. Nashville, TN Peter Frizzell, M.D. Johnson City, TN

Pharmacist Members:

Lynn Knott, Pharm.D., C.G.P., F.A.S.C.P. Brentwood, TN

Philip E. Johnston, Pharm.D. Nashville, TN

Stanley Dowell, M.D. Memphis, TN

Stephanie Johnson Nichols, Pharm.D. Harriman, TN

Sheila Spates, Pharm.D. Knoxville, TN

Richard Randolph, Pharm.D. Manchester, TN

Terry Shea, Pharm.D. Chattanooga, TN

David Shepard, Pharm.D., B.C.P.P. Dickson, TN

William Terrell, M.D. Memphis, TN

Bill Staggs, D.Ph. Nashville, TN

Tracy Purcell (ex-officio) Nashville, TN

Bureau of TennCare Members:

David Hollis, M.D. (ex-officio) Nashville, TN

Wendy Long, M.D., M.P.H. (ex-officio) Chief Medical Officer Jeffrey G. Stockard, D.Ph. (ex-officio) Assocciate Pharmacy Director First Health Member: Shana Bush, Pharm.D. Clinical Manager

TennCare Medical Care Advisory Committee Iris Snider, M.D. TN Chapter of American Academy of Pediatrics 111 Epperson Avenue Athens, TN 37303 Lloyd A. Walwyn, M.D., J.D. 601 Due West Avenue Madison, TN 37115 Deb Murph, R.N. Cherokee Health Systems 6350 West Andrew Johnson Highway Talbott, TN 37877

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National Pharmaceutical Council Jeannie Beauchamp, D.D.S. 1833 Memorial Drive Clarksville, TN 37043 Don Hazelwood, D.Ph. 3100 S. First Street Milan, TN 38358

Pharmaceutical Benefits 2004 Prescription Price Updating First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-6867 Medicaid Drug Rebate Contact

Cato Johnson Methodist Healthcare 1211 Union Street, Suite 700 Memphis, TN 38104 Joe Brown Hardin County Nursing Home 2006 Wayne Road Savannah, TN 38372

Sybil Creekmore Accounting Manager Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0018 F: 615/532-3479 E-mail: [email protected] Claims Submission Contact

Sheryl McCormick Region 2 Mental Health Council 7208 Merriwood Drive Knoxville, TN 37919 Don Redden Developmental Services of Dickson County P.O. Box 628 Dickson, TN 37056

Maria P. Hogan Plan Administrator First Health Service Corporator 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7451 F: 804/290-4831 E-mail: [email protected] Medicaid Managed Care Contact

Tony Halton National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206 Osbie Howard OmniCare Health Plan, Inc. 1991 Corporate Avenue, 5th Floor Memphis, TN 38132 Nancy Reykdal Blue Cross/Blue Shield of Tennessee 801 Pine Street Chattanooga, TN 37402 Yolanda McClain The Salvation Army 611 Stockell Street Nashville, TN 37207 Effie Candis Pelfrey Tennessee Health Care Campaign 1103 Foothill Court Nashville, TN 37217

Michael Drescher, Public Information Officer Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/741-0882 E-mail: [email protected] Mail Order Pharmacy Program Tennessee has a mail order pharmacy option in its Medical Assistance Program. All beneficiaries are entitled to participate. Disease Management Patient Education Contact Judith Black Director of Disease Management Bureau of TennCare 706 Church Street Nashville, TN 37247-6501 T: 615/532-6705 F: 615/741-0882 E-mail: [email protected]

Virginia T. Lodge, Commissioner Department of Human Services 400 Deaderick Street, 15th Floor Nashville, TN 37248

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National Pharmaceutical Council Executive Officers of State Medical and Pharmaceutical Societies Tennessee Medical Association Donald H. Alexander, CEO P.O. Box 120909 2301 21st Avenue South Nashville, TN 37212-0909 T: 615/385-2100 F: 615/385-3319 E-mail: [email protected] Internet address: www.medwire.org

Pharmaceutical Benefits 2004 Hospital Alliance of Tennessee Paige Kisber President 211 Seventh Avenue North, Suite 400 Nashville, TN 37219 T: 615/254-1941 F: 615/254-1942 E-mail: [email protected] Internet address: www.hospitalalliance.com

Tennessee Osteopathic Medical Association Michael Darling Executive Director 618 Church Street, Suite 220 Nashville, TN 37219 T: 615/254-3687 F: 615/254-7047 E-mail: [email protected] Internet address: www.tomanet.org Tennessee Pharmacists Association Baeteena M. Black, D.Ph. Executive Director 500 Church Street, Suite 650 Nashville, TN 37219 T: 615/256-3023 F: 615/255-3528 E-mail: [email protected] Internet address: www.tnpharm.org Tennessee State Board of Pharmacy Kendall M. Lynch, Director Davy Crocket Tower 500 James Robertson Parkway, 2nd Floor Nashville, TN 37243-1149 T: 615/741-2718 F: 615/741-2722 E-mail: [email protected] Internet address: www.state.tn.us/commerce/boards/ pharmacy Tennessee Hospital Association Craig A. Becker President 500 Interstate Boulevard South Nashville, TN 37210-4634 T: 615/256-8240 F: 615/242-4803 Internet address: www.tha.com

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TEXAS A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures TOTAL

Recipients

$1,591,828,224

2,153,316

$886,280,924 $257,064,144 $527,377,291 $57,465,862 $44,373,627

731,289 156,415 256,884 222,276 95,714

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$19,389,921 $0 $0 $51,557 $19,338,364

40,399 0 0 206 40,193

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$236,871,319 $726,956 $992,885 $209,138,086 $26,013,392 $0

1,015,231 863 974 854,824 158,570 0

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$449,286,060

366,397

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

2003** Expenditures Recipients $1,920,865,985

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

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C. ADMINISTRATION

Formulary/Prior Authorization

Texas Health and Human Services Commission. Vendor drug program was implemented September 1, 1971.

Formulary: Open formulary; however, products must be listed in the Texas Drug Code Index. Formulary managed through restrictions on use, prior authorization and preferred products. 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. Over-the-Counter Product Coverage: Products covered: feminine products; topical products; allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; smoking deterrent products. Products not covered: 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; 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 medications; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; thyroid agents; prescribed smoking deterrents; and sympathominetics (adrenergic). Prior authorization required for: anoretics; growth hormones; dextroamphetamines (>21 years of age); xenical (hyperlipidemia only) and drugs not included on the preferred drug list. Therapeutic categories not covered: anti-obesity agents; vitamins (except prenatal); children’s vitamins with fluoride; and DESI drugs. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, and extended care facilities and through physician payment when used in physicians’ offices. Vaccines: Vaccines reimbursable as part of EPSDT service, the Children’s Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable if there is not an added expense for the packaging.

Prior Authorization: State currently has a prior authorization procedure screening for drug classes and individual drugs. The prescriber can request reconsideration and the beneficiary can request a hearing through the fair hearings process to appeal a prior authorization decision. 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 (i.e., community based waiver programs) 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: . $5.14. 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. Ingredient Reimbursement Basis: EAC = AWP15% 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.

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(EAC+5.14) divided by 0.9805 = amount paid + $0.15 delivery service. DEAC only for Wyeth-Ayerst and Abbott.

National Pharmaceutical Council 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 plus 50% of cost, whichever is lower; 50% of cost not to exceed assigned variable dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Over 3,000 drugs are listed on the State-specific MAC list. Override requires “Dispense as Written”, “Medically Necessary”, “Brand Necessary”, or “Brand Medically Necessary.” Incentive Fee: None.

Pharmaceutical Benefits 2004 Community Health Choice 2636 South Loop, Suite 700 Houston, TX 77054 800/760-2600 Texas Health Network 12375-B Riata Trace Parkway Austin, TX 78727 800/925-9126 First Care Health Plan 12940 N. Highway 183 Austin, TX 78750 800/431-7798

Cognitive Services: Does not pay for cognitive services.

Parkland Health First 2777 N. Stemmons Freeway, Suite 300 Dallas, TX 75207 888/672-2277

Patient Cost Sharing: No copayment.

F. STATE CONTACTS State Drug Program Administrator

E. USE OF MANAGED CARE Approximately 900,000 Medicaid recipients were enrolled in MCOs in 2003 (all of whom are AFDC/AFDC-related). Recipients in managed care receive pharmaceutical benefits through the State. (Pharmacy program is “carved out.”) Managed Care Organizations AMERIGROUP, Inc. 1200 East Copeland Road, Suite 200 Arlington, TX 76011 800/600-4441 Community First Health Plan 4801 NW Loop 410, Suite 1000 San Antonio, TX 78229 800/434-2347 El Paso First Health Plans 2501 North Mesa El Paso, TX 79902 877/532-3778 Texas Children’s Health Plan 1919 Braeswood Houston, TX 77230 800/990-8247 Superior Health Plan 2100 S. IH35, Suite 202 Auston, TX 78704 800/302-6688

Barbara Dean, R.Ph. Acting Director, Vendor Drug Program Texas Health and Human Services Commission Medicaid/CHIP Division 1100 W. 49th Street Austin, TX 78756 T: 512/491-1101 F: 512/491-1962 E-mail: [email protected] Internet address: www.hhsc.state.tx.us/HCF/VDP Health and Human Services Commission Officials Albert Hawkins Executive Commissioner Texas Health and Human Service Commission 4900 N. Lamar Boulevard Austin, TX 78751 T: 512/424-6502 F: 512/424-6587 E-mail: [email protected] David Ballard, Interim Director Texas Health and Human Services Commission 4900 N. Lamar Boulevard, 4th Floor Austin, TX 78711 T: 512/491-1463 F: 512/424-6587 E-mail: [email protected]

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Prior Authorization Contact

New Brand Name Products Contact

Don Valdes, R.Ph. DUR Pharmacist Texas Health and Human Services Commission Vendor Drug Program 11209 Metric Boulevard Austin, TX 78756 T: 512/491-1172 F: 512/491-1962 E-mail: [email protected]

Martha McNeill, R.Ph. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected]

DUR Contact Barbara Dean, R.Ph. Manager, DUR Program Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1101 F: 512/491-1962 E-mail: [email protected] DUR Board Leroy Knodel, Pharm.D., Vice Chairman San Antonio, TX Thomas Lee Kurt, M.D., M.P.H. Dallas, TX Mark S. Gittings, D.O., R.Ph. Austin, TX Robert L. Hogue, M.D. Brownwood, TX Daniel Saylak, D.O., Chairman Bryan, TX Mary Spies Maxwell, M.D. Austin, TX

Prescription Price Updating Martha McNeill, R.Ph. 512/491-1157 Medicaid Drug Rebates Contact Heather Murphy, Manager Pharmacy Contracts and Rebates Vendor Drug Program Texas Health and Human Services Commission 11209 Metric Boulevard, Bulding H Austin, TX 78759 T: 512/491-1163 F: 512/491-1967 E-mail: [email protected] Claims Submission Contact Barbara Dean, R.Ph. 512/491-1101 Medicaid Managed Care Contact Pamela Coleman Director, Health Plan Operations Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 512/491-1302 E-mail: [email protected] Mail Order Pharmacy Program None

Adelina Barbosa, R.Ph. Brownsville, TX

Pharmaceutical and Therapeutics Committee

Anita Martinez, R.Ph., CDE San Antonio, TX

Richard C. Adams, M.D. Plano, TX

James B. Hills, R.Ph. Houston, TX

Anthony J. Busti, Pharm.D., R.Ph. Midlothian, TX

Robert T. Reilly, Pharm.D. El Paso, TX

Harris M. Hauser, M.D. (chair) Houston, TX Melbert C. Hillert, Jr., M.D. Dallas, TX David E. King, R.Ph. Kingwood, TX

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National Pharmaceutical Council Julie Elaine Lewis, M.S., R.Ph. Frisco, TX Valerie Robinson, M.D. Lubbock, TX Donna Burkett Rogers, M.S., R.Ph. (Vice Chair) San Antonio, TX J.C. Jackson, R.Ph. Seabrook, TX Guadalupe Zamora, M.D. Austin, TX John McCall Zerwas, M.D. Richmond, TX Executive Officers of State Medical and Pharmaceutical Societies

Pharmaceutical Benefits 2004 Texas State Board of Pharmacy Gay Dodson, R.Ph. Executive Director William P. Hobby Building Tower 3, Suite 600 333 Guadalupe Street, Suite 3-600 Austin, TX 78701-3942 T: 512/305-8000 F: 512/305-8082 E-mail: [email protected] Internet address: www.tsbp.tx.us Texas Hospital Association Richard Bettis, CAE President and CEO P.O. Box 15587 Austin, TX 78761-5587 T: 512/465-1000 F: 512/465-1090 E-mail: [email protected] Internet address: www.thaonline.org

Texas Medical Association Louis J. Goodman, Ph.D., CAE Executive Vice President and CEO 401 W. 15th Street Austin, TX 78701-1680 T: 800/880-1300 F: 512/370-1632 E-mail: [email protected] Internet address: www.texmed.org Texas Pharmacy Association Jim Martin, R.Ph. Executive Director and CEO P.O. Box 14709 Austin, TX 78761-4709 T: 800/505-5463 F: 512/836-0308 E-mail: [email protected] Internet address: www.txpharmacy.com Texas Osteopathic Medical Association Sam Tessen Executive Director 1415 Lavaca Street Austin, TX 78701-1634 T: 512/708-8662 F: 512/708-1415 E-mail: [email protected] Internet address: www.txosteo.org

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UTAH A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

2003** Expenditures Recipients

$140,520,420

152,268

$160,833,586

199,234

$65,104,788 $5,882,916 $42,629,889 $5,115,660 $11,476,323

58,926 2,943 12,766 26,318 16,899

$71,038,782 $6,277,365 $45,681,680 $6,337,127 $12,742,610

73,150 3,125 13,942 33,275 22,808

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$6,058,454 $1,270,722 $4,063,939 $110,743 $613,050

2,530 493 939 403 695

$6,720,897 $1,577,810 $4,535,970 $77,482 $529,635

5,475 1,561 2,650 494 770

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$29,475,262 $4,823,173 $16,876,649 $5,162,177 $2,526,754 $86,509

52,714 2,263 4,770 33,086 12,511 84

$34,233,657 $5,161,498 $19,228,073 $6,506,524 $3,337,562 N/A

69,852 2,656 6,399 44,553 16,244 N/A

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$39,881,916

38,098

$48,840,250

50,757

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2003 data provided by the Utah Department of Health Division of Health Care Financing. Source: CMS, MSIS Report, FY 2002 and Utah Medicaid Statistical Information System, FY 2003. Note: Utah estimates 2004 drug expenditures to be approximately $177.5 million and the number of Medicaid drug recipients to be 212,000.

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Psyllium muciloid powder Quinine, 5 gr. Products not covered: analgesics; feminine products; vitamins (except for expectant mothers and children to age 5); smoking deterrent products (special program for expectant mothers); and digestive products.

C. ADMINISTRATION

−

Division of Health Care Financing, State Department of Health.

D. PROVISIONS RELATING TO DRUGS Benefit Design

For additional information or to obtain a list of covered over-the-counter products, contact the Utah Medicaid program at http://health.utah.gov/medicaid/pdfs/otclist.pdf

Drug Benefit Product Coverage: Products covered: prescribed insulin; blood glucose test strips; urine ketone test strips. Prior authorization required for: amphetamines; Ritalin/methylphenidate; darvocet; darvon; enbrel; relenza; human growth hormones; lactulose syrup, lufyllin, oxandrin; panretin topiacal gel; prolastin; regranex retin-a-gel; tamiflu; zofran; aggrenox; cerezyme; adagen; xenical; lovenox; prilosec; prevacid; aciphex; protonix, normiflo; fragmin; kytril; anzemet; and self-administered injectables. Products covered under DME: disposable needles used for insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Products covered with restrictions: syringe combinations used for insulin (disposable syringes, prefilled covered only with prior authorization). Products not covered: cosmetics; fertility drugs; experimental drugs; and hair growth products.

Therapeutic Category Coverage: Products covered: antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; antihistamines; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT antiflammatory agents; estrogens; hypotensive agents; misc. GI drugs; and thyroid agents. Products covered with restrictions: anti-depressants; sympathominetics (adrenergic). Prior authorization required for: analgesics, antipyretics, and NSAIDs; anti-psychotics; and growth hormones (partial coverage). Products not covered: anabolic steroids; anoretics; prescribed smoking deterrents; diet medications.

Over-the-Counter Product Coverage: OTC products that are covered require a written prescription just like legend drugs in order for the pharmacy to fill them. Clients must present a Medicaid card and a prescription. Products covered: − Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix) − Allergy, asthma and sinus products (specific products covered by special programs only) − Analgesics (generics only) − Contraceptives − Cough and cold preparations (generics only) − 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 (100/month) − Kaolin w/pectin suspension (e.g., Kaopectate) − Lactobacillus acidophilus (e.g., Bacid, Lactinex) − Nutrients (all nutrients require prior approval) − Pedialyte liquid − Prophylactics male

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. Vaccines: Vaccines reimbursable at AWP minus 15% plus a fee as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary. No preferred drug list. Prior authorization required for some products. Prior Authorization: State has a prior authorization procedure screening for individual drugs with fair hearing appeal process to DUR board. Prescribing or Dispensing Limitations Prescription Refill Limit: Limited to five. Monthly Quantity Limit: In general, the quantity of medication shall be limited to a supply not to exceed 31 days. Cumulative limits on specific drugs Maximum scripts per month (except children and pregnant women).

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Drug Utilization Review

Med Utah Healthwise P.O. Box 30804 Salt Lake City, UT 84130-0804 800/624-6519

PRODUR system implemented in 1994. State has a DUR Board that meets monthly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.90 for urban, $4.40 for rural, effective 1995.

United Medchoice 7910 South 3500 East Salt Lake City, UT 84121 800/401-0660

Ingredient Reimbursement Basis: EAC = Lesser of AWP-15% or Federal/State MAC.

F. STATE CONTACTS State Drug Program Administrator

Prescription Charge Formula: Lowest of: 1. EAC/MAC plus a dispensing fee, or 2. Usual and customary charges to the private sector for legend and generic legend drugs. Formula for OTCs is AWP minus 15% plus dispensing fee.

RaeDell Ashley, R.Ph. Pharmacy Director, Medicaid Program Division of Health Care Financing Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected] Internet address: www.health.utah.gov/medicaid

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary” plus prior approval to obtain brand name product.

New Brand Name Products Contact

Incentive Fee: None.

RaeDell Ashley, R.Ph. 801/538-6495

Patient Cost Sharing: Copayment = $3.00

DUR Contact

Cognitive Services: Does not pay for cognitive services.

Duane Parke DUR Director, Medicaid Program Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6452 F: 801/538-6099 E-mail: [email protected]

E. USE OF MANAGED CARE Approximately 110,000 Medicaid recipients are enrolled in managed care in 2003. Pharmacy benefits are through the State. Managed Care Organizations

DUR Board

American Family Care 2120 South 13th East #303 Salt Lake City, UT 84106 888/483-0760

Lowry Bushnell, M.D. Western Institute of Neuropsychiatry 501 Chipeta Way Salt Lake City, UT 84108

Healthy U 35 W. Broadway Salt Lake City, VT 84101 888/271-5870

Bradford D. Hare, M.D., Ph.D. Department of Anesthesiology 50 North Medical Drive Salt Lake City, UT 84132

IHC Access P.O. Box 116670 Salt Lake City, UT 84147 800/442-9023

Jeff Jones, R.Ph. Riverton Drug 1741 West 12600 South Riverton, UT 84065 Wilhelm Tilehmann, M.D. 1520 Emerson Averson Salt Lake, UT 84105 Utah-3

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Pharmaceutical Benefits 2004

Karen M. Gunning, Pharm.D. Univ. of Utah College of Pharmacy 30 South 2000 East, Room 265 Salt Lake City, UT 84112-5820

Mail Order Pharmacy Program

Charles M. Arena, M.D. 5337 Cottonwood Club Drive Salt Lake City, UT 84117

Department of Health Officials

State has a mail order pharmacy program. Utah Medicaid beneficiaries may choose to obtain prescription drugs through mail order.

David Sundwall, M.D. Executive Director Department of Health P.O. Box 141000 Salt Lake City, UT 84114-1000 T: 801/538-6111 F: 801/538-6306 E-mail: [email protected]

Colin B. Van Orman, M.D. PCMC 100 North Medical Drive, Suite 2700 Salt Lake City, UT 84113 Derek Christensen, R.Ph. 9842 Grouse Bend Circle South Jordan, UT 84095

Michael Deily, Director Department of Health Division of Health Care Financing P.O. Box 143101 Salt Lake City, UT 84114-3101 T: 801/538-6406 F: 801/465-9546 E-mail: [email protected]

Joseph Miner, M.D. Utah County Health Department 589 South State Street Provo, UT 84601 Dominic DeRose, R.Ph. Value Drug 1080 West 300 North Clearfield, UT 84015

Executive Officers of State Medical and Pharmaceutical Societies Utah Medical Association J. Leon Sorenson Executive Vice President 540 East 500 South Salt Lake City, UT 84102 T: 801/355-7477 F: 801/532-1550 E-mail: [email protected] Internet address: www.utahmed.org

Prescription Price Updating RaeDell Ashley, R.Ph. 801/538-6495 Medicaid Drug Rebate Contacts Technical: RaeDell Ashley, R.Ph., 801/538-6495 Policy: RaeDell Ashley, R.Ph., 801/538-6495 PA: RaeDell Ashley, R.Ph., 801/538-6495 DUR: Duane Parke, 801/538-6452

Utah Osteopathic Medical Association Shelly Hanks Secretary 462 South 1240 East Payson, UT 84651-8533 T: 801/465-9545 F: 801/465-9546 E-mail: [email protected] Internet address: www.uoma.net

Claims Submission Contact Connie Higley Information Technology Director Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 801/538-6691 E-mail: [email protected] Medicaid Managed Care Contact Julie Olsen, Director, Managed Health Care Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6303 F: 801/538-6009 E-mail: [email protected]

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Utah Pharmaceutical Association Reid L. Barker Executive Director 1850 South Columbia Lane Orem, UT 84097 T: 801/762-0452 F: 801/762-0454 E-mail: [email protected] Internet address: www.upha.com Utah State Board of Pharmacy Diana L. Baker Bureau Director 160 East 300 South P.O. Box 146741 Salt Lake City, UT 84114-6741 T: 801/530-6628 F: 801/530-6511 E-mail: [email protected] Internet address: www.dopl.utah.gov/licensing/pharmacy Utah Hospitals and Health Systems Association Joseph M. Krella, FACHE President 2180 South 1300 East, Suite 440 Salt Lake City, UT 84016 T: 801/486-9915 F: 801/486-0882 E-mail: [email protected] Internet address: www.uha-utah.org

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VERMONT A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$115,623,970

112,227

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$40,886,714 $3,730,992 $31,655,468 $2,387,467 $3,112,787

24,609 1,680 10,964 7,760 4,205

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$19,598,384 $6,923,615 $9,935,004 $521,190 $2,218,575

10,415 2,889 2,730 1,542 3,254

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women Unknown

$6,798,032 $0 $0 $6,475,960 $312,886 $0 $9,186

29,107 0 0 27,574 1,523 0 10

$48,340,840

48,096

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $127,763,857

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

1 The State of Vermont did not respond to the 2001, 2002, or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Vermont Medicaid program to assess the accuracy and currency of the information included.

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Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION Agency of Human Services, Office of Vermont Health Access.

D. PROVISIONS RELATING TO DRUGS

Formulary: Open formulary with preferred drug list (PDL). PDL managed through exclusion of products based on contracting issues, restrictions on use, prior authorization, and preferred products. General exclusions include cosmetics and experimental drugs.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips. Products covered as DME: total parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; urine ketone test strips; and interdialytic parenteral nutrition (covered by Medicare). Prior authorization may be required for certain self-administered injectables. Over-the-Counter Product Coverage: Products covered with a prescription and manufacturer’s signed rebate agreement: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; single source/multisource vitamins pending condition; lice shampoos; and topical products. Products covered with restrictions: feminine products (for bladder control only) and smoking deterrent products (maximum of 2 scripts for up to 90-day supply each year). Therapeutic Category Coverage: Therapeutic categories covered: contraceptives; ENT antiinflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antipilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; growth hormones (must meet clinical criteria); prescribed smoking deterrents; erectile dysfunction products; and antiobesity drugs. Therapeutic categories not covered: anoretic.

Unit Dose: Unit dose packaging reimbursable.

Prescribing or Dispensing Limitations Prescription Refill Limit: Up to 5 may be authorized by a physician. 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. Drug Utilization Review PRODUR system implemented in November 1993. State currently has a DUR board with a bimonthly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.25, effective 7/1/96. Ingredient Reimbursement Basis: EAC = AWP11.9%.

Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physician offices, home health care, and extended care facilities. Vaccines: The Vermont Department of Health provides vaccines to physician offices.

Prior Authorization: State has formal prior authorization procedure and a method for appealing coverage of an excluded product and prior authorization decisions. To appeal coverage of an excluded product, a provider can request a review by the Medicaid program’s Medical director or request a fair hearing. For prior authorization decisions, the prescriber can initiate a first appeal and, if the request remains unresolved, contact the Medicaid Director. Prior authorization required for drugs not listed on the PDL.

Prescription Charge Formula: Pharmacies bill their usual and customary charge. Medicaid pays the lower of: 1. Usual and customary charge; 2. EAC plus a dispensing fee; or 3. Maximum allowable cost 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”, “Medically Necessary,” “Brand Necessary,”or DAW8 (generic not available). Incentive Fee: None.

Vermont-2

National Pharmaceutical Council Patient Cost Sharing: State uses a system of tired copayments ($1.00 - $3.00): $1.00 – for scripts < $30.00 $2.00 – for Scripts $30.00 - $49.99 $3.00 – for Scripts $50.00 and above. Cognitive Services: Does not pay for cognitive services.

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

F. STATE CONTACTS State Drug Program Administrator Ann E. Rugg Deputy Director Office of Vermont Health Access 312 Hurricane Lane, Suite 200 Williston, VT 05495 T: 802/879-5900 F: 802/879-5919 E-mail: [email protected] Internet address: www.ohva.state.vt.us Agency of Human Services Officials Michael K. Smith Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05671-0201 T: 802/241-2220 F: 802/241-2979 E-mail: [email protected] Internet address: www.ahs.state.vt.us Joshua Slen Medicaid Director Agency for Human Services Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676-1201 T: 802/879-5900 F: 802/879-5962 E-mail: [email protected] Prior Authorization Contact OVHA staff do not meet with pharmaceutical industry representatives

Pharmaceutical Benefits 2004 DUR Contact Felicia Montineri Pharmacist First Health Services Corporation 312 Hurricane Lane, Suite 200 Williston, VT O5495 T: 802/879-5900 F: 802/879-5919 E-mail: [email protected] DUR Board James A. Gray, M.D. (Chair) Jeffrey P. Firlik, R.Ph. Cheryl A. Gibson, M.D. Stuart Graves, M.D. Rich Harvie, R.Ph. Virginia L. Hood, M.D. Frank J. Landry, M.D. John R. Low, R.Ph. Andrew C. Miller, R.Ph. Michael Scovner, M.D. Lloyd (Tim) L. Thompson, M.D. Norman S. Ward, M.D. New Brand Name Products Contact Felicia Montineri 802/879-5900 Prescription Price Updating Cathy England, Manager Rebate Administration First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 804/965-7717 Medicaid Drug Rebate Contacts Christine Dapkiewicz EDS 312 Hurricane Lane, Suite 100 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440 Claims Submission Contact First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 804/965-7717 Mail Order Pharmacy Benefit None

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Pharmaceutical Benefits 2004 Executive Officers of State Medical and Pharmaceutical Societies

Medical Advisory Board Kim Cheney AARP

Vermont Medical Society Paul Harrington Executive Vice President 134 Main Street P.O. Box 1457 Montpelier, VT 05601 T: 802/223-7898 F: 802/223-1201 E-mail: [email protected] Internet address: www.vtmd.org

Dave Reynolds Bi-State Primary Care Association Michael Sirotkin Community of Vermont Elders Donna Sutton Fay Health Care Ombudsman

Vermont Pharmacists Association James Marmar Executive Director Box 90 Woodstock, VT 05091 T: 877/483-2646 F: 802/433-4803 E-mail: [email protected] Internet address: www.vtpharmacists.org

Jacqueline Majoros LTC Ombudsman Peter Cobb VT Assembly of Home Health Agencies Bea Grause VT Association of Hospitals and Health Systems Lila Richardson VT Coalition for Disability Rights

Vermont State Association of Osteopathic Physicians & Surgeons, Inc. John M. Peterson, D.O. Executive Director 72 Barre Street Montpelier, VT 05602-3508 T: 802/229-9418 T: 802/454-9663 E-mail: [email protected] Internet address: www.osteopathic.org/index

Peter Taylor VT Dental Society Mary Shriver VT Health Care Association Paul Harrington VT Medical Society Margaret Joyal VT Council of Community Mental Health Services Kristi Kistler Dartmouth Hitchcock Medical Center Julie Arel Parent to Parent Garry Schaedel Department of Health Edna Fairbanks-Williams Sarah Littlefeather Nancy Osborne Michelle Parent Linda Bassick

Vermont State Board of Pharmacy Peggy Atkins Board Administrator 26 Terrace Street, Drawer 09 Montpelier, VT 05609-1101 T: 802/828-2373 F: 802/828-2465 E-mail: [email protected] Internet address: www.vtprofessionals.org/oprl/pharmacists Vermont Association of Hospitals and Healthcare Systems Marie Beatrice Grause President and CEO 148 Main Street Montpelier, VT 05602 T: 802/223-3461 F: 802/223-0364 E-mail: [email protected] Internet address: www.vahhs.org

Dale Hacket

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VIRGINIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit

Categorically Needy Aged Blind/ Child Adult Disable d

Aged

Medically Needy (MN) Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

All eligible recipients under age 21

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$453,663,058

319,196

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$260,853,039 $81,793,724 $178,998,190 $17,496 $43,629

98,159 33,845 64,149 90 75

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$13,371,925 $5,782,597 $7,565,189 $19,393 $4,746

5,595 2,811 2,617 141 26

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$54,484,185 $12,378,967 $15,064,557 $24,558,740 $2,33,400 $148,521

137,210 7,008 6,389 106,379 17,324 110

$124,953,909

78,232

TOTAL OTHER EXPENDITURES/RECIPIENTS

2003** Expenditures Recipients $506,414,352

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Formulary/Prior Authorization

C. ADMINISTRATION

Formulary: Open Formulary with preferred drug list (PDL). Managed through prior authorization, therapeutic substitution, and preferred products.

Department of Medical Assistance Services. Eligibility determination by the Department of Social 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 total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; 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. These include: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products.

Prior Authorization: State currently has a formal prior authorization process with right to appeal prior authorization decisions (see www.dmas.virginia.gov under pharmacy initiatives for appropriate process). Prior authorization procedure screening for individual drugs for weight loss. Prescribing or Dispensing Limitations Prescription Refill Limit: Physicians may authorize refills according to legal requirements. Monthly Quantity Limit: 34-day supply. Drug Utilization Review PRODUR (online) system implemented in July 1994. RetroDUR Program also implemented in 1994. State currently has a DUR Board with quarterly meetings. Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; 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. Partial coverage for: anoretics (PA required). Prior authorization required for: weight loss drugs and non-preferred drugs.

Dispensing Fee: $3.75, effective 7/1/03.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, and extended care facilities, and through physican payment when used in physician offices.

Incentive Fee: None.

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable in nursing homes.

Ingredient Reimbursement Basis: EAC = AWP10.25%. Prescription Charge Formula: Based upon the lower of VMAC or EAC plus a fee, or the usual and customary charge minus a copayment of $1.00 for generics and $3.00 for brand-name products, where appropriate. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Medically Necessary.”

Patient Cost Sharing: Copayment is $1.00/Rx for generics and $3.00/Rx on brand-name products. 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.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

E. USE OF MANAGED CARE

DUR Board

Approximately 260,000 beneficiaries enrolled in HMOs in 2003. Recipients enrolled in managed care organizations receive pharmaceutical benefits through managed care plans.

Robert O. Friedel, M.D. Catherine Kelso, M.D. Jason Lynam, M.D. Jennifer Edwards, Pharm.D. Elaine Ferrary, M.S. Jane Settle, N.P., M.C.V. Geneva Briggs, Pharm.D. (Chair) Sandra Dawson, R.Ph. Kelly Goode, Pharm.D. Mark Johnson, Pharm.D. Bill Rock, Pharm.D. Thomas Moffatt, M.D. Mathew J. Goodman, M.D.

Managed Care Organizations Virginia Premier Health Plan Anthem HealthKeepers Plus Sentara Family Care Southern Health/CareNet UNICARE Health Plan of Virginia

F. STATE CONTACTS State Drug Program Administrator Javier Menendez, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/783-2196 F: 804/786-0973 E-mail: [email protected] Internet address: www.dmas.virginia.gov Prior Authorization Contact Debra Moody Clinical Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/956-7431 F: 804/273-6961 E-mail: [email protected] DUR Contact Rachel E. Cain Pharmacist I Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/225-2873 F: 804/786-0973 E-mail: [email protected]

New Brand Name Products Contact Keith T. Hayashi Pharmacist I Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/225-2773 F: 804/786-0973 E-mail: [email protected] Prescription Price Updating Keith T. Hayashi 804/225-2773 Medicaid Drug Rebate Contacts Policy: Audits:

Javier Menendez, R.Ph. 804/783-2196 Keith T. Hayashi 804/225-2773

Disputes: Lezli Jeter Rebate Pharmacist First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/527-3009 F: 804/217-7911 Disease Management/Patient Education Programs Disease/ Medical State: Cardiovascular Disease Program Name: Pilot Congestive Heart Failure and/or Cornary Artery Disease Program Program Manager: Policy Division and Director of Research Program Sponsor: Anthem

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Disease Management/Patient Education Initiatives Contact

Jan Burrus PhRMA

Howard B. Tomlinson II Director, Health Care Services Division Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/371-7398 F: 804/786-5799 E-mail: [email protected]

Ann Leigh Kerr Troutman Sanders LLP Richard Grossman Vectre Corporation Executive Officers of State Medical and Pharmaceutical Societies The Medical Society of Virginia Paul Kitchen Executive Vice President 4205 Dover Road Richmond, VA 23221 T: 804/377-1034 F: 804/355-6189 E-mail: [email protected] Internet address: www.msv.org

Claims Submission Contact Frank Fury Processing Admnistrator First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 804/965-7400 Medicaid Managed Care Contact

Virginia Pharmacists Association Rebecca P. Snead Executive Director 5501 Patterson Avenue, Suite 200 Richmond, VA 23226 T: 800/527-8742 F: 804/285-4227 E-mail: [email protected] Internet address: www.vapharmacy.org

Mary Mitchell Managed Care Unit Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-3594 F: 804/786-5799 E-mail: [email protected] Mail Order Pharmacy Program None Department of Medical Assistance Services Officials Patrick W. Finnerty Director Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-4231 F: 804/225-4512 E-mail: [email protected] Virginia Medicaid Pharmacy Liaison Committee Bill Hancock, R.Ph. Long Term Care Pharmacy Coalition Alexander Maculey, R.Ph. Community Pharmacy Michael Ayotte, R.Ph. Virginia Association of Chain Drug Stores Rebecca Snead, R.Ph. Virginia Pharmacist Association

Virginia State Board of Pharmacy Elizabeth Scott Russell Executive Director 6603 W. Broad Street, 5th Floor Richmond, VA 23230-1712 T: 804/662-9911 F: 804/662-9313 E-mail: [email protected] Internet address: www.dhp.state.va.us/pharmacy Virginia Osteopathic Medical Association Maria Harris, Executive Director 48 East Square Lane Richmond, VA 23238 T: 804/784-2204 F: 804/784-2231 E-mail: [email protected] Internet address: www.voma-net.org Virginia Hospital and Healthcare Association Laurens Sartoris, President 4200 Innslake Drive Glen Allen, VA 23060 T: 804/965-1216 F: 804/965-0475 E-mail: [email protected] Internet address: www.vhha.com

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WASHINGTON A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$549,216,380

423,758

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$303,547,520 $50,050,991 $245,256,705 $2,228,696 6,011,128

153,308 25,016 91,560 19,049 17,683

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$50,911,333 $13,280,920 $37,601,159 $8,139 $21,115

14,782 6,056 8,674 18 34

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$22,401,575 $2,533,118 $7,413,952 $7,841,982 $4,612,523 $0

102,651 1,852 2,754 61,232 36,813 0

$172,355,952

153,017

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $592,437,155

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

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Pharmaceutical Benefits 2004

C. ADMINISTRATION Medical Assistance Administration, Department of Social and 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; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered with restrictions: allergy, asthma and sinus products (selected items); analgesics (ASA and acetaminophen); cough and cold preparations (selected items); digestive products (selected items); feminine products (selected items); and topical products (selected items). Products not covered: smoking deterrent products. (Note: Zyban only covered for pregnant women in smoking cessation program). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; anti-depressants; cardiac drugs; chemotherapy agents; contraceptives; ENT antiinflammatory agents; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: anabolic steroids; analgesics, antipyretics, and NSAIDs; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; prescribed cold medications; estrogens; growth hormones; misc. GI drugs; and non-preferred drugs*. Therapeutic categories not covered: anoretics; prescribed smoking deterrents (except Zyban for pregnant women enrolled in a smoking cessation program); weight loss drugs; products for hair growth; drugs for infertility, and frigidity, impotency, or sexual dysfunction. *Drugs considered for prior authorization are drugs with high risk/benefit ratio, high potential for abuse/misuse, narrow therapeutic indication, and high cost. A complete list of drugs requiring prior authorization may be found on the Medical Assistance Administration’s web site: http://maa.dshs.wa.gov/pharmacy

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. Vaccines: Vaccines reimbursable at EAC as part of EPSDT services. Unit Dose: Unit dose packaging is reimbursable. Formulary/Prior Authorization Formulary: Open formulary with preferred drug list (PDL). Managed through excluding products based on contracting issues; prior authorization, therapeutic substitution; preferred products, and physician profiling. Prior Authorization: State currently has a prior authorization program and a Drug Utilization Review Team and a Drug Evaluation Matrix Team. 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 Prescription Limit: Review of client drug profile by a clinical pharmacist when request for 5th brand name prescription in any one-month period. Monthly Quantity Limit: Maximum 34-day supply (90 days on select items). Drug Utilization Review PRODUR system implemented in March 1996. State currently has a P&T Committee/DUR Board with a quarterly review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.20 to $5.20, effective 7/1/02. $4.20 - Retail pharmacies, filling over 35,000 Rxs annually. − $4.51 - Retail pharmacies, filling 15,00135,000 Rxs annually. − $5.20 - Retail pharmacies, filling 15,000 or less Rxs annually. − $5.20 - Unit dose systems (nursing home Rxs). −

Ingredient Reimbursement Basis: EAC = AWP14%, except drugs on the MAC list with 5 or more labelers/manufacturers are reimbursed at AWP50%.

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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 Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None.

Molina Healthcare of Washington, Inc. (MHC) P.O. Box 1469 Bothell, WA 98041 800/869-7165 Regence Blue Shield P.O. Box 21267 Mail Stop BR 390 Seattle, WA 98111-3267 800/689-8791

F. STATE CONTACTS

Patient Cost Sharing: No copayment.

State Drug Program Administrator

Cognitive Services: State pays for emergency contraceptive counseling and clozaril case management.

Siri A. Childs, Pharm D. Pharmacy Policy Manager Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/586-8827 E-mail: [email protected] Internet address: http://maa.dshs.wa.gov/pharmacy

E. USE OF MANAGED CARE Approximately 450,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through both the State and managed care plans. Anti-retrovirals, mental health drugs, and family planning products are carved out of managed care. Managed Care Organizations Asuris Northwest Health Plan P.O. Box 91130 Mail Stop BR 325 Seattle, WA 98111 888/240-9580 Columbia United Providers 19120 SE. 34th Street, Suite 201 Vancouver, WA 98683 800/315-7862 Community Health Plan of Washington 720 Olive Way, Suite 300 Seattle, WA 98101 800/440-1561 Group Health Cooperative 521 Wall Street Seattle, WA 98121 888/901-4636 Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah, Suite 100 Portland, OR 97232-2099 800/813-2000

Prior Authorization Contact Siri A. Childs, Pharm.D. 360/725-1564 DUR Contact Nicole N. Nguyen, Pharm.D. Clinical Pharmacist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1757 F: 360/586-8827 E-mail: [email protected] Pharmacy and Therapeutics Committee/DUR Board Robert Bray, M.D. Carol Cordy, M.D. ( Vice Chair) Daniel Lessler, M.D. (Chair) T. Vyn Reese, M.D. Angelo Ballasiotes, Pharm.D. Alvin Goo, Pharm.D. Jason Iltz, Pharm.D. Janet Kelly, Pharm.D. John White, P.A., Pharm.D. Patty Varley, A.R.N.P. New Brand Name Products Contact Siri A. Childs, Pharm.D. 360/725-1564

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Disease Management Program/Initiative Contact

Prescription Price Updating Tom Zuchlewski Pharmacy Rates Manager Medical Assistance Administrator, DSHS P.O. Box 45510 Olympia, WA 98504-5510 T: 360/725-1837 F: 360/753-9152 E-mail: [email protected]

Alice R. Lind Managed Care Coordination Section Medical Assistance Administration, DSHS P.O. Box 45530 Olympia, WA 98504-45530 360/725-1629 E-mail: [email protected]

Medicaid Drug Rebate Contact

Social and Health Services Department Officials

Connie L. Riddle Medical Assistance Administration P.O. Box 45503 Lacy, WA 98504-5503 360/725-1243 E-mail: [email protected]

Robin Arnold-Williams Secretary Department of Social and Health Services P.O. Box 45010 Olympia, WA 98504-5010 T: 360/902-7800 F: 360/902-7848 E-mail: [email protected]

Claims Submission Contact Chris Johnson Claims Processing Manager Medical Assistance Administrator, DSHS P.O. Box 45509 Olympia, WA 98504-5509 360/725-1239 E-mail: [email protected]

Doug Porter Assistant Secretary Medical Assistance Administration P.O. Box 45100 Olympia, WA 98504-5100 T: 360/725-1863 F: 360/902-7855 E-mail: [email protected]

Medicaid Managed Care Contact MaryAnne Lineblad, Director Division of Program Support Medical Assistance Administration, DSHS P.O. Box 45530 Lacey, WA 98504-5530 360/725-1786 E-mail: [email protected]

Department of Social and Health Services Title XIX Advisory Committee Janet Varon, Co-chair Executive Director, NoHLA 1820 East Pine Street, Suite 322 Seattle, WA 98122

Mail Order Pharmacy Program State has mail order pharmacy program for fee-forservice clients. Disease Management/Patient Education Programs Disease/Medical State: Asthma Program Manager: McKesson Disease/Medical State: Congestive Heart Failure Program Manager: McKesson Disease/Medical State: Diabetes Program Manager: McKesson Disease/Medical State: Renal Disease Program Manager: Renaissance

Robert Wardell, Co-chair 3815 N. Pearl, Apartment K-1 Tacoma, WA 98407 Elise Chayet WSHA Harborview Medical Center 325 Ninth Avenue Seattle, WA 98104-2499 Ted Rudd, M.D. WSMA 209 S. 12th Avenue, #A Yakima, WA 98902 Janene Jones-Heino WSPA 12856 NE Central Valley Road Poulsbo, WA 98370 360/377-3753

Washington-4

National Pharmaceutical Council Doug Porter Assistant Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080 Allena Barnes 7827 South 113th Street Seattle, WA 98178 Kathy Carson Sea-King Co. Dept. of Health 999 Third Avenue, Suite 900 Seattle, WA 98104-4039 Shawna Connolly Premera Blue Cross P.O. Box 327 Seattle, WA 98111-0327 Steven Gobin 6700 Totem Beach Road Marysville, WA 98271 Blanche Jones Gentiva Health Services 4020 South 56th Street, Suite 101 Tacoma, WA 98409 Barbara Malich Peninsula Community Health Services P.O. Box 960 Bremerton, WA 98337 Eleanor Owen 802 Northwest 70th Seattle, WA 98117 Mark Secord Neighborhood Health Centers 905 Spruce Street, Suite 201 Seattle, WA 98104 Laura Toepfer AOA 31708 2nd Avenue South Federal Way, WA 98003-5260 Raleigh Watts Department of Health P.O. Box 47481 Olympia, WA 98504-7841 Bruce Yoder, D.D.S. WSDA 1890 Pottery Avenue Port Orchard, WA 98366

Pharmaceutical Benefits 2004 DSHS Staff Members Debbie Meyer, Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080 Pharmacy Drug Use Review Team Members Siri A. Childs, Pharm.D. Nicole Nguyen, Pharm.D. Joan Baumgartner, M.D. Olin Cantrell, PA-C Linda Ayers, A.R.N.P. Valerie Vertz Charles Agte Debbie Bellerud Aimee Bennett David Conaway Kevin Davenport Do Huynh Celeste Moore Robin Pfeiffer Sam Trimble Patty Orth Executive Officers of State Medical and Pharmaceutical Societies Washington State Medical Association Thomas Curry Executive Director 2033 Sixth Avenue, Suite 1100 Seattle, WA 98121 T: 206/441-9762 F: 206/441-5863 E-mail: [email protected] Internet address: www.wsma.org Washington State Pharmacy Association Rod Shafer CEO 1501 Taylor Avenue, SW Renton, WA 98055-3139 T: 425/228-7171 F: 425/277-3897 E-mail: [email protected] Internet address: www.wsparx.org Washington Osteopathic Medical Association, Inc. Kathleen S. Itter Executive Director P.O. Box 16486 Seattle, WA 98116-0486 T: 206/937-5358 F: 206/933-6529 E-mail: [email protected] Internet address: www.woma.org

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Washington State Board of Pharmacy Steve Sax Executive Director Department of Health 310 Israel Road P.O. Box 47863 Olympia, WA 98504-7863 T: 360/236-4825 F: 360/586-4359 E-mail: [email protected] Internet address: wws2.wa.gov/doh/hpql/HPS4/Pharmacy/default.htm Washington State Hospital Association Leo F. Greenawalt President and CEO 300 Elliott Avenue W., Suite 300 Seattle, WA 98119-4118 T: 206/281-7211 F: 206/283-6122 E-mail: [email protected] Internet address: www.wsha.org

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Pharmaceutical Benefits 2004

WEST VIRGINIA A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Service

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2001 Expenditures

Recipients

2003** Expenditures Recipients

TOTAL

$274,613,136

276,338

$339,816,022

366,987

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind/Disabled Child Adult

$205,990,651 $49,146,107 $141,883,170 $83,757 $14,877,617

114,996 20,959 63,432 445 30,160

$253,457,293 $59,294,089 $177,696,813 -$1,108,621*** $17,575,011

129,958 23,842 70,138 491 35,487

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$6,336,007 $497,245 $4,630,102 $2,694 $1,205,966

4,365 423 2,566 13 1,363

$9,030,712 $722,820 $6,657,321 $3,253 $1,647,318

6,862 745 3,816 20 2,281

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$36,870,384 $581,879 $4,337,649 $29,971,587 $1,979,269 $0

133,411 342 1,794 123,471 7,804 0

$47,758,201 $569,126 $5,010,476 $39,356,061 $2,822,538 N/A

203,737 5,909 6,095 179,714 12,019 N/A

TOTAL OTHER EXPENDITURES/RECIPIENTS*

$25,416,094

23,566

$29,569,816

26,430

*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2003 data provided by the West Virginia Department of Health and Human Resources, Bureau for Medical Services. ***Represents a prior year adjustment. Source: CMS, MSIS Report, FY 2002 and West Virginia Medicaid Statistical Information System, FY 2003.

1 The State of West Virginia did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated the profile and the tables in other sections of the Compilation. Users should contact the West Virginia Medicaid program to assess the accuracy and currency of the information included.

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Note: West Virginia estimates 2004 drug expenditures to be approximately $360 million and the number of Medicaid drug recipients to be 364,000.

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable. Bureau for Medical Services, Department of Health & Human Resources.

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; fertility drugs; experimental drugs; total parenteral nutrition; and interdialytic parenternal nutrition. Over-the-Counter Product Coverage: Products covered with restrictions (i.e., limited formulary/prescription required): feminine products; topical products; allergy, asthma, and sinus products; analgesics; cough and cold preparations; and digestive products (non-H2 antagonist). Prior authorization for: smoking deterrent products. Products not covered: digestive products (H2 antagonists). Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; 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 anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: growth hormones; prescribed smoking deterrents; and all stimulants except strattera (for beneficiaries > 18 yrs. of age). Therapeutic categories not covered: anorectics; agents for cosmetic use; and weight loss products. Coverage of Injectables: Injectable medicines reimbursable under the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment in physician offices. All injectable medications dispensed through outpatient pharmacies require prior authorization.

Formulary/Prior Authorization Formulary: Closed formulary (as of 1/17/03) with preferred drug list. Restrictions include preferred products and prior authorization through the Rational Drug Therapy Program. General exclusions include: legend agents used for cosmetics purposes or hair growth; DESI drugs; fertility drugs; and products used for anorexia or weight gain. Prior Authorization: State currently has a prior authorization screening procedure for drug classes and home health care. Written appeal to the Medical Director by the prescriber required to appeal a prior authorization decision. P&T Committee and DUR Board make prior authorization recommendations. Prescribing or Dispensing Limitations All covered outpatient drugs are reimbursed up to a 34-day supply and eleven refills. Exceptions include: 1. Antibiotics are covered for a 14-day supply and one refill. 2. Opiate agonists (excluding Schedule II drugs), analgesics and miscellaneous antipyretics are covered for 30 days and five refills, in accordance with Federal law. 3. Sedatives and hypnotics are covered for a 30day supply and five refills, in accordance with Federal law. Drug Utilization Review PRODUR system implemented in March 1995. State currently has a DUR Board with a quarterly 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 = AWP12%.

Vaccines: Vaccines reimbursable as part of CHIP and the Vaccines for Children Program.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Prescription Charge Formula: Reimbursement based on the lowest of: 1. The estimated acquisition cost (EAC) plus a dispensing fee. 2. The maximum allowable cost (MAC) plus a dispensing fee. 3. 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. Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override will require physician certification of “Dispense as Written” or “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment varies - $0.50 to $3.00 based on ingredient costs. Exclusions include: 1. 2.

3. 4.

Family planning services and supplies. Prescriptions originating with the Early and Periodic Screening, Diagnosis and Treatment Program. Nursing home residents. Children under the age of 18 years.

Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 98,000 unduplicated Medicaid recipients were enrolled in MCOs in 2003. Beneficiares in managed care receive pharmacy services through the State. Managed Care Organizations Carelink Health Plans 500 Virginia Street East, Suite 400 Charleston, WV 25326-1711 T: 304/348-2041 F: 304/348-3948 The Health Plan of the Upper Ohio Valley 52160 National Road, East St. Clairsville, OH 43950 T: 740/695-3585 F: 740/695-5297 Wellpoint – Unicare 5151-A Camino Ruiz Camarillo, CO

F. STATE CONTACTS State Drug Program Administrator Peggy A. King, R.Ph. Director, Office of Pharmacy Services Department of Health and Human Resources Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected] Internet address: www.wvdhhr.org/bms/pharmacy Department of Health & Human Resources Officials Martha Yeager Walker, Secretary Department of Health and Human Resources Building 3, State Capitol Complex, Room 206 Charleston, WV 25305 T: 304-558-0684 F: 304/558-1130 E-mail: [email protected] Internet address: www.wvdhhr.org Nancy Atkins, Commissioner Department of Health and Human Resources Bureau for Medical Services 7012 MacCorkle Avenue, SE Charleston, WV 25301 T: 304/558-1700 F: 304/558-1509 E-mail: [email protected] Sandra Joseph, M.D. Medical Director Department of Health and Human Resources Division of Medical Care 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5967 F: 304/558-1509 Prior Authorization Contact Stephen Small, R.Ph., M.S. Director, Rational Drug Therapy Program West Virginia University School of Pharmacy Robert C. Byrd Health Sciences Center P.O. Box 9511 Morgantown, WV 26506-9511 T: 800/847-3859 F: 800/531-7787 E-mail: [email protected]

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Pharmaceutical Benefits 2004

DUR Contact

Pharmaceutical and Therapeutics Committee

Vicki M. Cunningham, R.Ph. DUR Coordinator Department of Health and Human Services Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-6541 F: 304/558-1542 E-mail: [email protected]

Kevin W. Yingling, M.D., R.Ph. Steve R. Matulis, M.D. (Chair) Thomas L. Gilligan, D.O. David Avery, M.D. John D. Justice, M.D. Teresa Dunsworth, Pharm.D. James D. Bartsch, R.Ph. Harriett Nottingham, R.Ph. Kristy H. Lucas, Pharm.D. David Grome, PA-C Barbara Koster, M.S.N., R.N.C. – A.N.P.

Medicaid DUR Board

Pharmaceutical Cost Management Council Robert W. Ferguson, Jr. Cabinet Secretary Department of Administration Martha Yeager Walker Secretary Department of Health and Human Resources Felice Joseph Pharmacy Director Public Employees Insurance Agency Nancy Atkins Commissioner Bureau for Medical Services George A. Burton Executive Director Workers’ Compensation Commission Charles “Laddie” Burdette”, R.Ph. Fruth Pharmacy Wayne C. Spiggle, M.D. Primary Care Physician Stephen Neal, R.Ph. The Health Plan William Lytton Program Director Bureau for Senior Services

Steven C. Judy, R.Ph. Kevin W. Yingling, M.D., R.Ph. David P. Elliott, Pharm.D. Bernard Lee Smith, R.Ph., M.B.A, M.H.A Patrick M. Regan, R.Ph. Karen Reed, R.Ph. (Chair) 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. Christopher Terpening, Pharm.D., R.Ph James M. Bennett, M.D. Kerry Sitzinger, R.Ph. George Bryant, PA-C Daniel Dickman, M.D. (Vice Chair) New Brand Name Products Contact Peggy A. King, R.Ph. 304/558-1700 Prescription Price Updating Heather Bodiford PBM Account Manager ACS State Healthcare 365 Northridge Rd. Northridge Center One, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 770/730-5198 E-mail: [email protected] Medicaid Drug Rebate Contact

Heather Bresch Vice President Mylan Laboratories, Inc. Kevin Outterson Associate Professor of Law West Virginia University College of Law

Gail A. Goodnight, R.Ph. Rebate Coordinator Department of Health and Human Services Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-5977

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National Pharmaceutical Council

Pharmaceutical Benefits 2004 Executive Officers of State Medical and Pharmaceutical Societies

F: 304/558-1542 E-mail: [email protected] Claims Submission Contact

West Virginia State Medical Association Evan Jenkins, Executive Director 4307 MacCorkle Avenue SE P.O. Box 4106 Charleston, WV 25364 T: 304/925-0342 F: 304/925-0345 E-mail: [email protected] Internet address: www.wvsma.com

Heather Bodiford 866/322-5960 Medicaid Managed Care Contact Shelley Baston, Director Office of Managed Care Bureau of Medical Services Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5978 F: 304/558-4398 E-mail: [email protected] Mail Order Pharmacy Program

West Virginia Pharmacists Association Patty Johnson, President 2003 Quarrier Street Charleston, WV 25311-2212 T: 304/252-5305 F: 304/344-5316 E-mail: [email protected]

None Disease Management/Patient Education Programs Disease/Medical State: Cardiovascular Disease Program Name: West Virginia on the Move Program Manager: Bonnie Mehan Program Sponsor: Pfizer Disease/Medical State: Diabetes Program Name: Medicaid Diabetes Management Program Program Manager: Bonnie Mehan Program Sponsor: West Virginia Diabetes Control Program Disease Management Initiative/Program Contact Bonnie Meehan Disease Management Coordinator Department of Health and Human Services Bureau for Medical Services 3500 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-1727 F: 304/558-4398 E-mail: [email protected] Medical Services Fund Advisory Council Violet Burdette William McFarland, R.Ph Doug Coffman John Elliott Sheryl Kiser Charles Smith, D.D.S. John Russell Scott McClanahan Mark B. Ayoubi, M.D. G. Anne Cather, M.D. Chris Cutis Fred Booth

West Virginia Society of Osteopathic Medicine Charlotte Ann Cales Pulliam Executive Director 400 Allen Drive, Suite 201 The Westmoreland Place Charleston, WV 23502 T: 304/345-9836 F: 304/345-9865 E-mail: [email protected] Internet address: www.wvsominc.org West Virginia State Board of Pharmacy William T. Douglas, Jr. Executive Director and General Counsel 232 Capitol Street Charleston, WV 25301 T: 304/558-0558 F: 304/558-0572 E-mail: [email protected] Internet address: www.wvbop.com West Virginia Hospital Association Steven J. Summer President and CEO 100 Association Drive Charleston, WV 25311 T: 304/344-9744 F: 304/344-9745 E-mail: [email protected] Internet address: www.wvha.com

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Pharmaceutical Benefits 2004

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Pharmaceutical Benefits 2004

WISCONSIN A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Medically Needy (MN) Aged Blind/ Child Adult Disabled

Prescribed Drugs

‹

‹

‹

‹

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

‹

‹

‹

‹

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients TOTAL

$455,720,622

309,795

RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult

$220,578,511 $22,398,037 $191,378,131 $2,277,339 $4,525,004

116,396 11,614 74,550 15,043 15,189

MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult

$31,711,402 $13,143,083 $18,053,101 $399,451 $115,767

16,672 6,424 5,070 4,243 935

POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult BCCA Women

$14,239,112 $315,971 $10,747,774 $2,632,959 $476,387 $66,021

26,101 521 3,584 17,837 4,096 63

$189,191,597

150,626

TOTAL OTHER EXPENDITURES/RECIPIENTS*

2003** Expenditures Recipients $592,295,000

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

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C. ADMINISTRATION Vaccines: Vaccines provided plus reimbursement for administrative fee as part of the Vaccines for Children Program.

State Department of Health and Family Services, Division of Health Care Financing.

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 not covered: cosmetics; fertility drugs; experimental drugs; progesterone for PMS; topical minoxidil, legend prenatal vitamins; and impotence treatment drugs. Over-The-Counter Product Coverage: Products covered: analgesics; digestive products (H2 antagonists) feminine products; and ophthalmic lubricants. Products covered with restrictions: allergy, asthma, and sinus products (loratadine, diphenhydramine, pseudoephedrine); cough and cold preparations (cough syrups containing expectorant with or without dextromethorphan only); non-H2 antagonists (Prilosec OTC only); topical products (antibiotics, antifungal agents; capsaicin, hydrocortisone). Products not covered: digestive smoking deterrent products.

Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary with preferred drug list. PDL managed through restrictions on use, prior authorization, therapeutic substitution, preferred products, and physical profiling. Prior Authorization: State currently has formal prior authorization procedure and a Medicaid Pharmacy Prior Authorization Committee. Beneficiaries can request an administrative hearing to appeal prior authorization decisions or coverage for an excluded product. Prescribing or Dispensing Limitations: Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend drug. Certain exceptions for some maintenance drugs (100 day supply limit). Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications. Dollar Limits: None. Pharmacy Payment and Patient Cost Sharing

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulauts; anticonvulsants; antihistamines; antilipemic agents; anti-psychotics; chemotherapy agents; prescribed cold medications; contraceptives, ENT-anti-inflammatory agents; estrogens; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid products. Prior authorization required for: analgesics; antipyretics, and (brand name) NSAIDs; anoretics; antidepressants; antidiabetic; agents; cardiac drugs; antilipemic agents; human growth hormone; hypotensive agents; misc. GI drugs; schedule III and IV stimulants; enteral nutrition products; Cerezyme; Mupirocin; fertility enhaning drugs; anti-obesity drugs; alitretinoin gel; brand name ACE inhibitors; brand name statins; brand name PPIs, stimulants and anti-obesity drugs; and medically necessary drugs with no rebate agreement.

Dispensing Fee: $4.88 to a maximum of $40.11, effective 7/1/98. Incremental increases based on pharmaceutical care services being provided. Maximum of two dispensing fees per month, per prescription.

Coverage of Injectables: Injectable medicines reimbursable through the prescription drug program when used in home health care and in extended care facilities, and through both the prescription drug program and physician payment when in physicians’ offices.

Incentive Fee: None.

Ingredient Reimbursement Basis: EAC = AWP3.0% (effective 7/1/04.) Prescription Charge Formula: Reimbursement at the lowest of: AWP-13.0% plus dispensing fee; Maximum Allowable Cost (MAC) plus dispensing fee; or providers usual and customary. Maximum Allowable Cost: State imposes Statespecific limits on generic drugs. Override requires hand written “Brand Medically Necessary” by the prescriber plus prior authorization.

Cognitive Services: Provides an expanded dispensing fee for cognitive services. Patient Cost Sharing: State uses tiered system of copayments. All generic legend drugs are subject to

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a $1.00 copay, brand legend drugs are subject to a $3.00 copay, limited to $12.00 per month maximum per pharmacy. OTCs are subject to a $0.50 copay. Disposable medical supplies are subject to a sliding scale copayment system. 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.

Approximately 495,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans. (Some mental health plans carve out pharmaceutical benefits.)

Abri Health Plan, Inc. 216 Green Bay Road, Suite 109 Thiensville, WI 53092 Atrium Health Plan, Inc. 4222 Bagley Parkway Madison, WI 53705 Dean Health Plan, Inc. 1277 Denning Way Madison, WI 53717 Group Health Cooperative of Eau Claire 2503 N. Hillcrest Parkway Eau Claire, WI 54702 Group Health of South Central Wisconsin 1265 John Q. Hammons Drive Madison, WI 53717 Health Tradition Health Plan 800 East Main Street Onalaska, WI 54650 Managed Health Services Insurance Corp. 1205 S. 70th Street, Suite 500 West Allis, WI 53214 MercyCare Insurance Company 3430 Palmer Drive Janesville, WI 53546 Network Health Plan 1570 Midway Place Menasha, WI 54952 Security Health Plan of Wisconsin, Inc. 1515 St. Joseph Avenue Marshfield, WI 54449

United Healthcare of Wisconsin 10701 W. Research Drive Milwaukee, WI 53226 Unity Health Plans Insurance Corporation 840 Carolina Street Sauk City, WI 53583-1374

E. USE OF MANAGED CARE

Managed Care Organizations

Touchpoint Health Plan 5 Innovation Court Appleton, WI 54912

Valley Health Plan 401 West Michigan Street Milwaukee, WI 53203

F. STATE CONTACTS Pharmacy Practices Consultant Mark Moody Administrator Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-8922 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us Prior Authorization Contact Rita Hallett Nurse 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: 608/267-0938 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us Prior Authorization Advisory Committee Standing Steve Maike, R.Ph. Larry Fleming, M.D. Peg Smelser Tom Frazier, Exec. Dir., CWAG Bradley Fedderly, M.D. James Heersma, M.D. Christine Sorkness, Pharm. D. John Gates, R.Ph. Tom Hirsch, M.D.

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DUR Contact

Claims Submission Contact

Michael A. Mergener, R.Ph., Ph.D. Chief Pharmacist APS Healthcare 10 East Doty Street, Suite 210 Madison, WI 53703 T: 608/258-3348 F: 608/258-3359 E-mail: [email protected]

Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567

Wisconsin Drug Utilization Review Committee Robert M. Breslow, R.Ph. Ward Brown, M.D. Mark E. Buhler, R.Ph. Daniel R. Erickson, M.D. Barry Hess, R.Ph. Nancy E. Ness, M.D. Pamela Ploetz, R.Ph. Lee C. Vermeulen, Jr., R.Ph., M.S. Mary Jo Willis, M.S., R.N., N.P.

Medicaid Managed Care Contact Angela Dombrowicki, Director Bureau of Managed Health Care Programs Division of Healthcare Financing Department of Health and Family Services One West Wilson P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1935 F: 608/261-7792 E-mail: [email protected] Mail Order Pharmacy Program

New Brand Name Prescription Contact Carol Neeno Pharmacy Assistant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1203 F: 608/267-3380 E-mail: [email protected] Prescription Price Updating First Databank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453 F: 415/588-6867 Medicaid Drug Rebate Contacts Ellen Orsburne Medicaid Systems Analyst Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 608/267-7939 E-mail: [email protected]

None Health and Family Services Department Officials Helene Nelson, Secretary Department of Health and Family Services One West Wilson Street, Room 650 Madison, WI 53702 T: 608/266-9622 F: 608/266-7882 E-mail: [email protected] Mark P. Moody, Administrator Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-8922 F: 608/266-1096 E-mail: [email protected] Executive Officers of State Medical and Pharmaceutical Societies State Medical Society of Wisconsin Susan L. Turney Executive Vice President/ CEO 330 East Lakeside P.O. Box 1109 Madison, WI 53701-1109 T: 866/442-3800 F: 608/442-3802 E-mail: [email protected] Internet address: www.wisconsinmedicalsociety.org

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Wisconsin Association of Osteopathic Physicians & Surgeons Patricia A. Hurley Executive Director P.O. Box 044657 Racine, WI 53402 T: 262/752-2280 F: 262/752-2280 E-mail: [email protected] Internet address: www.waops.org Pharmacy Society of Wisconsin Christopher J. Decker Executive Vice President 701 Heartland Trail Madison, WI 53717 T: 608/827-9200 F: 608/827-9292 E-mail: [email protected] Internet address: www.pswi.org Wisconsin Pharmacy Examing Board Tom Ryan, Director Bureau of Health Professions 1400 E. Washington Avenue Madison, WI 53703 T: 608/266-8098 F: 608/261-7083 E-mail: [email protected] Internet address: www.drl.wi.gov/boards/phm Wisconsin Hospital Association Steve Brenton, President 5510 Research Park Drive Madison, WI 53725-9038 T: 608/274-1820 F: 608/274-8554 E-mail: [email protected] Internet address: www.wha.org Wisconsin Health Care Association Thomas P. Moore Executive Director 121 South Pinckney Street, Suite 500 Madison, WI 53703 T: 608/257-0125 F : 608/257-0025 E-mail: [email protected] Internet address: www.whca.com

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WYOMING A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Aged

Categorically Needy Blind/ Child Disabled

Adult

Prescribed Drugs

‹

‹

‹

‹

Inpatient Hospital Care

‹

‹

‹

‹

Outpatient Hospital Care

‹

‹

‹

‹

Laboratory & X-ray Service

‹

‹

‹

‹

Nursing Facility Services

‹

‹

‹

‹

Physician Services

‹

‹

‹

‹

Dental Services

‹

‹

‹

‹

Medically Needy (MN) Aged Blind/ Child Adult Disabled

B. EXPENDITURES FOR DRUGS 2002 Expenditures Recipients

2003** Expenditures Recipients

TOTAL

$38,008,542

42,652

$49,106,118

RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult

$14,500,432 $1,506,985 $9,963,809 $1,031,505 $1,998,133

12,414 721 3,834 4,484 3,375

MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult

$0 $0 $0 $0 $0

0 0 0 0 0

POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult BCCA Women

$4,496,942 $23,845 $87,312 $3,852,812 $532,973 $0

20,111 20 53 17,310 2,728 0

$19,011,168

10,127

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

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Pharmaceutical Benefits 2004 Vaccines: Vaccines reimbursable at AWP plus a $7.00 injection fee as part of the EPSDT services, the Children’s Health Insurance Program, and the Vaccines for Children Program.

C. ADMINISTRATION Department of Health, Director’s Office.

D. PROVISIONS RELATING TO DRUGS

Unit Dose: Unit dose packaging not reimbursable.

Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin, syringe combinations and disposable needles used for insulin; blood glucose test strips; and urine ketone test strips. Products covered under DME: total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; tobacco cessation products; weight loss products; hair growth products; IQ enhancers; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered (must be ordered by a licensed prescribing practitioner, furnished to a client who is not residing in a nursing facility, is listed in State’s system, and filed with First DataBank): allergy, asthma, and sinus products; analgesics; cough and cold products; digestive products (H2 antagonists); topical agents; food thickeners; nutrition products; pediatric and prenatal vitamins; and artificial tears. Products covered with reatrictions: non-H2 antagonists (antacids, antidiarrheals and laxatives) and feminine products (vaginal anti-infective agents and contraceptives). Products not covered: smoking deterrent products. Therapeutic Category Coverage: Products covered: analgesics, antipyretics, and NSAIDs (prior authorization for COX 2s and oxycontin); antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamines; antilipemic agents (prior authorization for statins); anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; (prior authorization for ACE Inhibitors); misc. GI drugs (prior authorization for PPIs); sympathominetics (adrenergic); thyroid agents; antifungals; antiparasitic products; and bronchodilators. Partial coverage for: growth hormones. Products not covered; anabolic steroids; anoretics; and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in home health care, extended care facilities, and physician offices.

Formulary/Prior Authorization Formulary: Open formulary with preferred drug list (PDL). PDL managed through preferred products and prior authorization. General exclusions include anorexants, except amphetamines and derivatives which are used for narcolepsy and hyperkinetic states; products to stimulate hair growth. Prior authorization implemented 10/1/02. Prior Authorization: State currently has a formal prior authorization procedure with review/appeal process to the Department of Health Pharmacy Unit. Prescribing or Dispensing Limitations Monthly Quantity Limits: Quantity limits on some medications as deemed clinically appropriate. Drug Utilization Review PRODUR system implemented in October 1995. State currently has a DUR Board with 12 members that meet bimonthly. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.00 and 50% of AWP for OTCs, effective 7/01. Ingredient Reimbursement Basis: EAC = AWP11%. Prescription Charge Formula: Payments shall be the lowest of: 1. The Estimated Acquisition Cost (AWP-11%) of the ingredient, plus a dispensing fee. 2. Usual and customary charge. 3. The upper limit established by CMS for multiple source drugs or State MAC. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Currently, 1,226 drugs are included on the State’s MAC list. Incentive Fee: None.

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Patient Cost Sharing: State uses a system of tiered copayments: $3.00 – Non-preferred brand $2.00 – Preferred brand $1.00 – Generics 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.

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

F. STATE CONTACTS State Drug Program Administrator Antoinette K. Brown, R.Ph. Medicaid Pharmacist Department of Health-Pharmacy Unit 2300 Capitol Avenue, Suite 147 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 Email: [email protected] Internet address: www.pharmacy.state.wy.us Department of Health Officials Deb Fleming, Ph.D. Director Department of Health 117 Hathaway Building 2300 Capitol Avenue Cheyenne, WY 82002 T: 307/777-7656 F: 307/777-7439 E-mail: [email protected] Iris Oleske State Medicaid Agent 147 Hathaway Building Cheyenne, WY 82002 T: 307/777-7531 F: 307/777-6964 E-mail: [email protected]

DUR Contact Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071 T: 307/766-6750 F: 307/766-2953 E-mail: [email protected] DUR Board Antoinette Brown, R.Ph. (ex-officio) Debra Devereaux, R.Ph. (DUR Coordinator) Becky Drnas, R.Ph. Dean Winsch, Pharm.D. Roxanne Homar, R.Ph. (ex-officio) Kathryn Kohler, M.D. Leonard Kosirog, R.Ph. Scott Johnston, M.D. George Zaharas, R.Ph. Stephen Brown, M.D. Michael Carpenter, PA-C William Harrison, M.D. Kendra Grande, R.Ph. (ex-officio) Richard L. Johnson, R.Ph. Aimee Lewis (ex-officio) Linda G. Martin, Pharm.D. (ex-officio) New Brand Name Products Contact Antoinette Brown, R.Ph. 307/777-6016 Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 800/633-3453 F: 650/588-4003 Medicaid Drug Rebate Contacts Sheila McInerney TPL Manager ACS State Healthcare P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405 E-mail: [email protected] Claims Submission Contact ACS State Healthcare Northridge Center 1, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459

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Mail Order Pharmacy Program None Executive Officers of State Medical and Pharmaceutical Societies Wyoming State Medical Society Wendy P. Curran Executive Director 1920 Evans P.O. Box 4009 Cheyenne, WY 82003 T: 307/635-2424 F: 307/632-1973 E-mail: [email protected] Internet address: www.wyomed.org Wyoming Pharmacy Association Mindy Rassmussen Executive Director P.O. Box 366 Cheyenne, WY 82003 T: 307/772-8044 F: 307/772-8004 E-mail: [email protected] Internet address: www.wpha.net Wyoming State Board of Pharmacy Jim T. Carder Executive Director 4632 South David Street Casper, WY 82601 T: 307/234-0294 F: 307/234-7226 E-mail: [email protected] Internet address: www.pharmacyboard.state.wy.us Wyoming Hospital Association Robert C. Kidd II President 2005 Warren Avenue P.O. Box 249 Cheyenne, WY 82003 T: 307/632-9344 F: 307/632-9347 E-mail: [email protected] Internet address: www.wyohospitals.com

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Section 6: State Pharmacy Assistance Programs

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State Pharmacy Assistance Programs As of July 2005, 44 States and the District of Columbia had established various pharmaceutical assistance programs providing coverage or improved access to the low-income elderly and/or persons with disabilities who do not qualify for Medicaid. These programs range from Statenegotiated discounts or State subsidies, to tax credits for prescription drug costs, and coordinating seniors’ access to manufacturers’ charitable prescription assistance programs. The Federal Medicare Prescription Drug, Improvement, and Modernization Act of 2004 (P.L 108-173, commonly known as the Medicare Modernization Act) will impact every State, whether or not they have a pharmacy assistance program. State pharmacy assistance programs (SPAPs) are not required to coordinate or provide any financial assistance with respect to a Medicare Part D plan, but many are either planning to sunset current pharmacy assistance programs, use the SPAP as a “wrap-around” program, or develop some other coordination, yet to be determined. Currently, four States have indicated that their respective pharmacy assistance plans will end, barring State legislative action to modify and/or coordinate these programs with the Medicare Part D program. Authorized State Pharmacy Assistance Programs State Alabama Alaska Arizona Arkansas California Connecticut Delaware District of Columbia Florida Georgia Hawaii Illinois Indiana Iowa Kansas Kentucky Louisiana Maine

Program Name SenioRx SeniorCare Rx Prescription Discount Program (CoppeRx Card) ARx Senior Program Arkansas Rx Program Discount Prescription Medication Program Golden Bear State Pharmacy Assistance Program Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) Nemours Pharmacy Assistance Delaware Prescription Drug Assistance Program (DPAP) AccessRx Program

Law Enacted 2002* 2004 2004‡ 2001† 2005† 1999 2001† 1986 1981 1999 2004

Silver SaveRx (formerly, Ron Silver Senior Drug Program/Prescription Affordability Act) Prescription Discount Program Georgia Cares Program Hawaii Rx Plus Program Pharmaceutical Assistance Program (“Circuitbreaker”) Illinois SeniorCare Illinois Rx Buying Club Indiana Prescription Drug Program, “HoosierRx” Iowa Priority Prescription Savings Program Kansas Senior Pharmacy Assistance Program Kentucky Pharmaceutical Assistance Program Louisiana SenioRx Program Maine RX Plus Low Cost Drugs for the Elderly and Disabled Program (DEL)

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2002 2000 2002* 2004 1985 2001 2004† 2000 Federal grant 2000 2005† 2003 2003 1975

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Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nevada New Hampshire New Jersey New Mexico New York North Carolina Ohio Oklahoma Oregon Pennsylvania

Rhode Island South Carolina South Dakota Tennessee Texas

Vermont

Washington

West Virginia Wisconsin Wyoming

Pharmaceutical Benefits 2004

Maryland Pharmacy Assistance Program Senior Prescription Drug Program Maryland Pharmacy Discount Program Prescription Advantage Elder Prescription Insurance Coverage Program (EPIC) MI Rx Prescription Savings Program Prescription Drug Program Mississippi Seniors and Indigents Rx Program SenioRx Program Prescription Drug Expansion Program Pharmacy Access Prescription Drug Benefit Program Prescription Drug Plus Program Senior Rx Insurance Subsidy for Prescription Drugs Senior Prescription Drug Discount Program

1979 2000 2001 2000 2001 2004 1999 2004* 2001 2003† 2005† 2005† 2000 2000

Pharmaceutical Assistance to the Aged and Disabled 1975 (PAAD) Senior Gold Prescription Discount Program 2001 Senior Prescription Drug Program 2002 Elderly Pharmaceutical Insurance Coverage (EPIC) 1987 Program Senior Care 2002 Golden Buckeye Prescription Drug Program 2002 Ohio’s Best Rx Program 2003 Pharmacy Connection Council Program 2003* Oklahoma Prescription Drug Discount Program 2005† Senior Prescription Drug Assistance Program 2001 Pharmaceutical Assistance Contract for the Elderly 1984 (PACE) PACE Needs Enhancement Tier (PACENET) 1996 Rhode Island Pharmaceutical Assistance to the Elderly 1985 (RIPAE) Rhode Island Pharmacy Prescription Drug Discount 2005† Program for the Uninsured SilveRxCard Senior Prescription Drug Program 2000 2003 Senior Citizen Prescription Drug Benefit Program TennCare Rx 2003† Kidney Health Care Program (KHC) 1999 State Prescription Drug Program 2001† VSCRIPT 1989 VSCRIPT Expanded 1999 Vermont Health Access Plan (VHAP) Pharmacy 1996 Healthy Vermonters Program 2002 Washington Pharmacy Connections 2003* Rx Washington Card 2003 2003† Medicaid Prescription Drug Assistance Program Golden Mountaineer Card Program 2000 West Virginia Prescription Drug Assistance 2004* Clearinghouse Program SeniorCare Prescription Drug Assistance Program 2001 Prescription Drug Assistance Program 2002 * Coordination assistance for manufacturer pharmaceutical programs. † Program not operational; see below for more details. ‡ Established by executive order. 6-4

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The following programs were legislatively approved, but have yet to be implemented: •

Arkansas’ ARx Senior Program, a Federal §1115 waiver program, has not received approval from CMS. Program officials indicate that it is unlikely that the program will be implemented given the Medicare Part D prescription drug program beginning in 2006.

•

Arkansas Rx Program: HB1241 was signed into law March 3, 2005. It establishes a discount program for residents without prescription coverage. There are no income limits for those 65 and over, while those under 65 and below 350% of the FPL are eligible. Medicaid and Medicare Part D enrollees will not be eligible.

•

Golden Bear State Pharmacy Assistance Program: Authorized by passage of SB 696 in October 2001, the Golden Bear State Pharmacy Assistance Program would provide discounts to California seniors over and above those provided by the Discount Prescription Medication Program. The program has been tabled due to lack of manufacturer participation and the pending Federal Medicare prescription drug benefit program.

•

Kentucky Pharmaceutical Assistance Program: SB23 was signed into law March 18, 2005. It is designed to wrap around Medicare Part D for seniors over 65 and under 150% of the FPL. Enrollment is scheduled to begin October 1, 2005 with the program beginning January 1, 2006.

•

Montana Prescription Drug Expansion Program, a CMS pharmacy plus waiver, will not be implemented given the passage of the Medicare Modernization Act (MMA) of 2003 and the 2006 start date for the Part D program.

•

Montana’s Pharmacy Access Prescription Drug Benefit Program and Prescription Drug Plus Program: Both programs were authorized by the passage of SB324. The first program will cover Part D premiums for Medicare enrollees below 200 percent of the FPL, and deductibles if funds are available. The second program is a discount program open to any uninsured resident with income up to 250 percent of the FPL, regardless of age.

•

Oklahoma Prescription Drug Discount Program: SB547 was signed into law June 6, 2005. The law establishes a discount program for uninsured residents, with an enrollment fee only for those above 150 percent of the FPL.

•

The TennCare Rx Program Prescription Benefit (pending): HB 1650 was signed into law June 13, 2003. It creates the TennCare prescription drug program that will expand drug coverage to individuals lacking prescription drug insurance based on criteria established by the TennCare Bureau and the legislature. The program will serve a non-Medicaid population and may utilize tiered copayments, prior authorization and step therapy requirements based on the state PDL. Given TennCare funding difficulties, it is unclear when this program will be implemented.

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•

Texas Prescription Drug Program: State funding for the program was not established for 2004-2005.

•

South Dakota Senior Prescription Drug Benefit Program: Under South Dakota HB 1312, the Senior Prescription Drug Benefit Program was repealed by legislation, effective September 1, 2004.

•

Washington Medicaid Prescription Drug Assistance Program: Enacting legislation of 2003 required an 1115 waiver from the Centers for Medicare and Medicaid Services (CMS). The State decided not to pursue the waiver, given passage of the Medicare Modernization Act of 2003.

The following pharmacy assistance programs are scheduled to sunset during 2005, barring legislative action to operate the programs in conjunction with, or in addition to, the Medicare Part D program: Maryland Senior Prescription Drug Program, Minnesota Prescription Drug Program, Missouri SenioRx Program, and North Carolina Senior Care. There are 14 States that are reviewing current pharmacy assistance programs in an effort to coordinate benefits with the Medicare Part D program. (These States are noted throughout this section.) The following States authorized new programs, based on 2004 legislation: •

Alaska SeniorCare Program: HB 374, effective April 1, 2004, established the SeniorCare program within the Alaska Department of Health and Social Services. The program provides cash assistance or drug benefits to eligible senior citizens until 2006, when the Medicare Part D program begins. Legislation has been offered in the 2005 session (HB 106, SB 78) that would continue the program to complement the Medicare Part D.

•

District of Columbia AccessRx Program: B 569, effective May 18, 2004, established the AccessRx program, requiring drug manufacturers and labelers that sell prescription drugs in the District through a publicly funded pharmaceutical assistance program to enter into rebate agreements with the District. The rebates are used to fund the AccessRx program for low-income elderly District of Columbia residents.

•

Hawaii Rx Program: Authorized by passage of HB 2834 in June 2002, the Hawaii Rx Program was implemented in 2004, after further study and revisions to program guidelines. (Enacted by HB 2796 and SB 3237 during 2004.)

•

Mississippi Seniors and Indigents Rx Program: The Seniors and Indigents Rx Program was enacted July 1, 2004, to help seniors and qualified indigent persons access pharmaceutical manufacturers’ discount cards and programs. The program provides these clearinghouse services and an application for the appropriate program(s).

•

Rhode Island Prescription Drug Discount Program for the Uninsured: HB7374 (SB 2886), effective July 2, 2004, established the Rhode Island Prescription Drug Discount Program for the Uninsured. The program requires the Departments of Human Services and Elderly Affairs to develop a prescription drug discount program for uninsured State residents between 18 years and 65 years of age, with family 6-6

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incomes at or below 200 percent of the Federal poverty level (FPL). The State is currently developing the program and reviewing RFP bids from interested pharmacy benefit managers (PBMs). The program implementation date is slated for May 2005. •

West Virginia Pharmaceutical Availability and Affordability Act: HB 4084, effective March 13, 2004, established the West Virginia Pharmaceutical Availability and Affordability Act. The program creates a pharmaceutical information clearinghouse to assist low-income, uninsured State residents find access to prescription medications available through existing private and public section programs, and such programs offered by pharmaceutical manufacturers. The bill also established the West Virginia Pharmaceutical Cost Management Council to develop strategies and improve access to prescription drugs for all State residents.

The following pages provide profiles of the States that provided pharmacy assistance in 2004, as well as profiles of the new State programs. Details were provided by State contacts on program characteristics, including eligibility criteria, funding and reimbursement information, and drug coverage. Supplemental information was obtained from special surveys of State programs, including the National Conference of State Legislatures’ internet site (www.ncsl.org/programs/health/drugaid.htm), which is a good source for the most up-to-date information.

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Alabama Alabama SenioRx Program* Program Type: Coordinate Assistance Between Elderly and Manufacturers’ Pharmaceutical Programs Year Operational: 2002 Number of Recipients (January 2005): 16,769 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

60+ 200% of FPL

60+ 200% of FPL Individuals may not have any other insurance coverage for medicines. Individuals must re-enroll in the program on a quarterly basis to verify eligibility. Eligibility Age (Disabled): Eligible Income Level (Married):

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

State general revenue Not available Not available Not available None None None None None Not available The purpose of the program is to utilize available State resources to help eligible seniors find appropriate charitable pharmaceutical programs from various manufacturers. The State will also coordinate and complete all necessary paperwork for each participant.

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

None Based on a manufacturer’s charitable program criteria. Not available Enrollees must have chronic health care conditions to participate in the program, e.g., maintenance medications for long-term problems like hypertension. Participants with short-term illnesses are not eligible for the program.

*

The Alabama SenioRx Program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Tina Hartley Alabama Dept. of Senior Services 770 Washington Avenue RSA Plaza, Suite 470 Montgomery, AL 36130

Phone: 334/242-5743 Fax: 334/242-5594 Email: [email protected]

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Pharmaceutical Benefits 2004

Alaska SeniorCare Rx Program Type: Direct Assistance Year Operational: 2004 Number of Recipients (January 2005): 7,000∗ ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): 135% to 135% to Eligible Income Level (Married): 150% FPL 150% FPL SeniorCare bridges the gap for low-income seniors until the full Medicare prescription drug coverage begins in 2006, and provides a statewide senior information, resource, and referral service for all Alaska seniors. A beneficiary can receive direct prescription drug benefits or cash assistance. Recipient’s FPL dictates eligibility for one of two benefit levels.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type:

State general funds $15 million Not available Not available None

Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

AWP-5% (CMS rate for Medicaid) None None None $3.45 - $11. 46 (based on pharmacy/Medicaid volume, i.e., CMS rate) For a recipient at 135% FPL, without comprehensive Medicaid Rx coverage, the maximum cash benefit is $1,600 per year. For recipient between 135% and 150% FPL maximum cash benefit is $1,000 per year.

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

∗

State Preferred Drug List (PDL) State PDL None The legislature is considering two bills which would extend a modified SeniorCare pharmacy assistance program. The revised plan would complement the Medicare Part D program by helping eligible seniors with Part D copays and/or premiums.

Currently, only 50 beneficiaries are using a direct pharmaceutical benefit provided by the program. 6-11

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Jon Sherwood SeniorCare Department of Health and Social Services Post Office Box 110601 Juneau, AK 99811-0601

Phone: 907/465-5820 E-mail: [email protected]

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Pharmaceutical Benefits 2004

Arizona Prescription Discount Program (CoppeRx Card) Program Type: Discount Law Enacted: 2001 Estimated Number of Recipients (January 2005): 17,000* ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 65+ Eligibility Age (Disabled): None None Eligible Income Level (Married): Open to all seniors and Medicare-eligible disabled who are residents of Arizona.

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

Discounts/rebates from manufacturers; negotiated through contracted PBM. Not available Not available Not available Negotiated through PBM contract Not available None None None $3.00 for retail and $2.00 for mail order Average percent savings off the regular prescription price: brand name drugs- retail (15%) and generic drugs -retail (35%). Average discounts for mail order- brand name (20%); generic (55%). RxAmerica (PBM) negotiates discounts with participating manufacturers. 500 participating pharmacies throughout the State.

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

*

None All FDA-approved drugs None The State is discussing the impact of the Medicare Part D program on the CoppeRx program and future reforms. Preliminary discussions only at this time.

967,061 eligible residents sent program information, as of January 2005. 6-13

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Del Swan Pharmacy Program Administrator Arizona Health Care Cost Containment System 801 E. Jefferson St. Phoenix, AZ 85034

Phone: 602/417-4726

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Pharmaceutical Benefits 2004

Arkansas ARx Senior Program Program Type: Direct Assistance (1115 Waiver) Law Enacted: 2001∗ Projected Number of Recipients: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 65+ Eligibility Age (Disabled): 90% of FPL 90% of FPL Eligible Income Level (Married): Program provides prescription drug coverage to Qualified Medicare Beneficiary (QMB) seniors lacking prescription drug coverage.

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

State General Revenue Fund and Federal matching funds Not available Not available Not available Medicaid Medicaid reimbursement rate $25.00 per year $5.00 $10.00 for generic drugs and $20.00 for brand name drugs Not available The program has not received approval from CMS, as the State has been unable to design a program with budget neutrality. Arkansas will likely withdraw its 1115 waiver request depending on the success of the Medicare Part D program.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Same as Medicaid program Legend drugs and controlled substances Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT Carolyn Patrick Arkansas Department of Human Services Division of Medical Services Slot 415 P.O. Box 1437 Little Rock, AR 72203-1437

Phone: 501/682-8359 Fax: 501/683-4124 E-mail: [email protected]

∗

Program implementation is contingent upon CMS approval of 1115 waiver application. The State is unlikely to pursue the ARx program after implementation of the Medicare Part D program contained in the Medicare Prescription Drug, Improvements and Modernization Act of 2003. 6-15

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Arkansas Arkansas Rx Program Program Type: Discount Law Enacted: 2005∗ Projected Number of Recipients: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

See notes See notes Eligibility Age (Disabled): See notes See notes Eligible Income Level (Married): No income limit for 65+, under 65 < 350% FPL. Medicaid and Medicare Part D enrollees not eligible.

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

Manufacturer negotiated rebates Not available Not available Not available Not available Not available $25.00 per year Not available Not available Not available

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Not available

∗

Program is not yet operational. 6-16

National Pharmaceutical Council

Pharmaceutical Benefits 2004

California Prescription Drug Discount for Medicare Recipients Program Program Type: Discount Year Operational: 2000 Number of Recipients (January 2005): 1,595,434 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All Medicare Eligibility Age (Disabled): eligible All income Eligible Income Level (Married): levels Must be a Medicare beneficiary not on Medicaid.

All Medicare eligible All income levels

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

See notes Not available Not available 850,000 price inquiries per month∗ Medicaid Average wholesale price (AWP)-17% None None None $7.25 Pharmacies that participate in the Medi-Cal (Medicaid) program must allow Medicare recipients to purchase drugs for the same price paid by Medi-Cal. Recipients must pay Medi-Cal price for drug and a 15 cents processing fee.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

No formulary Almost all prescription drugs Over-the-counter drugs and compound drugs not covered.

PROGRAM CONTACT Janice Hall Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814

Phone: 916/552-9714 1-800-434-0222

∗

Price inquires do not always result in sales, because customers may elect not to purchase a pharmaceutical once its price has been quoted.

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Pharmaceutical Benefits 2004

California Golden Bear State Pharmacy Assistance Program Program Type: State-Negotiated Discounts Projected Operational Date: Not Available Estimated Eligibles (November 2002): 1 to 3 million ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

See notes See notes Eligibility Age (Disabled): All income All income Eligible Income Level (Married): levels levels Program covers pharmaceuticals not covered by a private insurer or other State program. Anyone who has a Medicare card is eligible; however, unlike the California Discount Prescription Medication Program, enrollment is required to receive services.

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

Manufacturer negotiated discounts None Not available Not available Medicaid rebate plus manufacturer-negotiated discounts AWP-10% None None None $4.05 per prescription The Golden Bear State Pharmacy Assistance Program has no pharmaceutical manufacturers participating and the program has been postponed due to the Federal Medicare prescription drug benefit enacted by Congress in 2003.

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions:

No formulary Prescription drugs for which the State has negotiated manufacturer discounts that supplement the Medi-Cal discount already mandated under the California Discount Prescription Medication Program. Only prescription drugs with manufacturer-negotiated discounts.

PROGRAM CONTACT Janice Spitzer Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814

Phone: 916/552-9557

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Pharmaceutical Benefits 2004

Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) Program Type: Direct Assistance Year Operational: 1986 Number of Recipients (January 2005): 49,138

ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18+ Eligibility Age (Disabled): $20,800 $28,100 Eligible Income Level (Married): Disabled persons aged 18-64 must be Social Security Disability Insurance (SSDI) eligible. Effective February 2004, new means test will be used to determine “liquid assets”; $100,000 for individuals; $120,000 for married.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State General Revenue Fund $77.9 million (estimated) Not available Not available Medicaid AWP-12% $30.00 per year None $16.25 $3.15 The governor wants cuts to program budget and dispensing fees and is urging the legislature to enact them. The State faces a $1 billion deficit.

DRUGS COVERAGE Formulary: Drugs Covered:

Open formulary All prescription drugs and insulin.

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National Pharmaceutical Council

Drug Coverage Restrictions:

Notes:

Pharmaceutical Benefits 2004

ConnPACE does not cover drugs prescribed for cosmetic purposes, experimental drugs, drugs FDA has determined are ineffective, antihistamines, contraceptives, cough preparations, anti-obesity drugs, multi-vitamin combinations, smoking cessation gum, vaccines obtained free of charge from the Department of Health Services, prescription drugs in excess of manufacturer’s recommendations with documented legal justification, drugs for lock-in clients from other than lock-in pharmacy, and over-the-counter drugs (with certain exceptions). Other drugs may not be covered if pharmaceutical manufacturers opt not to participate in the Drug Rebate Program. ConnPACE restricts beneficiaries to 120 units or a 30-day supply, whichever is greater. Generic drugs must be substituted for brand name drugs, unless otherwise indicated by the prescribing physician (prior authorization required). Prior authorization is required for early refills, drug product costs over $500, physician request for a brand name product. Under statutory authority, State is completing implementation of a preferred drug list (PDL). PDL will start after appropriate training and outreach with providers. ConnPACE enrollees were automatically enrolled in Medicareapproved prescription drug programs (PDPs), which will facilitate further State “wrap-around” efforts once the Part D benefit begins in 2006.

PROGRAM CONTACT Evelyn A. Dudley Manager Department of Social Services 25 Sigourney Street Hartford, CT 06106

Phone: 860/424-5654 Fax: 860/424-5206 E-mail: [email protected] Alternate contact: James Zakszewski Phone: 860/424-4961

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Pharmaceutical Benefits 2004

Delaware Nemours Pharmacy Assistance Program Type: Private Discount Year Operational: 1981 Number of Enrollees (January 2005): 9,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Eligibility Age (Disabled): $12,500 Eligible Income Level (Married): Must be a U.S. citizen and resident of Delaware.

65+ $17,125

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Enrollee: # of Rx’s Per Enrollee (2003): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

This program is a privately funded program; no State funds are used. Not available Not available 18 None Not available None None 20% of drug cost $5.00 Maximum annual benefit is $2,000.00 per enrollee.

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

None Due to severe budgetary constraints, covered drugs are chosen individually, based on physician recommendations. As many recommended drugs as allowed by the budget are purchased and made available to enrollees. One central pharmacy distributes all drugs by courier to branch locations where citizens can pick up a 2-3 month supply.

PROGRAM CONTACT Jack Lagowski Nemours Clinic Pharmacy Assistance 1801 Rockland Road Wilmington, DE 19803

Phone: 302/651-4403 Fax: 302/651-4445

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Pharmaceutical Benefits 2004

Delaware Prescription Assistance Program (DPAP) Program Type: Direct Assistance Year Operational: 2000 Number of Recipients (January 2005): 7,206 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18+ Eligibility Age (Disabled): 200% of FPL Eligible Income Level (Married): 200% of FPL Must be a U.S. citizen and resident of Delaware. Couples are counted as two individuals. Individuals with income over 200% of FPL can qualify if they have prescription costs exceeding 40% of their income. Those age 65 and over who are eligible for the Nemours Foundation prescription benefit are not eligible for DPAP. DPAP does not replicate coverage for Nemours clients. Disabled persons 18-64 must be Social Security Disability Insurance (SSDI) eligible.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Tobacco Settlement funds Not available; not subject to budget appropriation Not available Not available Negotiated between the State and individual manufacturers Lower of AWP-14% or Federal Upper Limit or State maximum allowable cost (MAC). Reimbursement rate for certain specialty pharmaceuticals is AWP-16%. None None Greater of $5.00 or 25% of the cost of the prescription $3.65 Annual maximum benefit of $2,500.00 per recipient. EDS administers program on behalf of the State.

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

Preferred Drug List (PDL) Medically necessary prescription drugs Only drugs from manufacturers that agree to participate in State rebate program. The prescription assistance program implemented a PDL program, effective April 1, 2005.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Cindy Denemark – EDS Division of Social Services 248 Chapman Road Suite 100 Newark, DE 19702

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

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Pharmaceutical Benefits 2004

District of Columbia Access Rx Program Type: Manufacturer Rebates Law Enacted: March 2004

ELIGIBILITY CRITERIA 65+ Not eligible Eligibility Age (Disabled): 88% - 120% 88% - 120% Eligible Income Level (Married): of FPL of FPL The program also has a component for uninsured individuals up to 350% of FPL.

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

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

Manufacturer rebates None Not available Not available Not available Not available Not available Not available Not available Not available The AccessRx Act of 2004 authorizes the Director of the Department to negotiate rebate agreements with drug manufacturers and labelers that sell prescription drugs through publicly funded pharmaceutical assistance programs in the District. Rebate monies will be placed in an AccessRx Fund and used to reimburse pharmacies for drug discounts. Manufacturers and labelers who do not participate in this program will have their names publicized, as a partial incentive to participate.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Department of Health 825 North Capitol Street, NE Washington DC 20002

Phone: 202/671-5000

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Florida Silver SaveRx Program Program Type: Direct Assistance (1115 Waiver) Year Operational: 2002 Number of Enrollees (January 2005): 55,036 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 88% - 120% of FPL

Eligibility Age (Disabled): Eligible Income Level (Married): Program covers dual eligibles.

Not eligible 88% - 120% of FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee (FY 05): # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State General Revenue Fund, Federal matching funds, and manufacturer rebates $100 million $160 per month maximum benefit per user, per month Between 2.77 and 3.67 per user/per month Medicaid The lesser of AWP-13.25%, Wholesalers Acquisition Cost (WAC)+7%, or the usual and customary None None $2.00 for generic drugs, $5.00 for brand name drugs on the preferred drug list, and $15.00 for brand name drugs not on the preferred drug list $4.23 Enrollees will have $160 deposited in a Silver Saver account that is maintained by the Medicaid program. Eligibility is determined on a monthly basis. During Calendar Year 2004, an average of 23% of beneficiaries used the maximum allowed benefit of $160 per month.

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

Preferred drug list Same as Medicaid Same as Medicaid The program will likely be restructured to better integrate options with the Medicare Part D program. Preliminary discussions are underway but specific details have yet to be announced.

PROGRAM CONTACT Jeffrey Parrott Agency for Health Care Admin. 2727 Mahan Drive Tallahassee, FL 32308-7703

Phone: 850/487-4441 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Florida Medicare Prescription Discount Program∗ Program Type: Discount Year Operational: 2000 Estimated Participants: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

See notes Eligibility Age (Disabled): All income Eligible Income Level (Married): levels Anyone who has a Medicare card is eligible.

See notes All income levels

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

None None Not available Not available Not available AWP-9% None None None $4.50 Pharmacies that participate in Medicaid must offer participants a discount based on AWP-9% + $4.50 dispensing fee.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None All prescription drugs None

PROGRAM CONTACT Jeff Parrott Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308-7703

∗

Phone: 850/487-4441 E-mail: [email protected]

By law Florida pharmacies are required to provide this discount in order to participate in Medicaid. 6-26

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Georgia Georgia Cares Program* Program Type: Coordinate Assistance Between Elderly and Charitable Pharmaceutical Programs Year Operational: 2002 Number of Recipients (January 2005): 24,739 ELIGIBILITY CRITERIA 65+ 65+ Eligibility Age (Disabled): None None Eligible Income Level (Married): Individuals may not have any other insurance coverage for medicines.

Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes: FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State and Federal grant money $580,000 Not available Not available None None None None None Not available The purpose of the program is to utilize available State resources to help eligible seniors find appropriate charitable pharmaceutical programs from various manufacturers. The program also receives some in-kind grant money from the “Thanks Mom & Dad Fund,” a 501(c)(3) charitable organization that collects private donations for senior assistance programs.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None Based on a manufacturer’s charitable program criteria Not available

PROGRAM CONTACT Jennie Deese Coordinator Georgia Cares Division of Aging Services 2 Peachtree Street, NW Atlanta, GA 30303

Phone: 404/463-8578 Fax: 404/657-5285

*

The Georgia Cares Program assists eligible State residents in health care insurance counseling and in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs. 6-27

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Hawaii Hawaii Rx Plus Program Type: Direct Discount Operational Date: 2004 Number of Recipients (January 2005): 147,685 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All ages All ages Eligibility Age (Disabled): $38,000 $51,000 Eligible Income Level (Married): Open to all Hawaii residents, providing that they have no other prescription drug coverage.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Manufacturer rebates Not available Not available Not available Rebate amounts equal to or greater than the rebate calculated for Medicaid. AWP-10.5% None None None Not less than fee provided under the State Medicaid program.

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

None All FDA approved drugs None Each pharmacy participating in the program discounts the price of drugs covered by the program and sold to program participants. Participating pharmacies submit claims to the Department of Human Services and are reimbursed for the discounted drugs. Legislation is being considered to restructure this program in order to “wrap-around” the Medicare Part D program. The legislation would provide benefits for dual eligibles to pay co-payments.

PROGRAM CONTACT Tracey Okubo Department of Human Services 1390 Miller Street, Room 209 Honolulu, HI 96813

Phone: 808/586-5036

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Illinois Pharmaceutical Assistance Program (PAP) “Circuit Breaker” Program Type: Direct Assistance Year Operational: 1985 Number of Recipients (January 2005): 45,394 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 16+ Eligibility Age (Disabled): 250% of FPL Eligible Income Level (Married): 250% of FPL A widow or widower who turns 63 or 64 before a deceased enrollee’s death is eligible for PAP. Also, a married couple with a $35,740 annual household income would be eligible if they were filing with one other resident. An individual would be eligible with a $35,740 annual household income if they were filing with two other residents.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 04): Cost per Participant (FY 03): # of Rx’s Per Participant: Manufacturer Rebate Type Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee:

State General Revenue Fund and Tobacco Settlement Fund $83 million $1,255.66 Not available Negotiated by State AWP-14% $5.00 if income is below 100% of FPL and $25.00 if income is at or above 100% of FPL None For income less than 100% of FPL, there is no copayment until annual drug cost exceeds $2,000; then copayment is 20% of drug cost. For income at 100% of FPL or greater, there is a $3.00 copayment until annual drug cost exceeds $2,000.00; then copayment is 20% of drug cost. $2.55

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions

Some drugs covered by preferred drug list (PDL); prior authorization. Prescription medication used for cancer, Alzheimer’s disease, Parkinson’s disease, glaucoma, lung disease and smoking-related diseases, cardiovascular, arthritis, diabetes, and osteoporosis, heart and blood pressure problems, multiple sclerosis, and osteoporosis. Some classes of drugs covered by preferred drug list (PDL); prior authorization.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Susan Rohrer Pharmaceutical Assistance Programs Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Illinois Illinois SeniorCare Program Type: Direct Assistance (1115 Waiver) Year Operational: 2002 Number of Recipients (January 2005): 195,746 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not applicable Eligibility Age (Disabled): 200% of FPL 200% of FPL Eligible Income Level (Married): Eligible individuals who already have pharmaceutical health insurance benefits may choose to receive a $25 rebate check monthly. By choosing the SeniorCare Rebate, individuals must use their own health insurance to pay for prescription drugs.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 03): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

State General Revenue Fund and Tobacco Settlement Fund $102 million Not available Not available Negotiated by State AWP-14% or MAC if generic is available None, but participants must reapply every year. None If the participant is single with income of no more than $9,569 a year, or if participant lives with his/her spouse and together the income is no more than $12,829, SeniorCare pays up to $1,750 per person in a year at no cost. After $1,750, participant pays 20% of each prescription. If the participant is a single individual with an income of $9,750 to $19,140 a year, or if the participants are a married and living together with a total household income of $12,830 to $25,600 a year, SeniorCare pays for the first $1,750 per person. The participants are also required to pay $1 for a generic drug and $4 for each brand name drug. After the $1,750 limit is met, the participants continue to pay $1 for a generic drug and $4 for each brand name drug plus 20% of the cost of each prescription.

Dispensing Fee:

If a generic drug is available but the participant requests a brand name drug, participants must pay $4 for each prescription plus the difference in price between the generic and the brand name drug. $2.25

DRUGS COVERAGE Formulary: Drugs Covered:

All prescription medications manufactured by companies participating in the Federal rebate program. Most prescription drugs

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Drug Coverage Restrictions

Pharmaceutical Benefits 2004

Some classes of drugs covered by the preferred drug list (PDL) or prior authorization.

PROGRAM CONTACT Pamela J. Bunch SeniorCare Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 627636-0001

Phone: 217/524-7478 Fax: 217/524-7535 E-mail: [email protected]

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Pharmaceutical Benefits 2004

Illinois Illinois Rx Buying Club Program Type: Direct Discount Year Operational: 2004 Number of Eligible Recipients: 1.5 million ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+

Medicare eligible None See notes Eligible Income Level (Married): Membership is available to individuals only. Circuit Breaker/ Pharmaceutical Assistance participants are automatically enrolled in the buying club. Eligibility Age (Disabled):

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

Enrollment fees Not available Not available Not available Sav-Rx (PBM) negotiates discounts with participating manufacturers. Not available $25.00 None None Not available The Illinois Rx Buying Club provides discounts on all categories of prescription drugs. The program also has a mail-order option for enrollees. The $25.00 enrollment fee entitles beneficiary to savings of 20% or more on each prescription for 12 months.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Preferred Drug List All prescriptions ordered by physician that are on the PDL All FDA-approved drugs are eligible for the program.

PROGRAM CONTACT Deb Corso Illinois Department on Aging 421 East Capitol Avenue, #100 Springfield, IL 62701-1789

Phone: 217/524-7478 Fax: 217/785-4477

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Pharmaceutical Benefits 2004

Indiana Indiana Prescription Drug Program “HoosierRx” Program Type: Discount Year Operational: 2000 Number of Recipients (January 2005): 26,800 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): 135% of FPL Eligible Income Level (Married): 135% of FPL Must be an Indiana resident for at least 90 days in the past 12 months, without prescription drug coverage through an insurance plan, Medicaid or Medicaid with a spend-down. Benefit is available for one year.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 03): # of Rx’s Per Participant (FY 03): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

Tobacco Settlement Fund $22 million $450.54 51.6 None Medicaid reimbursement rate None None 25% of HoosierRx negotiated price, up to the maximum benefit limit (MBL) is based on when the participant applied. If the applicant applied in June 2004, the MBL was $1,200; in October it was $1,000. For 2005, the figures, based on enrollment month, are: January: $800, April: $600, July: $400, October: $200. $4.90 Once maximum benefit limit is reached, recipients may continue to receive the HoosierRx discounted rate during the rest of the enrollment year.

DRUGS COVERAGE Formulary: Drugs Covered:

None All prescription drugs, as well as insulin

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PROGRAM CONTACT Neil Steffens HoosierRx Family & Social Services Administration 402 W. Washington Street W-386, MS-07 Indianapolis, IN 46204-2739

Phone: 317/233-0587 Fax: 317/232-7382 Email: [email protected]

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Pharmaceutical Benefits 2004

Iowa Iowa Priority Prescription Savings Program Program Type: Negotiated Discount Year Operational: 2002 Number of Enrollees (January 2005): 50,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly):

All Medicare eligibles

Eligible Income Level (Single):

All income levels

Other Eligibility Notes:

Eligibility Age (Disabled):

All Medicare eligibles All income levels

Eligible Income Level (Married): Medicaid recipients are not eligible. Novartis has an income requirement: only a couple with an income of more than $16,862 and less than $24,000, or individuals with an income of more than $12,569 and less than $18,000, qualifies for medications at a flat-fee of $12.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee: # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Federal grant and enrollment fees Not available Not available Not available A pharmacy benefit manager (PBM) negotiates discounts with participating manufacturers. Reimbursement rate based on negotiated contract with each participating manufacturer. $20.00 per year None None Not available The Iowa Priority prescription savings program is a nonprofit plan run by the non-profit Iowa Prescription Drug Corporation. Discounts are available on participating manufacturers’ drugs (Bristol-Myers Squibb, Merck, Novartis, and Schering-Plough). 100% of the discount is passed through directly to the consumer at the point of sale. Budget, cost and prescription usage is not provided for proprietary reasons.

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DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions:

Preferred drug list The following therapeutic classes of drugs are covered: Allergy, Alzheimer’s Disease, Anti-Convulsant Agents, Anti-Fungal Agent, Anti-Psychotic Agent, Antiviral, Arthritis and Analgesia, Asthma, Breast Cancer, Central Nervous System Stimulants, Cholesterol Lowering Agents, Dermatological Products, Diabetes, Enlarged Prostate Treatment, Glaucoma Agents, Hormone Replacement, Hypertension/High Blood Pressure and Cardiovascular, Irritable Bowel Syndrome, Osteoporosis Treatment, Parkinson’s Disease, and Voltaren Ophthalmic® (diclofenac ophthalmic). None

PROGRAM CONTACT David Fries Iowa Prescription Drug Corporation 1231 8th Street, Suite 232 West Des Moines, IA 50265

Phone: 515/327-5405, ext. 203 Fax: 515/327-5422 Email: [email protected]

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Pharmaceutical Benefits 2004

Kansas Kansas Senior Pharmacy Assistance Program Program Type: Reimbursement Year Operational: 2001 Number of Enrollees (January 2005): 2,416 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 65+ Eligibility Age (Disabled): 135% of FPL 135% of FPL Eligible Income Level (Married): Must be a Kansas resident; not covered under a private prescription reimbursement plan; not eligible for or enrolled in any other local, State, or Federal prescription program; not have voluntarily canceled a local, State, Federal, or private prescription drug program within six months of application to the program. Must be current recipient of benefits through the Qualified Medicare Beneficiary Program (QMB) or Low Income Medicare Beneficiary (SLMB) Program.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee (FY 05): # of Rx’s Per Enrollee: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State funds $1.2 million $471 (estimated) Not available None None None None 30% of pharmaceutical cost None Maximum annual benefit is $1,200.00 per enrollee annually, with reimbursement checks to be sent by December 31 of each year. Benefit is direct reimbursement from State to enrollee.

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

None Legend drugs, diabetic supplies not covered by Medicare Program does not cover over-the-counter or lifestyle drugs. Kansas Senior Pharmacy Assistance Program will be terminated once the Medicare Part D program begins.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Janet Boscom Department on Aging 503 S. Kansas Avenue Topeka, KS 66603-3404

Phone: 785/296-4986 General E-mail: [email protected]

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Pharmaceutical Benefits 2004

Kentucky Kentucky Pharmaceutical Assistance Program Program Type: Direct Assistance Year Operational: Begins 1/1/2006 Projected Number of Enrollees: not available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

Medicare eligible 150% FPL

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

Medicare eligible 150% FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Program is designed to wrap around Medicare Part D. “May pay all of some of the deductibles, coinsurance payments, premiums, and copayments” for Part D.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Not available

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Louisiana Louisiana SenioRx Program* Program Type: Coordinate Assistance between Elderly and Charitable Pharmaceutical Programs Year Operational: 2003 Number of Enrollees (January 2005): 7,182 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

60+ 60+ Eligibility Age (Disabled): $28,710 $38,490 Eligible Income Level (Married): Individuals may not have any other insurance coverage for medicines.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State general revenue $500,000 Not available 84 None None None None None Not available The purpose of the program is to utilize available State resources to help eligible seniors find appropriate charitable pharmaceutical programs from various manufacturers. The State will also coordinate and complete all necessary paperwork for each participant.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None Based on a manufacturer’s charitable program criteria. Not available

PROGRAM CONTACT Sharon Booker Coordinator Governor's Office of Elderly Affairs P.O. Box 80374 Baton Rouge, LA 70898

Phone: 225/342-3570 Fax: 225/342-7133 Alternate Contact : Charlene Hayes 225/342-7129

*

The Louisiana SeniorRx Program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. State does not contribute money for direct purchase of prescription drugs. 6-41

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Pharmaceutical Benefits 2004

Maine Maine Rx Plus* Program Type: Subsidy and Discount Law Enacted: 2003 Number of Enrollees (Fiscal Year 2005): 275,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All ages All ages Eligibility Age (Disabled): 350% of FPL 350% of FPL Eligible Income Level (Married): Any person who incurs unreimbursed expenses for prescription drugs equaling 5% or more of family income, or who incurs unreimbursed expenses for all medical care equaling 15% or more of family income, is eligible for the remainder of the eligibility period.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State appropriations and subsidies $800,000 (estimated) Not available Not available State-only rebates AWP-13% None None Program combines discounts from participating pharmacies with negotiated rebates from manufacturers. $3.35

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

Closed formulary Only “preferred” drugs included on the MaineCare (Maine Medicaid) PDL. Non-preferred drugs (as indicated non-covered on the MaineCare PDL). Legislation is being considered to enable the Maine Rx Plus program to “wrap-around” the Medicare Part D program.

PROGRAM CONTACT Jude Walsh Department of Human Services 11 State House Station Augusta, ME 04333-0011

Phone: 207/624-9844 Fax: 207/287-8601 E-mail: [email protected]

*

This program replaces the Maine Rx Program, which faced significant legal challenges and was never implemented. Additionally, beneficiaries from the former Healthy Maine Prescription Program were immediately eligible for the Maine Rx Plus program. Program includes a pharmacy incentive program, in which Maine Rx Plus sends out over $50,000 per year to pharmacies that qualify. 6-42

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Maine Low Cost Drugs for the Elderly and Disabled Program (DEL)* Program Type: Subsidy and Discount Year Operational: 1975 Number of Recipients (January 2005): 41,200 ELIGIBILITY CRITERIA 62+ 19+ Eligibility Age (Disabled): 185% of FPL Eligible Income Level (Married): 185% of FPL This program is made available to Maine residents fitting the age and income eligibility criteria. Individuals with full MaineCare (Maine Medicaid) benefits are not eligible. Medicare recipients are not necessarily excluded.

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

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

State appropriations and subsidies Not available Not available Not available State-only rebates AWP-15% None None Basic: 20% +$2.00 of the cost of generic drugs; 20% + $2.00 of the cost of prescriptions for select medical conditions; 84% of the cost of other covered prescriptions. Supplemental: State pays $2.00 toward the cost of all other drugs from participating manufacturers. $2.35 A participant is eligible for a Catastrophic benefit once he or she has paid total copayments in the DEL benefit of at least $1,000 between August 1 and July 31 of any year(s) in which the participant is eligible.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Notes:

Open formulary Only those drugs covered with manufacturer participation 34-day supply limit for brand name drugs, 90-day limit for generic drugs. Some prescriptions require prior approval to assure quality, dose strength, and cost effectiveness. Legislation is being considered to enable the DEL program to wrap around the Medicare Part D program.

*

The Low Cost Drugs for the Elderly and Disabled (DEL) Program is also run under the Maine Rx Plus umbrella, distinguished by the eligibility criteria differences. Program includes a pharmacy incentive program, in which the DEL program sends out over $200,000 per year to pharmacies that qualify. 6-43

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PROGRAM CONTACT Jude Walsh Department of Human Services 11 State House Station Augusta, ME 04333-0011

Phone: 207/624-9844 Fax: 207/287-8601 E-mail: [email protected]

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Maryland Maryland Pharmacy Assistance Program Program Type: Direct Assistance Year Operational: 1979 Number of Recipients (January 2005): 62,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ See notes Eligibility Age (Disabled): $926/mo $1,070/mo Eligible Income Level (Married): This program also takes into account resources and assets. A single person must have resources below $4,000, and married couples must have resources below $6,000. No age restrictions on eligibility if enrollees are Medicare-eligible and Maryland residents. The following groups are ineligible for participation: people detained in a correctional (Federal, State, local) system, Medicaid recipients. Disabled are covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Revenue Fund Not available Not available Not available Medicaid For brand name drugs, lower of AWP-11%, WAC+9%, Direct Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For generic drugs, lower of Estimated Acquisition Cost (EAC), State MAC, or Federal MAC. None None $7.50 for brand-name; $2.50 for generics (per prescription) $3.69 for brand-name; $4.69 for generics

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

PDL for certain therapeutic classes Follows Medicaid guidelines Prior authorization for certain medications, including steroids and some controlled substances. 75% utilization required for prescription refill.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Paul A. Roeger Division Chief Office of Operations & Eligibility Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201

Phone: 443/263-7031 E-mail: [email protected]

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Maryland Senior Prescription Drug Program Program Type: Direct Assistance Year Operational: 2001 Number of Recipients (January 2005): 35,500 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ See notes Eligibility Age (Disabled): 300% of FPL Eligible Income Level (Married): 300% of FPL Program is open to all Maryland residents who have no other prescription drug insurance plan. Disabled are covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

CareFirst subsidizes program through a 2% premium tax exemption from the State of Maryland. $26 million Not available Not available PBM-negotiated with individual drug companies PBM-negotiated with contracted pharmacies $10 monthly premium None $10 for generics, $20 for preferred brand name products, $35 nonpreferred brand-name products Varies among contracted pharmacies. Maximum benefit is $1,100 per enrollee per 12-month period. Caremark administers the pharmacy benefit and negotiates contracts with individual pharmaceutical manufacturers and pharmacies. Enrollees are expected to save between 13% and 16% on each prescription once they have met maximum benefits.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Notes:

CareFirst formulary Most generic and brand drugs approved by the Food and Drug Administration (FDA) are included under this program. Anorexants are excluded. Over-the-counter drugs, with the exception of insulin, are excluded. Quantity limits on certain drugs such as Viagra, migraine medicines and Oxycontin. Prior authorization on certain drugs such as growth hormones. The program sunsets June 30, 2005, but may be extended through 12/31/05 to coincide with Federal Medicare drug benefit program changes. There are, however, several measures in the General Assembly to enable the Senior Rx program to continue as a “wraparound” program in conjunction with the Medicare Part D program. 6-47

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PROGRAM CONTACT Robin Vahle Project Manager Senior Rx Program 1 Calvert Place Baltimore, MD 21202

Phone: 410/998-5444 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Maryland Maryland Pharmacy Discount Program Program Type: Discount (1115 Waiver) Operational Date: July 1, 2003 Number of Recipients (January 2005): 3,965 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ See notes Eligibility Age (Disabled): $1,396/mo $1,872/mo Eligible Income Level (Married): Must be a Medicare recipient and a Maryland resident. Disabled are covered if they are Medicare-eligible.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Revenue funds and Federal matching funds Not available Not available Not available Medicaid guidelines For brand name drugs, lower of AWP-11%, WAC+9%, Direct Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For generic drugs, lower of EAC, State MAC, or Federal MAC. None None 65% of the State’s reduced cost $1.00 per prescription

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

PDL for certain therapeutic classes Medicaid guidelines Medicaid guidelines

PROGRAM CONTACT Paul A. Roeger Division Chief Office of Operations & Eligibility Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201

Phone: 443/767-5394 E-mail: [email protected]

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Pharmaceutical Benefits 2004

Massachusetts Prescription Advantage Program Type: Direct Assistance Year Operational: 2001 Number of Recipients (January 2005): 84,880 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ See notes Eligibility Age (Disabled): Sliding scale Eligible Income Level (Married): Sliding scale Disabled participants may participate if they are under age 65, work 40 or fewer hours per month, meet CommonHealth disability guidelines and have gross annual household incomes at or below 188% of the Federal Poverty Level. Individuals receiving Medicaid are not eligible to join Prescription Advantage.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

State general funding $104 million $90 per member per month (est.) $1,085 (est.) Caremark negotiates price and rebates with drug manufacturers. AWP-14% Single: $0-$99 per month per enrollee, depending on income; Married: $0-$74 per month per enrollee, depending on income $0-$500 annually, depending on income. Payments are accepted quarterly. 30-day Rx fill (retail): $9 to $50 based on drug plan level (tiered) 90-day Rx fill (mail-order): $18 to $100 based on drug plan level (tiered) $2.40 for retail pharmacy Premiums, deductibles and copayments are determined through a sliding scale based on income levels. The annual out-of-pocket limit per enrollee is $2,000 or 10% of income, whichever is less. For married members, the out-of-pocket spending limit is $3,000 combined, or 10% of gross annual household income, whichever is less. The lower premium for married members only applies to those members who are both enrolled in the plan; when not joining as a couple, a married member must pay the individual rate.

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DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions: Notes:

Prescription Advantage formulary All therapeutic classes, except those excluded from MassHealth. Includes all FDA approved oral drugs as well as many injectable drugs, including insulin and disposable insulin syringes with needles. No OTC The plan utilizes a formulary that categorizes prescription drugs into three categories: generic drugs, brand name drugs, and additional brand name drugs. Generic drugs have the lowest copayment, while additional brand name drugs have the highest copayment. Plan officials have begun early discussions regarding changes to the program in light of Medicare prescription drug coverage. Preliminary efforts are focused on enabling Prescription Advantage to continue as a “wrap-around” program in conjunction with the Medicare Part D program.

PROGRAM CONTACT Molly McGinnis Massachusetts Executive Office of Elder Affairs One Ashburton Place Boston, MA 02108

Phone: 617/727-7750 Fax: 617/727-9368 Prescription Advantage information line: 800/243-4636

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Michigan Elder Prescription Insurance Coverage (EPIC) Program Program Type: Direct Assistance Year Operational: 2001 Number of Enrollees (February 2005): 10,900 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 65+ Eligibility Age (Disabled): 200% of FPL Eligible Income Level (Married): 200% of FPL EPIC enrollment is currently closed due to budget constraints, except for 45-day emergency coverage, which is available up to two times a year. In addition to normal coverage eligibility requirements, to be eligible for emergency coverage: • A single applicant must make less than 150% of FPL • A married applicant must make equal to or less than 150% of FPL • A true medical emergency must exist. To be eligible for normal coverage, an applicant: • Must be a resident of Michigan for three months prior to application • Cannot be residing in an institution • Cannot have other insurance or program coverage for prescription drugs • Cannot currently receive Medicaid benefits.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Enrollee (FY 05): # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount:

Copayment Amount:

Dispensing Fee:

State General Fund plus rebate revenue Not available $2,400 (estimated) 60 Medicaid Lesser of usual and customary charge, AWP-15.1% or 13.5% (depending on the pharmacy), or the State MAC price $25.00 Based on the participant’s total annual household income. Maximum annual cost-share amount is divided into twelfths so that a monthly amount must be met. If the out-of-pocket amount is not met in that month, the amount is cumulative, and any remainder is added to the following month. Deductibles are re-established yearly. If a brand name drug is prescribed and dispensed when a generically equivalent drug is available, a $15.00 copayment in addition to the monthly out-of-pocket share is charged. No copayment may exceed 20% of the cost of the drug $3.77

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DRUGS COVERAGE Formulary:

Drugs Covered: Drug Coverage Restrictions:

Notes:

Drugs not on the Michigan Pharmaceutical Products List (MPPL) may require prior authorization before they are paid for by EPIC. The use of generic drugs is encouraged. Most prescription drugs plus insulin and syringes for diabetics, with some exceptions. The EPIC program does not cover the following types of drugs: products used for weight loss or weight gain; fertility or infertility drugs; drugs used to treat erectile dysfunction; drugs or products used for contraception; products used to promote hair growth or for other cosmetic purposes; drugs used to treat the skin aging process; smoking cessation products; cold and cough preparations; fluoride preparations; experimental and investigational drugs; Drug Efficacy Study Implementation program (DESI) drugs; vitamins/minerals, alone or in combination; dietary formulas or nutritional supplements; central nervous system (CNS) stimulants; Acquired Immunodeficiency Syndrome (AIDS) drugs/injectables and orals; injectable drugs; allergy serums; compounds; over-the-counter (OTC) drugs except for prescription insulin and OTC drugs with prescriptions used for approved step therapy programs; miscellaneous products associated with a specific drug administration, except for diabetes needles and syringes; drugs produced by manufacturers not participating in the rebate program; non-Food and Drug Administration (FDA) approved drugs; and drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. Most prescription drugs have a 30-day supply; however, covered maintenance drugs may be filled for 100-day supply.

PROGRAM CONTACT Tom Chisnell Department of Community Health 611 West Ottawa, P.O. Box 30676 Lansing, MI 48909-8176

Phone: 517/373-3364

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Michigan MI Rx Prescription Savings Program Program Type: Discount Operational Date: September 2004 Number of Recipients: Est: 50,000 – 200,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

none Sliding scale

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

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

Not available Not available Not available Not available Medicaid guidelines Discount of 20%-- negotiated by State None Not available Not available Not available

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Michigan Department of Community Health

Phone: 1-866-755-6479

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Minnesota Prescription Drug Program∗ Program Type: Direct Assistance Year Operational: 1999 Number of Enrollees (January 2005): 7,500 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18-64 Eligibility Age (Disabled): 120% of FPL Eligible Income Level (Married): 120% of FPL On July 1, 2002, the program expanded to include coverage for persons on Medicare due to a disability. To be eligible, enrollees must: • Be a Medicare enrollee, age 65 or older, or disabled • Be a Minnesota resident for six months • Have liquid assets (other than home, car, burial funds, etc.) of $10,000 or less for one person or $18,000 or less for a married couple • Not be eligible for Medicaid • Not have prescription drug coverage within four months of applying • Not be enrolled in MinnesotaCare • Be enrolled in, or applying for, one of the following Medicare supplement programs, which help enrollees pay their Medicare premiums: Qualified Medicare Beneficiary (QMB), or Service Limited Medicare Beneficiary (SLMB).

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee: # of Rx’s Per Enrollee: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

∗

State General Revenue Fund plus manufacturer rebates $9 million (estimated) Not available Not available Same as Medicaid AWP-11.5% None $35.00 per month None $3.65

Formerly the Senior Citizen Drug Program. 6-55

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Pharmaceutical Benefits 2004

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions: Notes:

Minnesota Medicaid program formulary Same drugs as covered under Medicaid if manufacturer signs rebate agreement with Department of Human Services. Covers over-thecounter drugs for antacid, insulin products, smoking cessation products, lice medication and vitamins. Most other over-the-counter drugs are not covered. The sunset date for this program is December 31, 2005. State officials and lawmakers are in preliminary discussions on whether or not to terminate the program and implement a revised plan that would complement the Medicare Part D program.

PROGRAM CONTACT Steve Hamilton Rebate Analyst Prescription Drug Program Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853

Phone: 651/297-7699 E-mail: [email protected]

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Mississippi Mississippi Seniors and Indigents Rx Program Program Type: Coordinate Assistance Between Eligibles and Manufacturers’ Charitable Pharmaceutical Programs Law enacted: July 2004 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

Not available Eligibility Age (Disabled): Not available Eligible Income Level (Married): The program awaits implementation.

Not available Not available

FUNDING AND REIMBURSEMENT Funding Source:

Budget: Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Federal funds and gifts, voluntary funding in the form of grants available to build community, public sector and private sector partnerships. Not available Not available Not available Not available Not available Not available Not available Not available Not available The purpose of the program is to help seniors and qualified indigents in accessing pharmaceutical manufacturers’ discount cards and pharmaceutical assistance programs and to provide seniors and qualified indigents with applications for those programs.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Larry Calvert, R. Ph. Chairman State Board of Health Gulfport, MS 39505

Phone: 601/576-7400 Fax: 228/896-4549

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Missouri SenioRx Program Program Type: Direct Assistance Year Operational: 2002 Number of Enrollees (January 2005): 17,500 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): Tier I: $12,000 Eligible Income Level (Married): Tier I: $17,000 Tier II: $23,000 Tier II: $17,000 Applicant must be a Missouri resident and have lived in the state for 12 months by July 1, 2003. Applicants may not receive Medicaid or veterans pharmacy benefits or have prescription insurance that is equivalent to or greater than the Missouri SenioRx Program. Married couples may have household income up to $25,000 before a $2,000 marital deduction.

FUNDING AND REIMBURSEMENT Funding Source:

Budget (FY 05): Cost Per Enrollee (FY 05): # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Funding comes from the Missouri Senior Rx Fund, consisting of enrollment fees and manufacturer rebates, and funds appropriated by the General Assembly. $26.7 million $800 per year 32.4 15% for brand drugs; 11% for generic drugs AWP-10.43% $25.00 or $35.00, depending on income level $250.00 or $500.00, depending on income level 40% of prescription cost $4.09 Maximum annual benefit of $5,000.00 If an enrollee has already met the deductible and a brand name drug is needed, the enrollee must pay: 1) the cost difference between the brand name and generic drug and 2) 40% of the generic drug price. If the enrollee has not met the deductible, the enrollee pays the full cost of the brand name drug and the cost of the generic drug will be applied to the deductible.

DRUGS COVERAGE Formulary: Drugs Covered:

None Medicaid guidelines.

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Drug Coverage Restrictions:

Notes:

Pharmaceutical Benefits 2004

The following drugs are not covered: drugs manufactured by companies that do not participate in the Missouri SenioRx rebate program; over-the-counter (OTC) products; drugs used for weight gain or anorexia; drugs used to promote fertility; cosmetic and hair growth agents; cough and cold preparations; prescription strength vitamins; barbiturates; benzodiazepines; insulin syringes and diabetic supplies; food supplements; and medical equipment, devices and supplies. Use of generics is encouraged. The program requires the use of generic drugs whenever available. If a drug is available in generic form, the program covers the brand name drug only if the doctor determines it is necessary. Discount cards cannot be used in conjunction with the program. The program is to sunset, effective 12/13/05. There are, however, several measures in the General Assembly to enable the Senior Rx program to continue as a “wrap-around” program in conjunction with the Medicare Part D program.

PROGRAM CONTACT Jerry Simon Interim Director Missouri Senior Rx Program Health and Senior Services Department P.O. Box 570 Jefferson City, MO 65102

Phone: 573/522-3064 Fax: 573/522-3073 Email: [email protected]

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Pharmaceutical Benefits 2004

Montana Prescription Drug Expansion Program Program Type: Discount (CMS Pharmacy Plus Program Waiver) Law Enacted: 2003* ELIGIBILITY CRITERIA Eligibility Age (Elderly):

62+

Eligible Income Level (Single): Other Eligibility Notes:

200% of FPL Eligible Income Level (Married): Montana resident

Eligibility Age (Disabled):

Medicare eligible 200% of FPL

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

$1 million State loan and Federal funding Not available Not available Not available Medicaid equivalent Medicaid rate $25.00 None None See notes Client is responsible for paying the dispensing fee. Dispensing fee set at the discretion of each participating pharmacist. (This was done to alleviate concerns that the pharmacists’ $4.70 dispensing fee for Medicaid is inadequate.) State pays the discount rate of the prescription drug and the “client” pays the remaining drug costs. Discounts average between 6% and 25%.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None Based on participating manufacturers’ pharmaceutical products None

PROGRAM CONTACT Duane Preshinger Section Supervisor Medicaid Services Bureau Cogswell Building 1400 Broadway Helena, MT 59620

*

Phone: 406/444-4144 Fax : 406/444-1861 E-mail: [email protected]

The program will not be implemented given the passage of the Federal Medicare prescription drug program. 6-60

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Montana Pharmacy Access Prescription Drug Benefit Program Program Type: Direct Assistance Law Enacted: 2005* ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

Medicare enrollee 200% of FPL

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

Medicare enrollee 200% of FPL

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

Not available Not available Not available Not available Not available Not available Not available Not available Not available Not available Program will pay premiums for Part D, and may pay deductibles if funds are available.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Not available

*

The program is not yet operational. 6-61

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Montana Prescription Drug Plus Program Program Type: Discount Law Enacted: 2005* ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

See notes See notes Eligibility Age (Disabled): 250% of FPL Eligible Income Level (Married): 250% of FPL No age limit. Must lack Rx coverage or have exhausted benefit.

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

Manufacturer negotiated rebates Not available Not available Not available Not available Medicaid rate Not available Not available Not available Not available

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Not available

*

The program is not yet operational. 6-62

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Nevada Senior Rx Insurance Subsidy for Prescription Drugs∗ Program Type: Subsidy Year Operational: 2001 Number of Recipients (January 2005): 9,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

62+ Not eligible Eligibility Age (Disabled): $22,434 $29,205 Eligible Income Level (Married): Must be a Nevada resident for at least one year and not eligible for full Medicaid benefits. Eligibility income levels will change every July along with changes in consumer pricing.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

Tobacco Settlement Fund $9.8 million $65 per member, per month Not available Not available Brand: AWP-14%; Generics: lower of AWP-14% or CMS’ MAC rate None None Retail Pharmacy Co-Pays (30-day fill): $10.00 for generics; $25.00 for preferred brand name drugs or medically necessary brand name drugs; and provider’s discounted rate for all other drugs. Mail Order Co-Pays (90-day fill): $20.00 for generics, $50.00 for preferred brand name drugs or medically necessary brand name drugs. $2.25 Maximum benefit of $5,000.00 per year. An annual per enrollee deductible of $100.00 is paid by the State to Pharmaceutical Care Network (PCN), the pharmacy benefit manager that manages the program.

DRUGS COVERAGE Formulary: Drugs Covered:

∗

Managed formulary (by PCN) Most prescription drugs

Formerly the Nevada Senior Rx. 6-63

National Pharmaceutical Council

Drug Coverage Restrictions:

Pharmaceutical Benefits 2004

Coverage for generic and preferred brand name drugs is provided under the Senior Rx Prescription Drug Program for the co-pay options outlined above. If the prescription is for a non-preferred brand name drug, coverage is available if the drug is determined to be medically necessary. The copay for medically necessary non-preferred drugs is $25.00. If the non-preferred drug is not medically necessary, or is specifically excluded by the policy, it will cost 100% of the pharmacy discount rate. General exclusions for over-the-counter drugs; blood glucose meters; insulin injecting devices; biologicals; durable medical equipment; nutritional supplements; and cosmetic drugs.

PROGRAM CONTACT Jane Smedes Department of Human Resources 505 E. King Street, Room 201 Carson City, NV 89701-4797

Phone: 775/687-8711 E-mail: [email protected]

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Pharmaceutical Benefits 2004

New Hampshire Senior Prescription Drug Discount Program* Program Type: Discount Year Operational: 2000 Number of Enrollees (January 2005): 70,000† ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Eligibility Age (Disabled): All income Eligible Income Level (Married): levels Must be a New Hampshire resident.

Not eligible All income levels

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost Per Enrollee: # of Rx’s Per Enrollee: Manufacturer Rebate Type: Ingredient Cost Calculation: Deductible Amount: Enrollment Fee: Copayment Amount: Dispensing Fee: Notes:

Rebates and incentives from pharmaceutical manufacturers negotiated through Express Scripts, which operates the program. The State has not had to fund the program, since it is based on rebates and incentives. There is no associated cost per enrollee. Not available Rebates negotiated by Express Scripts with manufacturer. Not available None None Participant receives discount and must pay remainder of cost of prescription. None This program is offered solely at the discretion of Express Scripts. Discounts vary depending on pharmacy and medication. Discounts can be up to 16% for brand name products and up to 40% for generics.

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

* †

No formulary All prescription drugs Over-the-counter drugs are not covered. The State will likely offer some type of additional “wrap-around” program to better integrate options with the Medicare Part D program. Legislation is pending in the Legislature and very early discussions have begun on a program framework and implementation.

The program is offered by Express Scripts and has no State funding. Active number of participants about 12,000. 6-65

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Kim Hadank Swenson Health And Human Services Division Of Elderly And Adult Services 129 Pleasant Street Concord, NH 03301

Phone: 603/271-7857

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD) Program Type: Direct Assistance Year Operational: 1975 Estimated Number of Recipients (January 2005): 191,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18-64 Eligibility Age (Disabled): $20,437 $25,058 Eligible Income Level (Married): Disabled individuals are only eligible if they receive Title II Social Security Disability benefits. Married couples must file individual PAAD applications. If an individual has health insurance or a retiree prescription benefit equal to or better than PAAD, or if s/he receives Medicaid, s/he is not eligible for the PAAD program.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Fund and Casino Revenue Fund $414 million Senior: $2,680.00 (estimated) Disabled: $4,780.00 (estimated) Not available Medicaid AWP-12.5% None None $5.00 per prescription $3.73 to $4.07

DRUGS COVERAGE Formulary: Drugs Covered:

No formulary Legend drugs, insulin, syringes, insulin needles, certain diabetic testing materials and syringes, and injectables used in treatment of multiple sclerosis

Drug Coverage Restrictions:

Drugs must be purchased in New Jersey, and must be covered by a Manufacturer’s Rebate Agreement. Drug Efficacy Study Implementation program (DESI) drugs are not covered. Generic drugs must be dispensed unless physician requires brand name drug. (Medical justification required in obtaining authorization for brand version of multi-source drugs.) All first-time prescriptions are limited to a 34-day supply. PAAD allows for refills up to a 34-day supply or 100 unit doses, whichever is greater. Program mandates an enhanced Drug Utilization Review (DUR). 6-67

National Pharmaceutical Council

Notes:

Pharmaceutical Benefits 2004

The program will likely be restructured to better integrate options with the Medicare Part D program. Preliminary changes are under consideration but formal discussions have not started.

PROGRAM CONTACT Wade Daniel Epps Director PAAD/Senior Gold Operations P.O. Box 715 Trenton, NJ 08625-0715

Phone: 609/588-3460 Fax: 609/588-7139 Email: [email protected] Alternate contact: Jennifer Barron PAAD/Senior Gold Operations E-mail: [email protected]

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Pharmaceutical Benefits 2004

New Jersey Senior Gold Prescription Discount Program Program Type: Direct Assistance Year Operational: 2001 Estimated Number of Recipients (January 2005): 29,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18-64 Eligibility Age (Disabled): $20,437 $25,058 Eligible Income Level (Married): $30,437 $35,058 Senior citizens and disabled individuals eligible for the Pharmaceutical Assistance for the Aged and Disabled program are not eligible for the Senior Gold Prescription Discount Program. Disabled individuals are only eligible if they receive Title II Social Security Disability benefits. Program eligibility is required annually.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost Per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

Tobacco Settlement Fund $24.9 million Senior: $574.00 (projected) Disabled: $764.00 (projected) Senior: 25.4 (projected) Disabled: 31.2 (projected) Medicaid AWP-12.5% None None $15.00 plus 50% of the remaining cost of the prescription or the actual cost if less than $15.00. After unreimbursed out-of-pocket costs reach $2,000.00 for an individual, or $3,000.00 for a couple, copayments for additional prescriptions are $15.00 for the remainder of the year. $3.73 to $4.07 Once an enrollee incurs in one year unreimbursed out-of-pocket costs of $2,000.00, if single, or $3,000.00, if married, prescriptions may be obtained for the balance of that eligibility period for a flat $15.00 copayment or the actual price, if less than $15.00.

DRUGS COVERAGE Formulary: Drugs Covered:

No formulary Legend drugs, insulin, syringes, insulin needles, certain diabetic testing materials and syringes, and injectables used in treatment of multiple sclerosis

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National Pharmaceutical Council

Drug Coverage Restrictions:

Pharmaceutical Benefits 2004

Drugs must be purchased in New Jersey, and must be covered by a Manufacturer’s Rebate Agreement. Drug Efficacy Study Implementation program (DESI) drugs are not covered. Generic drugs must be dispensed unless physician requires dispensing of brand name drug. (Medical justification required in obtaining authorization for brand version of multi-source drugs.) All first-time prescriptions are limited to a 34-day supply. Senior Gold allows for refills up to a 34-day supply or 100 unit doses, whichever is greater.

Notes:

Program mandates an enhanced Drug Utilization Review (DUR). The program will likely be restructured to better integrate options with the Medicare Part D program. Preliminary changes are under consideration but formal discussions have not started.

PROGRAM CONTACT Wade Daniel Epps Director PAAD/Senior Gold Operations P.O. Box 715 Trenton, NJ 08625-0715

Phone: 609/588-3460 Fax: 609/588-7139 Email: [email protected] Alternate contact: Jennifer Barron PAAD/Senior Gold Operations E-mail: [email protected]

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Pharmaceutical Benefits 2004

New Mexico Senior Prescription Drug Program Program Type: Discount Operational Date: 2003 Number of Recipients (January 2005): 4,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): All income All income Eligible Income Level (Married): levels levels Must be a New Mexico resident and have no other prescription drug benefit through private insurance or other government programs.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Recipient: # of Rx’s Per Recipient: Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

$10,000 left from State general funds Not available Not available Not available Negotiated by PBM with individual manufacturers Retail: AWP-12% for brand name drugs; AWP-50% for generics Mail order: AWP-19.5% for brand name drugs; AWP-55% for generics None None See notes $3.50 – retail pharmacy; $1.50 – mail order Cost of prescription is contracted discounted price plus dispensing fee. For brand name prescriptions average discount is 13%; for generics average discount is 50%. Express Scripts administers the pharmacy benefit. The State receives an additional $2 for each prescription when enrollees use mail order pharmacy.

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

None Manufacturers’ participating prescription drug products None

PROGRAM CONTACT Lauri Michael New Mexico Retiree Health Care Authority 810 West San Mateo, Suite D Santa Fe, NM 87505

Phone: 505/848-9545 Fax: 505/983-8667 E-mail: [email protected]

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Pharmaceutical Benefits 2004

New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program Program Type: Direct Assistance Year Operational: 1987 Number of Recipients (January 2005): 348,269 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level, Fee Plan (Single): Eligible Income Level, Deductible Plan (Single): Other Eligibility Notes:

65+ $20,000

Eligibility Age (Disabled): Eligible Income Level, Fee Plan (Married): $20,001Eligible Income Level, Deductible $35,000 Plan (Married): Medicaid enrollees are not eligible.

Not eligible $26,000 $26,001$50,000

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee:

State General Fund $851 million $2,083 Not available Full Medicaid rate (base rate plus Consumer Price Index penalty) AWP-16.5% or Federal Upper Limit (FUL) where available, on generics and AWP-12.75% on brands $2.00 - $75.00 per quarter, based on income level $530.00 - $1,715.00 annually, based on income level $3.00 (prescription cost up to $15.00); $7.00 (prescription cost from $15.01 to $35.00); $15.00 (prescription cost from $35.01 to $55.00); and $20.00 (prescription cost over $55.00) $4.50 for generics and $3.50 for brand name drugs

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

None All legend drugs, insulin and insulin syringes and needles Drug Efficacy Study and Implementation program (DESI) drugs and nonparticipating manufacturers excluded There are several measures in the legislation to enable the EPIC program to fully wraparound Part D if a senior joins Part D, and would waive EPIC enrollment fees for participants that join Part D as a full subsidy individual.

PROGRAM CONTACT Julie A. Naglieri, Acting Director NYS EPIC Program 1 Corporate Plaza 260 Washington Avenue Ext. Albany, NY 12203

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

North Carolina Senior Care∗ Program Type: Direct Assistance Year Operational: 2002 Number of Recipients (January 2005): 113,000 ELIGIBILITY CRITERIA 65+ 65+ Eligibility Age (Disabled): 250% of FPL Eligible Income Level (Married): 250% of FPL Individuals must not be eligible for Medicaid benefits or have other coverage for drugs covered by Senior Care.

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

FUNDING AND REIMBURSEMENT Tobacco settlement funds Not available Not available Not available Medicaid AWP-10% None None 5%-10% of the prescription cost $4.90 (40 cents retained by claims processor) Maximum annual prescription benefit of $600.00. Senior Care pays for 60% of the first $1,000.00 of prescription costs, and members pay the remaining 40%. Maximum benefit per year of $1,000

Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

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

None All prescription drugs This program will not pay for over-the-counter drugs or potassium supplements. Identical restrictions as those for the Medicare Discount Card. Sunset date for this program is on December 31, 2005. There are no plans addressing the Medicare Part D program as of yet, however legislation is being considered.

PROGRAM CONTACT Michael Keough Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699 ∗

Phone: 919/733-2040 E-mail: [email protected]

Previously referred to as Carolina CaRxes in State legislation. 6-73

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Ohio Golden Buckeye Prescription Drug Program Program Type: Negotiated Discounts Operational Date: 2003 Estimated Eligibles: 2 million ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

60+ 18-59 Eligibility Age (Disabled): All income All income Eligible Income Level (Married): levels levels Must be an Ohio resident. The “Special Assistance Program” within the Golden Buckeye Prescription Drug Program establishes further savings for Medicare eligible beneficiaries who have no other prescription drug assistance. Eligibility income levels for the “Special Assistance Program” are: $30,000-individual; $40,000-married.

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

Manufacturer negotiated rebates, 50% of which go to a PBM for running the program. Based on manufacturers’ negotiated rebates Not available Not available Negotiated by PBM with individual manufacturers. Estimated savings range from 5% to 40%. Reimbursement rate based on negotiated contract with each participating manufacturer. None None None Not available MemberHealth is the PBM administrator for the Golden Buckeye Prescription Drug Program and the Ohio’s Best Rx Program. Nineteen manufacturers are participating in the Golden Buckeye Prescription Drug Program, including Solvay, Procter & Gamble Pharmaceuticals, KOS, Boerhinger, Bausch & Lomb, Andrx Labs, Bayer, Barr, Schering, Merck, Celltech, Abbott Labs, Daiichi, Novo Nordisk, and Novartis. Four manufacturers are participating in the Special Assistance Prescription Drug Program within the Golden Buckeye Program: GlaxoSmithKline, Novartis, Bristol Myers Squibb, and Merck.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

Preferred Drug List Drugs for which the PBM has negotiated rebates with manufacturers. None MemberHealth conducts drug utilization reviews for these programs.

PROGRAM CONTACT Gary Panek Manager of Golden Buckeye Program Department of Aging 50 W. Broad Street, 9th Floor Columbus, OH 43215

Phone: 614/466-3583 Fax: 614/466-8893 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Ohio Ohio’s Best Rx Program Program Type: Negotiated Discounts Year Operational: 2005 Number of Recipients (January 2005): 14,934 ELIGIBILITY CRITERIA 60 + 18+ Eligibility Age (Disabled): 250% of FPL Eligible Income Level (Married): 250% of FPL Enrollee must not have other outpatient prescription drug coverage. No income requirements for those over 60.

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

FUNDING AND REIMBURSEMENT Funding Source:

Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Initially State funded; however, by January 2006 this program is expected to be self-funded by obtaining rebates from drug manufacturers and collecting a small administrative fee from participants. $10 million for start-up costs from the State $34.78 Not available Negotiated with each individual manufacturer. Estimated discounts range between 20% and 40%. Based on contractual arrangements with participating manufacturers None None $1 transaction cost $3.00 Discounts are calculated from the average rebate paid by drug manufacturers to State retirement and employees benefit plans. Up to 5% of the money collected through manufacturers’ rebates may be used for the contract with the PBM program administrator, MemberHealth.

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

Open Based on pharmaceutical manufacturers participating in the program. None

PROGRAM CONTACT Cynthia Burnell, Program Director Ohio's Best Rx Ohio Department of Job & Family Services Office of Family Stability 145 S. Front St, 2nd Floor Columbus, OH 43215

Phone: 614/446-9783 Fax: 614/466-9181 E-mail: [email protected]

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Pharmaceutical Benefits 2004

Oklahoma Pharmacy Connection Council Program* Program Type: Coordinate Assistance Between Elderly and Manufacturers’ Pharmaceutical Programs Year Operational: 2003 Number of Recipients: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+

Medicare eligible Not available Eligible Income Level (Married): Not available Eligibility criteria may vary according to manufacturers’ programs. Eligibility Age (Disabled):

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

None None None Not available None None None None None Not available To obtain these free or discounted prescriptions, the individual must complete an application on a form provided by the manufacturer of the drug. One section is for the patient to complete and the other for the prescriber. The doctor submits the application and the prescription to the manufacturer. When approved, the manufacturer sends the free drug to the doctor, who then gives it to the patient.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None Based on a manufacturer’s charitable program criteria. Not available

*

The Pharmacy Connection Council program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs. 6-77

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Nancy Davis Pharmacy Bureau State Dept. of Health 1000 Northeast Tenth St Oklahoma City, OK 73117

Phone: 405/271-6576 Fax: 405/271-1308 General E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Oklahoma Oklahoma Prescription Drug Assistance Program* Program Type: Discount Law Enacted: 2005 Projected Number of Recipients: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

See notes See notes Eligibility Age (Disabled): See notes See notes Eligible Income Level (Married): No age limit, all uninsured residents are eligible. No income limit, but enrollment fee for those above 150% FPL.

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

Manufacturer negotiated rebates Not available Not available Not available Not available Medicaid reimbursement Only for those above 150% FPL Not available Not available Not available

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

PROGRAM CONTACT Not available

*

The program is not yet operational. 6-79

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Oregon Senior Prescription Drug Assistance Program* Program Type: Discount Operational Date: 2003 Number of Recipients (January 2005): 100 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 65+ Eligibility Age (Disabled): 185% of FPL 185% of FPL Eligible Income Level (Married): Individuals must not be covered under any public or private prescription drug benefit program for the previous six months and must have less than $2,000.00 in liquid resources. Enrollees are issued enrollment cards that entitle them to Medicaid prices.

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

Enrollment fees None Not available Not available Not available Matches Medicaid rate or AWP-14% $50.00 annually None None $3.50 for retail pharmacy; $3.80 for institutional pharmacies The law authorizing the program allows for coverage up to 50% of pharmaceutical cost, with a maximum annual benefit of $2,000.00. The program operates as a discount program based on voluntary participation from pharmacies.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions

None All legend drugs OTC drugs and medical supplies and medical equipment are not covered.

*

Legislation was enacted in 2003 seeking a CMS waiver for the creation of the Medication Expansion for Disabled Persons and Seniors (MEDS) program. MEDS would have expanded drug coverage for additional seniors’ 65 years of age and older using a sliding scale, cost-share and co-insurance matrix based on income levels. The waiver has not been approved to date. Oregon officials may not seek implementation of the program given the Medicare prescription drug benefit enacted by Congress in 2003. 6-80

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Sandy Wood Program Manager Office of Medical Assistance Programs Human Services Building 500 Summer St. NE, E25 Salem, OR 97301-1098

Phone: 503/945-6530 Email: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE) Type of Program: Direct Assistance Year Operational: 1984 Number of Recipients (January 2005): 194,717 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): $14,500 Eligible Income Level (Married): $17,700 Must be a resident of Pennsylvania for at least 90 days prior to the date of application. Must establish intent to maintain a permanent home in Pennsylvania for the indefinite future.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State Lottery, Tobacco Settlement funds $507 million $2,367 50.88 22% of Average Manufacturer Price Lesser of AWP-10% or usual and customary None None $9.00 for brand name drugs; $6.00 for generics $4.00 Quarterly reporting for Average Manufacturer Price (AMP) rebate information.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None All Federal legend drugs and insulin, insulin syringes and needles 30-day supply or 100 units, whichever is less. No experimental drugs, drugs for baldness and wrinkles, over-the-counter drugs, or most off-label uses. Mandatory generic substitution for A-rated (therapeutically equivalent) products. Drug Efficacy Study and Implementation program (DESI) drugs require documentation of medical necessity.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Thomas Snedden Director, PACE Program Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

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

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Pennsylvania PACE Needs Enhancement Tier (PACENET) Program Type: Direct Assistance Year Operational: 1996 Number of Recipients (January 2005): 104,178 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): $14,500 to $17,700 to Eligible Income Level (Married): $23,500 $31,500 Must be a resident of Pennsylvania for at least 90 days prior to the date of application.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05-06): Cost per Participant (FY 05-06): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State Lottery, Tobacco Settlement funds $507 million $1,503 43.40 22% of Average Manufacturer Price (AMP) Lesser of AWP-10% or usual and customary None $480.00 per year ($40/month) $15.00 for brand name drugs and $8.00 for generics $4.00 Quarterly reporting for Average Manufacturer Price (AMP) rebate information.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None All Federal legend drugs and insulin, insulin syringes and needles 30-day supply or 100 units, whichever is less. No experimental drugs, drugs for baldness and wrinkles, over-the-counter drugs, or most offlabel uses. Mandatory generic substitution for A-rated (therapeutically equivalent) products. Drug Efficacy Study and Implementation program (DESI) drugs require documentation of medical necessity.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Thomas Snedden Director, PACE Program Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

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

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Pharmaceutical Benefits 2004

Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) Program Type: Direct Assistance, Discount Year Operational: 1985 Number of Enrollees (January 2005): 38,500 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 55-65 Eligibility Age (Disabled): See notes See notes Eligible Income Level (Married): Income levels exclude income spent on medical expenses if greater than 3% of total income.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee (FY 05): # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee: Notes:

State General Revenue Fund Not available Not available Not available Medicaid AWP-13% for brand name drugs; MAC for generics None None Participant pays co-pay of 40%, 70%, or 85% of prescription cost depending on income levels. For members in the lowest income class, the program will pay 100% of the cost of covered medications after the member has paid $1,500.00 in copayments. $2.75 Participating pharmaceutical manufacturers must sign a rebate agreement with the State for covered products.

DRUGS COVERAGE Formulary: Drugs Covered:

Drug Coverage Restrictions:

Notes:

Open formulary Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and other chronic respiratory conditions, cancer, circulatory insufficiency, depression, diabetes (including insulin syringes), glaucoma, heart problems, high cholesterol, hypertension, osteoporosis, Parkinson’s disease, prescription mineral and vitamin supplements for renal patients, and urinary incontinence. Non-cosmetic Food and Drug Administration approved drugs that were not previously listed are covered at the program’s discount price or at the Federal MAC price, whichever is lower. Program officials have begun preliminary discussions on using the RIPAE program as a “wrap-around” program once the Medicare Prescription Drug Program (Part D) is operational. Specific criteria have yet to be determined.

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Kristin Pono Rhode Island Dept. of Elderly Affairs Benjamin Rush Building #55 35 Howard Avenue Cranston, RI 02920

Phone: 401/462-0510 Fax: 401/462-0586

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Pharmaceutical Benefits 2004

Rhode Island Rhode Island Pharmacy Prescription Drug Discount Program for the Uninsured Program Type: Cash Discount Year Operational: 2005∗ Number of Enrollees: Not Available ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

19-65 19-65 Eligibility Age (Disabled): 200% (FPL) 200% (FPL) Eligible Income Level (Married): Must be uninsured with no prescription drug coverage. Family income may not exceed 200 percent of the Federal poverty level (FPL).

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee (FY 05): # of Rx’s Per Enrollee (FY 05): Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

PBM negotiated contracts with manufacturers Not available Not available Not available PBM negotiated contracts with pharmaceutical manufacturers Criteria based on the lower of the usual and customary or: AWP-15% (retail –brand); AWP-17% (retail – mail); Retail generic: CMS MAC rate or AWP-40%; Mail-order generic: CMS MAC rate or AWP-50%. Annual, non-refundable enrollment fee, up to $30, may be charged. Not available Not available Not available Request for Proposal (RFP) is under evaluation. Specific funding and reimbursement criteria will be determined based on the winning vendor bid from pharmacy benefits manager (PBM).

DRUGS COVERAGE Formulary: Drugs Covered:

To be determined based on winning RFP bid. To be determined based on winning RFP bid.

∗

Program is scheduled to begin May 2005; however, the Request For Proposal (RFP) is still under evaluation, as of April 1, 2005. 6-88

National Pharmaceutical Council

Pharmaceutical Benefits 2004

PROGRAM CONTACT Kristin Pono Rhode Island Dept. of Elderly Affairs Benjamin Rush Building #55 35 Howard Avenue Cranston, RI 02920

Phone: 401/462-0510 Fax: 401/462-0586

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

South Carolina SilveRxCard Senior Prescription Drug Program Program Type: Direct Assistance (1115 Waiver) Year Operational: 2003 Number of Enrollees (January 2005): 53,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): 200% of FPL Eligible Income Level (Married): 200% of FPL Must be a South Carolina resident. Must be ineligible for Medicaid with no prescription benefits from any other source.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Enrollee: # of Rx’s Per Enrollee : Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount:

Dispensing Fee:

Tobacco Settlement Fund and Federal matching funds $14 million Not available 4 per month Medicaid AWP-10% None $500.00 per calendar year Members receive discounts up to 10% on prescriptions until the deductible is met. After the $500.00 deductible, the copayment is $10.00 for generic drugs, $15.00 for brand name drugs, and $21.00 for drugs requiring prior authorization. $4.05

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Same as Medicaid Same as Medicaid Some drugs require prior authorization. SilveRxCard covers up to a 34 days’ supply of medication and generally 4 covered prescriptions or refills during a calendar month. Overrides of the monthly limit are allowed for some conditions, including acute sickle cell disease, behavioral health disorder, cancer, cardiac disease, diabetes, HIV/AIDS, hypertension, and terminal illnesses.

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Notes:

Pharmaceutical Benefits 2004

Brand name drugs are dispensed when generic drugs are not available. Over-the-counter drugs are paid for when authorized with a prescription. Insulin syringes, insulin, or other injectable products that are either administered at home or self-administered are also covered. Diabetic supplies such as alcohol wipes and test strips; smoking cessation products; certain lifestyle drugs; and, injectable products administered in a physician’s office or clinic are not covered. The program will likely be restructured to better integrate options with the Medicare Part D program. Legislation is being discussed but specific details have yet to be announced. An effort to expand drug coverage through the South Carolina Retirees and Individuals Pooling Together for Savings (SCRIPTS) Program has been postponed due to the Federal Medicare prescription drug coverage program.

PROGRAM CONTACT Frank Williams SilveRxCard Office of Insurance Services 1201 Main Street, Suite 350 Columbia, SC 29201

Phone: 803/898-2511 General E-mail: [email protected]

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Pharmaceutical Benefits 2004

South Dakota Senior Citizen Prescription Drug Benefit Program Program Type: Negotiated Discount Year Operational: 2003* Number of Enrollees (December 2003): 36,361 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All Medicare Eligibility Age (Disabled): All Medicare eligibles eligibles All income All income Eligible Income Level (Married): levels levels Must be a resident of South Dakota. Medicaid recipients are not eligible.

FUNDING AND REIMBURSEMENT Funding Source: Budget: Cost per Enrollee: # of Rx’s Per Enrollee: Manufacturer Rebate Type:

Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Not available Not available Not available Not available PBM negotiated discounted prescription costs rather than trying to set mandatory price reductions. Prescription discounts averaged between 15% and 20%. AWP-10.5% None None None $3.50

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None All prescription drugs None

PROGRAM CONTACT Larry Kucker Bureau of Personnel 500 East Capitol Avenue Pierre, SD 57501

*

Phone: 605/773-3148 Fax: 605/773-4344

This program was repealed by legislation, effective September 1, 2004. 6-92

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Pharmaceutical Benefits 2004

Tennessee TennCare Rx Program Type: Direct Assistance (1115 Waiver) Law Enacted: 2003* Number of Recipients: None ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

To be To be Eligibility Age (Disabled): determined determined To be To be Eligible Income Level (Married): determined determined Chapter Number 350 of the Public Acts of 2003 says only that this program is “intended to provide a prescription drug benefit to individuals lacking prescription drug insurance coverage who meet criteria established by the Bureau of TennCare and the General Assembly in its annual appropriations bill.” These criteria have yet to be established.

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

State and Federal funds None Not available Not available Rebates negotiated by State or by State PBM with manufacturers. Not available Authorized by enacting legislation but not yet specified. None Authorized by enacting legislation but not yet specified. Not available Enacting legislation provides that program participants may purchase drugs through pharmacies participating in the State network.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

State PDL Not available Enacting legislation authorizes, but does not specify, prior authorization and step therapy requirements.

PROGRAM CONTACT Jeff Stockard, Associate Director TennCare Pharmacy Bureau 729 Church Street Nashville, Tennessee 37247 *

Phone: 615/ 741-0213 E-mail: [email protected]

This program has not yet been implemented. 6-93

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Pharmaceutical Benefits 2004

Texas Kidney Health Care Program (KHC) Program Type: Direct Assistance Year Operational: 1999 Number of Recipients (January 2005): 17,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

None None Eligibility Age (Disabled): $60,000 $60,000 Eligible Income Level (Married): To be eligible for KHC benefits the following criteria must be met: 1) Texas residency must be documented; 2) end-state renal disease (ESRD) must be certified; 3) applicant must be receiving a regular course of chronic renal dialysis treatments or have received a kidney transplant; 4) an application for benefits must be submitted through a Medicare approved hospital, VA facility, or KHC approved facility; 5) an application for ESRD benefits must be filed with Medicare; and 6) KHC-established financial criteria must be met. Medicaid recipients are not eligible for this program.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 04-05): Cost per Participant (FY 04): # of Rx’s Per Participant (FY 04): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State funds $38.7 million Approximately $1,473 Approximately 2 per month Voluntary AWP-15% or WAC+12%, whichever is lowest None None $6.00 $5.14

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Closed formulary Drugs for end-state renal disease and transplants Restricted to drugs for end-state renal disease and transplants

PROGRAM CONTACT Lisa Rodriguez, M. Ed. Manager, Customer Services Kidney Health Care Program Department of State Health Services 1100 West 49th Street (1938) Austin, TX 78756

Phone: 512/458-7150 Fax: 512/456-7162

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Pharmaceutical Benefits 2004

Texas State Prescription Drug Program Program Type: Subsidy Law Enacted: 2001∗ Estimated Eligibles: None ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ Not eligible Eligibility Age (Disabled): 100% of FPL 100% of FPL Eligible Income Level (Married): Upper income limits may increase if funding becomes available. However, the categories most likely to qualify for the program at proposed FY 04-05 funding levels are Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs).

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

State General Revenue Fund, unless funds are available under Federal law to fund all or part of the program None Not available Not available Not available Not available Not available Not available Not available Not available According to statute, the Health and Human Services Commission may require a cost-sharing payment.

DRUGS COVERAGE Not available Formulary: Not available Drugs Covered: Drug Coverage Restrictions: Not available The Health and Human Services Commission may require that, unless the practitioner’s signature on Notes: a prescription clearly indicates that the prescription must be dispensed as written, the pharmacist may select a generic equivalent of the prescribed drugs. The Health and Human Resources Commission is also authorized to establish a formulary, prior authorization requirements, and a drug utilization program. PROGRAM CONTACT Sharon Carter Health and Human Services Commission P.O. Box 13247 Austin, TX 787111-3247 ∗

Phone: 512/424-6514

This program has not been implemented due to the fact that no funding has been budgeted. 6-95

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Pharmaceutical Benefits 2004

Vermont VSCRIPT Program Type: Direct Assistance (1115 Waiver) Year Operational: 1989∗ Number of Eligibles (February 2005): 2,752 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single):

65+ 150% - 175% of FPL

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

All ages 150% - 175% of FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Federal and State funds $5.5 million $155.90 per month Not available Medicaid AWP-11.9% $17.00 per month None None $4.25

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Preferred Drug List Maintenance drugs covered by Medicaid No experimental or over-the-counter drugs, except Prilosec OTC and Loratadine.

PROGRAM CONTACT Esther Perlman Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676

∗

Phone: 802/879-5900 Fax: 802/879-5962

This program was integrated into the VHAP (1115 waiver) program in 1999. 6-96

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Pharmaceutical Benefits 2004

Vermont VSCRIPT Expanded Program Type: Direct Assistance Year Operational: 2000 Number of Recipients (February 2005): 2,665 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single):

65+ 175% - 225% of FPL

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

All ages 175% - 225% of FPL

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY 05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State General Fund $5.7 million Not available Not available Medicaid equivalent AWP-11.9% $35.00 per month None None $4.25

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Preferred Drug List Medicaid covered maintenance drugs under separate manufacturer’s rebate agreement No experimental or over-the-counter drugs, except Prilosec OTC and Loratadine.

PROGRAM CONTACT Esther Perlman Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676

Phone: 802/879-5900 Fax: 802/879-5962

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Pharmaceutical Benefits 2004

Vermont Vermont Health Access Plan (VHAP) Pharmacy Program Type: Direct Assistance (1115 Waiver) Year Operational: 1996 Number of Recipients (February 2005): 8,465 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+

Medicare eligible 150% of FPL Eligible Income Level (Married): 150% of FPL Medicaid recipients are not eligible. Individuals may not have any other prescription drug insurance. Eligibility Age (Disabled):

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant (FY05): # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

Federal and State funds $15.4 million Not available Not available Medicaid AWP-11.9% $13.00 per month None None $4.25

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Preferred Drug List All drugs covered by Vermont Medicaid, including insulin and insulin syringes. No experimental or over-the-counter drugs, except Prilosec OTC and Loratadine.

PROGRAM CONTACT Esther Perlman Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676

Phone: 802/879-5900 Fax: 802/879-5962

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Pharmaceutical Benefits 2004

Vermont Healthy Vermonters Program Program Type: Direct Assistance (1115 Waiver) Year Operational: July 1, 2002 Eligible Recipients (February 2005): 13,469

ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+

Medicare eligible 400% of FPL Eligible Income Level (Married): 400% of FPL Vermont residentsof any age with incomes at or below 300% FPL are also eligible. This program is for those who have no insurance for prescriptions or those who have a commercial insurance plan with a yearly limit. This program also covers drugs for acute conditions for VScript or VScript Expanded beneficiaries (up to 225% of FPL) who previously received a benefit only for maintenance drugs. VScript and VScript Expanded beneficiaries will be automatically enrolled in Healthy Vermonters and have the advantage of Healthy Vermonters benefits for prescriptions not covered under the VScripts programs. Eligibility Age (Disabled):

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing fee: Note:

None None Not available Not available Not available AWP-11.9% None None None $4.25 Beneficiary purchases drugs at the Medicaid payment rate.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Medicaid Formulary Drugs covered by Medicaid No experimental or over-the-counter drugs

PROGRAM CONTACT Esther Perlman Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676

Phone: 802/879-5900 Fax: 802/879-5962

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Pharmaceutical Benefits 2004

Washington Pharmacy Connections Program Type: Coordinate Assistance Between Elderly and Manufacturers’ Pharmaceutical Programs Year Operational: 2003 Number of Individuals Assisted (2004): 26,000∗ ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

None None Eligibility Age (Disabled): None None Eligible Income Level (Married): Pharmacy Connections provides toll-free telephone assistance for Washington residents to get information about manufacturersponsored prescription drug assistance programs and to assist them with applying for these programs. The program also serves as a onestop “clearinghouse” to provide information on other prescription drug resources such as the Medicare discount cards and the Rx Washington Card program. Although the program specifically targets senior citizens, it is open to all Washington residents.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 04-05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee:

State funds $750,000 Not available Not applicable Not applicable Not applicable None Not applicable Not applicable Not applicable

DRUGS COVERAGE Formulary: Drugs Covered:

Not applicable Not applicable

∗

The program provided 15,000 individuals with referral information for drug manufacturer-sponsored patient assistance programs and drug discount cards. The program also helped 11,000 individuals complete applications. These numbers are expected to increase dramatically based on confusion surrounding implementation of the Medicare prescription drug benefit in 2006. 6-100

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Erika Clayton Project Coordinator Prescription Drug Program Health Care Authority P.O. Box 91132 Seattle, WA 98111-9232

Phone: 206/521-2027

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Pharmaceutical Benefits 2004

Washington Rx Washington Card Program Type: Direct Discounts Year Operational: 2004 Number of Recipients (February 2005): 50∗ ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

50+ 19-49 Eligibility Age (Disabled): 300% of FPL Eligible Income Level (Married): 300% of FPL Individuals may not have any other prescription drug insurance coverage or prescription drug benefits.

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

None None Not available Not available Discounts of 15%-20% negotiated by Express Scripts, Inc. Pass-through negotiated by Express Scripts. In 2004, the average for brand name drugs was AWP-16.4%; for generics AWP-63.5%. $10.00 None None Ranges from $2.00 to $2.50, depending on pharmacy.

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

PBM formulary Not available None State officials wanted to use a State-sponsored PDL; however, the PBM would not agree to these terms, as the program’s overall market share is not large enough.

∗

Enrollment in Rx Washington has remained low due to a variety of factors, including: (1) availability of the Medicare drug discount card; (2) provisions in law preventing negotiated discounts from hurt retail pharmacies; (3) the existence of programs offered by drug manufacturers; and (4) the fact that the program is mail order only. 6-102

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Erika Clayton Project Coordinator Prescription Drug Program Health Care Authority P.O. Box 91132 Seattle, WA 98111-9232

Phone: 206/521-2027

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Pharmaceutical Benefits 2004

Washington Medicaid Prescription Drug Assistance Program Program Type: Direct Assistance (1115 Waiver) Law Enacted: 2003∗ Number of Recipients: None ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ 18-64 Eligibility Age (Disabled): 200% of FPL Eligible Income Level (Married): 200% of FPL Must not be Medicaid eligible and must lack prescription drug insurance coverage. Enacting legislation provides that enrollment may be limited to prevent over expenditure or to comply with Federal waiver budget neutrality requirements.

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

State and Federal funds None Not available Not available Not available Not available Authorized by enacting legislation but not specified. Authorized by enacting legislation but not specified. Authorized by enacting legislation but not specified. Not available Enacting legislation provides that the benefit design may differ from the Medical Assistance Program benefit design, that more than one benefit design may be offered, and that it may include a deductible benefit to provide coverage when enrollees incur higher prescription drug costs.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

Not available Not available Not available

∗

The program has not been implemented. The State decided not to pursue the requisite 1115 demonstration waiver after passage of the Medicare Prescription Drug Improvements and Modernization Act of 2003. 6-104

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Pharmaceutical Benefits 2004

PROGRAM CONTACT Erika Clayton Project Coordinator Prescription Drug Program Health Care Authority P.O. Box 91132 Seattle, WA 98111-9232

Phone: 206/521-2027

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Pharmaceutical Benefits 2004

West Virginia Golden Mountaineer Card Program Program Type: Direct Assistance Year Operational: 2001 Number of Recipients (2004): 14,000-16,000/month* ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

60+ Eligibility Age (Disabled): All income Eligible Income Level (Married): levels Must be a resident of West Virginia.

60+ All income levels

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 05): Cost per Participant: # of Rx’s Per Participant (2004): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

Lottery funds and State General Fund $25,000 Not available 33 Rebates negotiated by PBM (Caremark) with individual manufacturers AWP-13% for brand name drugs and generics and AWP-60% for MAC drugs. None None None $3.50 Enrollees will receive discounts set by PBM.

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

None All FDA Federal legend pharmaceuticals and diabetic supplies None

PROGRAM CONTACT Jan Bowen Bureau of Senior Services Holly Grove, Building No. 10 Charleston, WV 25305-0160

*

Phone: 304/558-3317 Fax: 304/558-0004

There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage varies. 6-106

National Pharmaceutical Council

Pharmaceutical Benefits 2004

West Virginia West Virginia Prescription Drug Assistance Clearinghouse Program Program Type: Coordinate Assistance Between Elderly and Manufacturers’ Pharmaceutical Programs Law Enacted: April 2004 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

Not available Eligibility Age (Disabled): Not available 200% FPL 200% FPL Eligible Income Level (Married): Uninsured West Virginia residents who have had no coverage for at least 6 months.

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

Brand name drug manufacturers Not available Not available Not available Not available Not available Not available Not available Not available $3.50 Pharmacies participating in the voluntary program(s) will be responsible for no more than fifty percent of the discount offered by the manufacturer to the participant.

DRUGS COVERAGE None Formulary: None Drugs Covered: None Drug Coverage Restrictions: The clearinghouse portion of the program assists low-income State residents or uninsured to gain Notes: access to existing manufacturers’ private and public sector prescription drug assistance programs offered by manufacturers. The discount drug program provides low-income, uninsured individuals prescription drugs from participating brand pharmaceutical companies and pharmacists through either a State-sponsored discount card program or a program extending current brand pharmaceutical manufacturer prescription drug assistance programs. PROGRAM CONTACT Robert W. Ferguson, Jr., Cabinet Secretary State Capitol Complex, Room E-119 Charleston, West Virginia 25305

Phone: 304/558-4331 Fax: 304/558-2999 E-mail: [email protected]

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Pharmaceutical Benefits 2004

Wisconsin SeniorCare Prescription Drug Assistance Program Program Type: Direct Assistance Year Operational: 2002 Estimated Enrollment (March 2005): 88,000 ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

65+ N/A Eligibility Age (Disabled): See note See note Eligible Income Level (Married): Person must not be a recipient of medical assistance and must be a resident of the State. The State implemented four participation levels for the program and each has a corresponding out-of-pocket expense and/or co-pay amount. SeniorCare level Level 1 Level 2a Level 2b Level 3

FPL up to 160% between 160% and 200% between 200% and 240% greater than 240%

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 03-05): Cost per Participant: # of Rx’s Per Participant: Manufacturer Rebate Type: Ingredient Cost Calculation:

Enrollment Fee: Deductible Amount:

State general revenue and Federal funding. $79.6 million in State general revenue $1,914 46 Manufacturers must sign separate SeniorCare rebate agreement with the State. AWP-13% or MAC. The National Drug Code (NDC) innovator price will be paid when “Brand Medically Necessary” is handwritten on the prescription by the physician and prior authorization is granted. $30.00 Level 1: No deductible. Level 2a: $500 deductible per person and pay SeniorCare rate for drugs. Level 2b: $850 deductible per person and pay SeniorCare rate for drugs. Level 3: Pay retail price for drugs equal to the difference between your income and $22,968 per individual or $30,792 per couple. This is called "spenddown." During “spenddown”, no discount for drugs. After “spenddown”, meet an $850 deductible per person but pay SeniorCare rate for covered drugs.

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Copayment Amount:

Pharmaceutical Benefits 2004

Level 1: Level 2a: Level 2b: Level 3:

Dispensing Fee:

$15 co-pay for covered brand name drugs, $5 co-pay for covered generics After $500 deductible, $15 co-pay for covered brand name drugs, $5 co-pay for covered generics After $850 deductible, $15 co-pay for covered brand name drugs, $5 co-pay for covered generics After spenddown and an $850 deductible are met, $15 co-pay for covered brand name drugs, $5 co-pay for covered generics

$4.88

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

PDL Manufacturers’ products that have a signed SeniorCare rebate agreement Reimbursement for most drugs is limited to a 34-day supply. Some maintenance drugs may be provided in a 100-day supply. A preferred drug list (PDL) has been implemented.

PROGRAM CONTACT Pamela S. Appleby Budget & Policy Analyst Division of Health Care Financing 1 West Wilson Street P.O. Box 309 Madison, WI 53701-0309

Phone: 608/266-7685 Fax: 608/266-1096

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Wyoming Prescription Drug Assistance Program Program Type: Direct Assistance Year Operational: 2003 Number of Recipients (FY 2004): 1,066 (monthly average)* ELIGIBILITY CRITERIA Eligibility Age (Elderly): Eligible Income Level (Single): Other Eligibility Notes:

All ages All ages Eligibility Age (Disabled): 100% of FPL Eligible Income Level (Married): 100% of FPL Medicaid enrollees are not eligible for this program. Also, an asset test was implemented effective July 1, 2004. The asset test takes into account motor vehicles worth more than $15,000 and resources in excess of $2,500. Homes are exempt.

FUNDING AND REIMBURSEMENT Funding Source: Budget (FY 04-05): Cost per Participant (FY 04-05): # of Rx’s Per Participant (FY 0405): Manufacturer Rebate Type: Ingredient Cost Calculation: Enrollment Fee: Deductible Amount: Copayment Amount: Dispensing Fee: Notes:

State General Revenue Fund $4 million $135.56 per month 2.17 per month Voluntary manufacturer rebate. (Program may shift to mandatory rebates in future.) AWP-11% None None $10.00 for generics and $25.00 for brand-name drugs $5.00 Maximum 3 prescriptions per month

DRUGS COVERAGE Formulary: Drugs Covered: Drug Coverage Restrictions:

*

Medicaid PDL Any FDA approved prescription medications No smoking cessation agents, hair growth products, anorexiant products, cosmetic agents (e.g., retin-A), weight gain agents (e.g., anabolic steroids), or fertility promotion agents. One month supply restriction.

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PROGRAM CONTACT Susan Malm Community and Family Health Division Hathaway Bldg, Rm 157 2300 Capitol Ave. Cheyenne, WY 82002

Phone: 307/777-5548 Fax: 307/777-6964

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Appendix A: State and Federal Medicaid Contacts

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STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2004 ALABAMA

CALIFORNIA

Louise F. Jones Director Pharmacy Services 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] Internet address: www.medicaid.state.al.us

J. Kevin Gorospe, Pharm.D. Chief, Pharmacy Policy Unit California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] Internet address: http://www.medi-cal.ca.gov

ALASKA COLORADO

Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected] Internet address: www.hss.state.ak.us/dhcs

Martha Warner Pharmacy Supervisor Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-3176 F: 303/866-2573 E-mail: [email protected] CONNECTICUT

ARIZONA

Evelyn A. Dudley Manager, Pharmacy Unit Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] Internet address: www.dss.state.ct.us

Dell Swan Pharmacy Program Administrator AHCCCS 701 East Jefferson Street MD 8000 Phoenix, AZ 85034 T: 612/417-4726 E-mail: [email protected] Internet address: www.ahcccs.state.az.us

DELAWARE

ARKANSAS

Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected] Internet address: www.dmap.state.de.us

Suzette Bridges, P.D., Administrator Pharmacy Program Department of Human Services Division of Medical Services P.O. Box 1437, Slot 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

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DISTRICT OF COLUMBIA

IDAHO

Cheryl S. Wilson Risk Manager – Pharmacy/DME Department of Health Medical Assistance Administration 825 North Capitol Street, NE, Suite 5135 Washington, DC 20002 T: 202/442-9078 F: 202/442-4790 E-mail: [email protected]

Ike Gayfield Bureau Chief – Acting Pharmacy Manager Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1829 F: 208/364-1864 E-mail: [email protected] Internet address: www.healthandwelfare.idaho.gov

FLORIDA ILLINOIS

Jerry F. Wells Bureau Chief Medicaid Pharmacy Services Agency for Healthcare Administration Services 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected] Internet address: www.ahca.myflorida.com

Pamela Bunch Medicaid Pharmacy Manager Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/524-7478 F: 217/524-7535 E-mail: [email protected] Internet address: www.dpaillinois.com

GEORGIA

INDIANA

Jerry L. Dubberly, R.Ph., M.B.A. Director, Pharmacy Services Department of Community Health Division of Medical Assistance 2 Peachtree Street, N.W., 37th Floor Atlanta, GA 30303-3159 T: 404/657-4044 F: 404/657-5461 E-mail: [email protected] Internet address: www.dch.state.ga.us

Marc Shirley, R.Ph. Pharmacist Office of Medicaid Policy and Planning Indiana State Government Center South-Rm. W382 402 West Washington Street Indianapolis, IN 46204-2739 T: 317/232-4343 F: 317/232-7382 E-mail: [email protected] Note: All requests for information by, or on behalf of drug manufacturers must be made ONLY to: [email protected]. Phone requests will not be accepted.

HAWAII Lynn S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kamokila Boulevard, Room 506B P.O. Box 700190 Honolulu, HI 96707 T: 808/692-8116 F: 808/692-8131 Internet address: www.med-quest.us

IOWA Susan L. Parker, Pharm.D. Pharmacy Consultant Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010 E-mail: [email protected] Internet address: www.iowamedicaidpdl.com

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KANSAS

MARYLAND

Mary H. Obley, Pharmacist Pharmacy Program Manager Health Care Policy Division Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected] Internet address: www.srskansas.org/hcp

Joseph L. Fine Director Maryland Pharmacy Program DHMH, Office of Operations and Eligibility, and Pharmacy 201 West Preston Street, Room 407 Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 E-mail: [email protected] Internet address: www.dhmh.state.md.us/mma/mpap

KENTUCKY

MASSACHUSETTS

Dan Yeager, R.Ph. Interim Pharmacy Director Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected]

Paul L. Jeffrey Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210/5865 E-mail: [email protected] Internet address: www.state.ma.us/dma

LOUISIANA Mary J. Terrebonne, Pharm.D. Pharmacy Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected] Internet address: www.lamedicaid.com

MICHIGAN Giovannino A. Perri, M.D. Chief Medical Consultant MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Internet address: www.michigan.gov/mdch

MAINE

MINNESOTA

Bruce McClanahan Pharmacy Unit Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 886/796-2463 F: 207/287-8601 E-mail: [email protected] Internet address: www.maine.gov/bms

Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet address: www.dhs.mn.us/provider/pharm

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MISSISSIPPI

NEVADA

Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: www.dom.state.ms.us

Dionne Coston, R.N. Medicaid Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected] Internet address: www.dhcfp.state.nv.us

MISSOURI

NEW HAMPSHIRE

George L. Oestreich, Pharm.D., M.P.A. Pharmacy Program Director Department of Social Services Division of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected] Internet address: www.dss.mo.gov/dms

Margaret A. Clifford Pharmacy Administrator Office of Medicaid Business and Policy 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4210 F: 603/271-8701 E-mail: [email protected] Internet address: www.dhhs.state.nh.us/DHHS/MEDICAIDPROGRAM/

MONTANA

NEW JERSEY

Dan Peterson Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau 1400 Broadway, P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected] Internet address: www.mtmedicaid.org

Joseph B. Martinez Chief, Pharmaceutical Services Department of Medical Assistance and Human Services Office of Utilization Management P.O. Box 712 Trenton, NJ 08619 T: 609/588-2774 F: 609/588-3889 E-mail: [email protected]

NEBRASKA

NEW MEXICO

Dyke Anderson, R.Ph. Pharmacy Consultant Department of Health and Human Services Finance and Support/Medicaid Division 301 Centennial Mall South, 5th Floor - NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected] Internet address: www.hhs.state.ne.us/med

Neal Solomon, M.P.H., R.Ph. Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3196 E-mail: [email protected]

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NEW YORK

OKLAHOMA

Mark-Richard Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Office of Medicaid Management Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Internet address: www.health.state.ny.us

Nancy Nesser, D.Ph., J.D. Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln Boulevard, Suite 124 Oklahoma City, OK 73105 T: 405/522-7325 F: 405/530-3235 E-mail: [email protected] Internet address: www.ohca.state.ok.us OREGON

NORTH CAROLINA

Thomas Drawbaugh Pharmacy Program Manager Department of Human Resources Office of Medical Assistance Programs 500 Summer Street, NE, E-35 Salem, OR 97301-1077 T: 503/945-6492 F: 503/373-7689 E-mail: [email protected] Internet address: www.dhs.state.or.us/healthplan

Tom D’Andrea, R.Ph., M.B.A. Chief of Pharmacy and Ancillary Services Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma

PENNSYLVANIA Terri Cathers Director of Pharmacy Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6195 F: 717/705-8391 E-mail: [email protected] Internet address: www.dpw.state.pa.us/omap

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected] Internet address: www.state.nd.us/humanservices

RHODE ISLAND Paula J. Avarista, R.Ph., M.B.A. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6836 E-mail: [email protected] Internet address: www.dhs.state.ri.us

OHIO Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad St., 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected] Internet address: www.jfs.ohio.gov

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SOUTH CAROLINA

UTAH

James M. Assey, R.Ph., Division Director Division of Pharmaceutical Services and DME 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] Internet address: www.dhhs.state.sc.us

RaeDell Ashley, R.Ph. Pharmacy Director Medicaid Program Division of Health Care Financing Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected] Internet address: www.health.utah.gov/medicaid

SOUTH DAKOTA Mark E. Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3498 F: 605/773-5246 E-mail: [email protected] Internet address: www.state.sd.us/social/medical/index.htm

VERMONT Ann E. Rugg Deputy Director Office of Vermont Health Access 312 Hurricane Lane, Suite 200 Williston, VT 05495 T: 802/879-5900 F: 802/879-5919 E-mail: [email protected] Internet address: www.OVHA.state.vt.us

TENNESSEE VIRGINIA

Jeffrey G. Stockard, D.Ph. Associate Pharmacy Director Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-3107 F: 615/253-5481 E-mail: [email protected] Internet address: www.tennessee.gov/tenncare

Javier Menendez, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-2196 F: 804/786-0973 E-mail: [email protected] Internet address: www.dmas.virginia.gov

TEXAS WASHINGTON

Barbara Dean, R.Ph. Acting Director, Vendor Drug Program Health and Human Services Commission Medicaid/CHIP Division 1100 W. 49th Street Austin, TX 78756 T: 512/491-1101 F: 512/491-1962 E-mail: [email protected] Internet address: www.hhsc.state.tx.us

Siri A. Childs, Pharm.D. Pharmacy Policy Manager Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/586-8827 E-mail: [email protected] Internet address: http://maa.dshs.wa.gov/pharmacy

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WEST VIRGINIA Peggy A. King, R.Ph. Director, Office of Pharmacy Services Department of Health and Human Resources Bureau for Medical Services 350 Capitol St., Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected] Internet address: www.wvhhhr.org/bms/pharmacy WISCONSIN Mark Moody Administrator Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-8922 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us WYOMING Antoinette K. Brown, R.Ph. Medicaid Pharmacist Department of Health-Pharmacy Unit 2300 Capitol Avenue, Suite 147 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 E-mail: [email protected] Internet address: www.pharmacy.state.wy.us

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NEW BRAND NAME PRODUCT CONTACT INFORMATION, 2004 ALABAMA

CALIFORNIA

Louise F. Jones Director Pharmacy Services 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]

J. Kevin Gorospe, Pharm.D. Chief, Pharmacy Policy Unit California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

ALASKA Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected]

COLORADO Martha Warner Pharmacy Supervisor Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-3176 F: 303/866-2573 E-mail: [email protected]

ARIZONA Contact health plans directly.

CONNECTICUT Evelyn A. Dudley Manager, Pharmacy Unit Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected]

ARKANSAS Suzette Bridges, P.D., Administrator Pharmacy Program Department of Human Services Division of Medical Services P.O. Box 1437, Slot S 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

DELAWARE Joli Martini Pharmacist Consultant – Clinical Reviews DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

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DISTRICT OF COLUMBIA Cheryl S. Wilson Risk Manager – Pharmacy/DME Department of Health Medical Assistance Administration 825 North Capitol Street, NE Suite 5135 Washington, DC 20002 T: 202/442-9078 F: 202/442-4790 E-mail: [email protected]

IDAHO Mary Wheatley, R.Ph. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1832 F: 208/364-1864 E-mail: [email protected]

FLORIDA

ILLINOIS

Jerry F. Wells Bureau Chief Medicaid Pharmacy Services 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]

Lisa Voils Special Assistant to the Medicaid Deputy Adminstrator Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/782-2570 F: 217/782-5672 E-mail: [email protected]

GEORGIA

INDIANA

Etta L. Hawkins, R.Ph. Medicaid Program Pharmacy Manager Department of Community Health Division of Medical Assistance 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303-3159 T: 404/657-4044 F: 404/657-5461 E-mail: [email protected]

Marc Shirley, R.Ph. Pharmacist Office of Medicaid Policy and Planning Room W382 Indiana State Government Center South 402 West Washington Street Indianapolis, IN 46204-2739 T: 317/232-4343 F: 317/232-7382 Note: All manufacturer inquiries and/or submissions must be in electronic format and sent to [email protected]. Paper copies will not be accepted and should not be mailed to any of the involved parties, including OMPP, ACS, or the Therapeutic Committee. Visit: http://indianapbm.com/downloads/Tcommitte%20PDL%20submission%20Form1-5-04.pdf for necessary forms.

HAWAII Lynn S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kamokila Boulevard, Suite 506B Kapolei, HI 96707 T: 808/692-8116 F: 808/692-8131

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IOWA

MAINE

Susan L. Parker, Pharm.D. Pharmacy Consultant Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010 E-mail: [email protected].

Bruce McClanahan Pharmacy Unit Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 886/796-2463 F: 207/287-8601 E-mail: [email protected]

KANSAS MARYLAND

Mary H. Obley Pharmacist Pharmacy Program Manager Health Care Policy Division Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785-296-3981 F: 785/296-4813 E-mail: [email protected]

Frank Tetkoski, P.D Pharmacist Consultant Maryland Pharmacy Program DHMH Division of Pharmacy Services 201 W. Preston Street, Room 409 Baltimore, MD 21201 T: 410/767-1460 F: 410/333-5398 E-mail: [email protected]

KENTUCKY

MASSASCHUSETTS

Debra Bahr, R.Ph. Pharmacy Services Program Manager Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected]

Christopher T. Burke Policy Analyst Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5592 F: 617/210-5597 E-mail: [email protected] MICHIGAN

LOUISIANA

Donna Hammel Office of Medical Affairs MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]

Mary J. Terrebonne, Pharm.D. Pharmacy Director Department of Health & Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected]

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MINNESOTA

NEBRASKA

Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected]

Dyke Anderson, R.Ph Pharmacy Consultant Department of Health and Human Services Finance and Support/Medicaid Division 301 Centennial Mall South 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected]

MISSISSIPPI Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected]

NEVADA Dionne Coston, R.N. Medical Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected]

MISSOURI Rhonda A. Driver Clinical Pharmacist Department of Social Services Division of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102- 6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected]

NEW HAMPSHIRE Lisè C. Farrand, R.Ph. Pharmaceutical Services Specialist Office of Medicaid Business and Policy 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected]

MONTANA Dan Peterson Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau 1400 Broadway P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected]

NEW JERSEY Joseph B. Martinez Chief, Pharmaceutical Services Department of Medical Assistance and Human Services Office of Utilization Management P.O. Box 712 Trenton, NJ 08619 T: 609/588-2774 F: 609/588-3889 E-mail: [email protected]

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NEW MEXICO

OHIO

Neal Solomon, M.P.H., R.Ph. Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3196 E-mail: [email protected]

Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

NEW YORK

OKLAHOMA

Mark-Richard A. Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Office of Medicaid Management Department of Health 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]

Rodney Ramsey Drug Reference Coordinator Oklahoma Health Care Authority 4545 North Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7492 F: 405/530-7119 E-mail: [email protected]

OREGON NORTH CAROLINA

Kathy L. Ketchum, R.Ph., M.P.A.-H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected]

Tom D’Andrea, R.Ph., M.B.A. Chief of Pharmacy and Ancillary Services Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive, 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected]

PENNSYLVANIA Terri Cathers Director of Pharmacy Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6195 F: 717/705-8391 E-mail: [email protected]

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

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RHODE ISLAND

TEXAS

Paula J. Avarista, R.Ph., M.B.A. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6836 E-mail: [email protected]

Martha McNeil, R.Ph. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected]

SOUTH CAROLINA

UTAH

James M. Assey, R.Ph., Division Director Division of Pharmaceutical Services and DME Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected]

RaeDell Ashley, R.Ph. Pharmacy Director Medicaid Program Division of Health Care Financing Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected]

SOUTH DAKOTA Mark E. Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3498 F: 605/773-5246 E-mail: [email protected]

VERMONT Felicia Montineri Clinical Pharmacist First Health Services Corporation 312 Hurricane Lane, Suite 200 Williston, VT 05495 T: 802/879-5900 F: 802/879-5919 E-mail: [email protected]

TENNESSEE Jeffrey G. Stockard, D.Ph. Associate Pharmacy Director Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-3107 F: 615/253-5481 E-mail: [email protected]

VIRGINIA Keith T. Hayashi Pharmacist I Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/225-2773 F: 804/786-0973 E-mail: [email protected]

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Pharmaceutical Benefits 2004

WASHINGTON Siri A. Childs, Pharm D. Pharmacy Policy Manager Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/586-8827 E-mail: [email protected]

WEST VIRGINIA Peggy A. King, R.Ph. Director, Office of Pharmacy Services Department of Health and Human Resources Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected]

WISCONSIN Carol Neeno Pharmacy Assistant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1203 F: 608/267-3380 E-mail: [email protected]

WYOMING Antoinette K. Brown, R.Ph. Medicaid Pharmacist Department of Health Pharmacy Unit 2300 Capitol Avenue, Suite 147 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 E-mail: [email protected]

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Pharmaceutical Benefits 2004

DUR CONTACT INFORMATION, 2004

ALABAMA Contracted DUR

ALASKA In-House DUR

ARIZONA DUR is conducted at the plan level.

ARKANSAS Contracted DUR

State Contact Louise F. Jones, Director Pharmacy Services 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]

Contractor Health Information Designs

State Contact Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected] Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. State Contact Pamela Ford, P.D. Pharmacist II Arkansas Department of Human Services Division of Medical Services Pharmacy Program P.O. Box 1437, Slot 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

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Contractor Cherly Avants Director, Retrospective DUR Health Information Design 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Contractor Not Available

CALIFORNIA Contracted DUR

State Contact Ellis Ellis, Pharm.D. Pharmaceutical Consultant II California Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

Contractor Catherine Traugott Pharmacist

COLORADO Contracted DUR

State Contact Catherine Traugott Pharmacist Deptartment of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: [email protected]

CONNECTICUT Contracted DUR

State Contact James R. Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services Medical Operations Unit 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

Contractor Michelle Laster-Bradley Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 866/246-8510 E-mail: [email protected]

DELAWARE Contracted DUR

State Contact Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

Contractor Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS

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Pharmaceutical Benefits 2004

DISTRICT OF COLUMBIA Contracted DUR

State Contact Christopher A. Keeys, Pharm.D., R.Ph. Chairman Clinical Pharmacy Associates, Inc. 316 Talbott Avenue Laurel, MD 20707 T: 301/617-0555 F: 301/617-0225 E-mail: [email protected]

Contractor Jeffrey Dzieweczynski, R.Ph., M.S. ACS State Healthcare 750 First Street, NE Washington, DC 20002 T: 202/906-8353 F: 202/906-8399 E-mail: [email protected] Contractor Heritage Information Systems

FLORIDA Contracted DUR

State Contact Linda G. Barnes 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]

GEORGIA In-House DUR

State Contact Patricia Zeigler Jeter, R.Ph., M.P.A. DUR Coordinator-Rebate Pharmacist Department of Community Health Division of Medical Assistance 2 Peachtree St. NW, 37th Floor Atlanta, GA 30303-3159 T: 404/657-9181 F: 404/657-5461 E-mail: [email protected]

HAWAII In-House DUR

State Contact Kathleen Kang-Kaulupali Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kamokila Boulevard, Room 506-B Kapolei, HI 90707 T: 808/692-8065 F: 808/692-8131

IDAHO Contracted DUR

State Contact Tamara Eide, Pharm.D., BCPS, FASHP Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1821 F: 208/364-1864 E-mail: [email protected]

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Contractor Idaho Drug Utilization Review Idaho State U. - College of Pharmacy 970 South 5th Street Campus Box 8288 Pocatello, ID 83209-8288 T: 208/282-4597

National Pharmaceutical Council

Pharmaceutical Benefits 2004

ILLINOIS In-House DUR

State Contact Pamela Bunch Medicaid Pharmacy Manager Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/524-7478 F: 217/524-7535 E-mail: [email protected]

INDIANA Contracted DUR

State Contact DUR Board Secretary Office of Medicaid Policy and Planning Indiana State Government Center South-Room W382 402 West Washington Street Indianapolis, IN 46204 T: 317/232-4307 F: 317/232-7382

Contractor ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 866/759-4100

IOWA Contracted DUR

State Contact Julie Kuhle, R.Ph. Project Coordinator Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010

Contractor Julie Kuhle, R.Ph. Project Coordinator Iowa Medicaid Enterprise

KANSAS Contracted DUR

State Contact Vicki L. Schmidt Pharmacist Health Care Policy Division Kansas Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harris, Room 651-South Topeka, KS 66612-1570 T: 785/274-4287 F: 785/296-4813 E-mail: [email protected]

Contractor Heritage Information Systems, Inc. 2810 N. Parham Road Suite 210 Richmond, VA 23294 T: 804/644-8707

KENTUCKY In-House DUR

State Contact Debra Bahr, R.Ph. Pharmacy Services Program Manager Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected]

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Pharmaceutical Benefits 2004

LOUISIANA Contracted DUR

State Contact Mary J. Terrebonne, Pharm.D. Pharmacy Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected]

Contractor Shelly Delaville Pharmacist Unisys 8591 United Plaza Blvd., Ste.300 Baton Rouge, LA 70809 T: 225/237-3227 F: 225/237-3334 E-mail: [email protected]

Contractor Not Available

MAINE Contracted DUR

State Contact Bruce McClanahan Pharmacy Unit Manager 442 Civic Center Drive 11SHS, DHS – Bureau of Medical Services Augusta, ME 04333 T: 886/796-2463 F: 207/287-8601 E-mail: [email protected]

Contractor Health Information Design

MARYLAND Contracted DUR

State Contact Jeffrey Gruel Deputy Director Maryland Pharmacy Program DHMH Division of Pharmacy Services 201 W. Preston St., Room 408 Baltimore, MD 21201 T: 410/787-1455 F: 410/333-5398 E-mail: [email protected]

Contractor Paul L. Jeffrey Director of Pharmacy

MASSACHUSETTS Contracted DUR

State Contact Paul L. Jeffrey Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210-5865 E-mail: [email protected]

MICHIGAN Contracted DUR

State Contact Debera Eggleston, M.D. MDCH/Medical Services Administration 400 S. Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]

Contractor First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696

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Pharmaceutical Benefits 2004

MINNESOTA In-House DUR

State Contact Mary Beth Reinke, Pharm.D., M.S.A. DUR Coordinator Minnesota Dept. of Human Services 444 Lafayette Rd. North St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected]

MISSISSIPPI Contracted DUR

State Contact Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Ste. 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected]

MISSOURI In-House DUR

State Contact Tisha A. Pomering DUR Coordinator Div. of Medical Services 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected]

MONTANA Contracted DUR

State Contact Mark Eichler, R.Ph., FASCP Pharmacy Programs Director Mountain-Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 T: 406/457-5818 F: 406/443-7014 E-mail: [email protected]

Contractor Mark Eichler, R.Ph. Mountain-Pacific Quality Health Foundation

NEBRASKA Contracted DUR

State Contact Beth Wilson DUR Director Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

Contractor Beth Wilson DUR Director Nebraska Pharmacists Association

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Contractor Sam Warman, R.Ph. Project Manager Heritage Information Design P.O. Box 320506 Flowood, MS 39232 T: 601/709-0000 F: 800/459-2135 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEVADA Contracted DUR

State Contact Dionne Coston, R.N. Medical Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected]

Contractor Steve Espy, R.Ph. Director of Drug Utilization Health Info. Design, Inc. 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531

NEW HAMPSHIRE Contracted DUR

State Contact Robert Coppola Clinical Manager First Health Services Corp. 17 Chennell Drive Concord, NH 03301 T: 603/224-2083 F: 603/224-6690 E-mail: [email protected]

Contractor Robert Coppola Clinical Manager First Health Services Corp.

NEW JERSEY In-House DUR

State Contact Kaye S. Morrow Assistant Director Department of Medical Assistance and Human Services Office of Provider Relations P.O Box 712 Trenton, NJ 08619 T: 609/631-2396 F: 609/588-3889 E-mail: [email protected]

NEW MEXICO In-House DUR

State Contact Neal Solomon, M.P.H., R. Ph. Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Sante Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3196 E-mail: [email protected]

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NEW YORK In-House DUR

State Contact Lydia J. Kosinski, R.Ph., Manager Recipient Activities and Utilization Review Office of Medicaid Management NYS Dept. of Health 800 North Pearl Street Albany, NY 12204 T: 518/474-6866 F: 518/473-5332 E-mail: [email protected]

NORTH CAROLINA Contacted DUR

State Contact Melissa Weeks, R.Ph., Pharm.D. Department of Human Resources Division of Medical Assistance 1985 Umstead Drive 2501 Mail Services Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected]

NORTH DAKOTA In-House DUR

State Contact Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services North Dakota Department of Human Services 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

OHIO In-House and Contracted DUR

State Contact Jeff Corzine DUR Administrator 255 East Main Street Columbus, OH 43215 T: 614/466-9689 F: 614/466-2866

Contractor First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7696

OKLAHOMA Contracted DUR

State Contact Ronald Graham, D.Ph. Manager, Operations/DUR University of Oklahoma College of Pharmacy P.O. Box 26801 Oklahoma City, OK 73109 T: 405/271-6614 F: 405/271-2615 E-mail: [email protected]

Contractor Ronald Graham, D.Ph. Manager, Operations/DUR University of Oklahoma College of Pharmacy

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Contractor UNC-Chapel Hill Office of Sponsored Research Administrative Office Building 104 Airport Drive Chapel Hill, NC 27599

National Pharmaceutical Council

Pharmaceutical Benefits 2004

OREGON Contracted DUR

State Contact Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected]

Contractor Jim Rowland Account Manager First Health Services Corporation 925 Commercial Street SE Salem, OR 97302 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected] Contractor EDS

PENNSYLVANIA Contracted DUR

State Contact Terri Cathers Director of Pharmacy Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6195 F: 717/705-8391 E-mail: [email protected]

Contractor Not Available

RHODE ISLAND Contracted DUR

State Contact Paula J. Avarista, R.Ph., M.B.A. Chief of Pharmacy Departrment of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6836 E-mail: [email protected]

SOUTH CAROLINA In-House and Contracted DUR

State Contact Caroline Y. Sojourner, R.Ph. Deptartment Head, Pharmacy Services Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected]

Contractor First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/273-6961

SOUTH DAKOTA In-House DUR

State Contact Teddi Martell Rebate Coordinator Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3653 E-mail: [email protected]

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National Pharmaceutical Council

TENNESSEE Contracted DUR

Pharmaceutical Benefits 2004

State Contact Jeffery G. Stockard, D.Ph. Associate Pharmacy Director Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-3107 F: 615/253-5481 E-mail: [email protected]

Contractor First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/273-6961

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

TEXAS In-House DUR

State Contact Barbara Dean, R.Ph. Acting Director, Vendor Drug Program Texas Health and Human Services Commision 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1101 F: 512/491-1962 E-mail: [email protected]

UTAH In-House DUR

State Contact Duane Parke DUR Director Medicaid Program Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6452 F: 801/538-6099 E-mail: [email protected]

VERMONT Contracted DUR

State Contact Felicia Montineri Clinical Pharmacist First Health Services Corporation 312 Hurricane Lane, Suite 200 Williston, VT 05495 T: 802/879-5900 F: 802/879-5919 E-mail: [email protected]

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Contractor Felicia Montineri Clinical Pharmacist First Health Services Corporation

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Contractor Donna Johnson Clinical Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/290-4833 E-mail: [email protected]

VIRGINIA Contracted DUR

State Contact Rachel E. Cain Pharmacist I Deparment of Medical Asistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/783-2873 F: 804/786-0973 E-mail: [email protected]

WASHINGTON In-House DUR

State Contact Nicole N. Nguyen, Pharm.D. Clinical Pharmacist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1757 F: 360/586-8827 E-mail: [email protected]

WEST VIRGINIA Contracted DUR

State Contact Vicki M. Cunningham, R.Ph. DUR Coordinator Department of Health and Human Services Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-6541 F: 304/558-1542 E-mail: [email protected]

Contractor Craig Boon, Director Account Management ACS-Heritage Information Systems 2810 N. Parham Road, Suite 210 Richmond, VA 23294 T: 804/644-8707 F: 804/644-0644 E-mail: [email protected]

State Contact Michael Mergener, R.Ph., Ph.D. Chief Pharmacist APS Healthcare 10 East Doty St., Suite 210 Madison, WI 53703 T: 608/258-3348 F: 608/258-3359 E-mail: mergema.state.wi.us

Contractor Michael Mergener, R.Ph. Ph.D. Chief Pharmacist APS Healthcare

State Contact Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071 T: 307/766-6750 F: 307/766-2953 E-mail: [email protected]

Contractor Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy

WISCONSIN Contracted DUR

WYOMING Contracted DUR

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Pharmaceutical Benefits 2004

CLAIMS SUBMISSION CONTACTS, 2004 COLORADO

ALABAMA

ACS State Healthcare 600 17th Street Suite 600 North Denver, CO 80202 T: 800/237-0757 F: 303/534-0439

Cyndi Crockett Supervisor EDS 301 Technacenter Dr. Montgomery, AL 36117 T: 334/215-0111

CONNECTICUT

ALASKA

Ellen Arce, R.Ph. Pharmacy Manager EDS 1000 Stanley Drive New Britain, CT 06053 T: 860/832-5885 F: 860/832-5921 E-mail: [email protected]

Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 901/561-1684 E-mail: [email protected]

DELAWARE

ARIZONA

Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Rd, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

Dell Swan Pharmacy Program Administrator AHCCCS 701 East Jefferson Street MD 8000 Phoenix, AZ 85034 T: 612/417-4726 E-mail: [email protected]

DISTRICT OF COLUMBIA

ARKANSAS

Jacqueline Bonner Clinical Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/273-6961 E-mail: [email protected]

John Herzog Account Manager EDS 500 President Clinton Ave., Suite 400 Little Rock, AR 72201 T: 501/374-6608 F: 501/372-2971 E-mail: [email protected] CALIFORNIA EDS P.O. Box 13029 Sacramento, CA 95813-4029 T: 916/636-1000

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FLORIDA

INDIANA

Kevin Whittington Clinical Program Coordinator ACS State Healthcare 9040 Roswell Road Roswell, GA T: 850/201-1418

ACS State Healthcare 365 Northridge Rd., Suite 400 Atlanta, GA 30350 T: 866-322-5960 F: 866/759-4100 IOWA

GEORGIA

Patrick Danlen POS Account Manager Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010

Mary K. Kruchten Senior Account Manager Express Scripts, Inc. 6625 W. 78th St., BL-0440 Bloomington, MN 55439 T: 952/837-7401 F: 952/837-7184 E-mail: [email protected]

KANSAS EDS 3600 SW Topeka Boulevard Suite 204 Topeka, KS 66611 T: 785/274-4200 F: 785/267-7687

HAWAII Becky Garrigan Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 Attn: Hawaii Medicaid T: 866/322-5960 F: 866/759-4100

KENTUCKY Unisys Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

IDAHO EDS P.O. Box 23 Boise, ID 83707 T: 208/395-2000 F: 208/395-2030

LOUISIANA Doug Hasty Project Manager Unisys 8591 United Plaza Blvd., Ste. 300 Baton Rouge, LA 70809 T: 225/237-3391 F: 225/237-3334 E-mail: [email protected]

ILLINOIS Illinois Dept. of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/782-2570 F: 217/782-5672 E-mail: [email protected]

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MAINE

MISSISSIPPI

Marcia Pykare Manager of Data Processing Goold Health Systems P.O. Box 1090 Augusta, ME 04332-1090 T: 207/622-7153 F: 207/623-5125 E-mail: [email protected]

Robert Reedy, C.Ph.T. PBM Account Manager ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/296-2936 F: 601/296-3119 E-mail: [email protected]

MARYLAND

MISSOURI

James Demery Manager, Pharmacy Services First Health Services Corporation Division of Claims Processing 201 W. Preston St. Baltimore, MD 21201 T: 401/767-6028 F: 410/333-5398 E-mail: [email protected]

Diane Twehous Account Manager Infocrossing Health Care Services, Inc. 905 Weathered Rock Rd. Jefferson City, MO 65109 T: 573/635-2434 MONTANA Brett Jakovac Executive Account Manager ACS State Healthcare 34 N. Last Chance Gulch, Suite 200 Helena, MT 59601 T: 406/457-9555 F: 406/442-2819 E-mail: [email protected]

MASSACHUSETTS ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 800/358-2381 F: 770/730-5198

NEBRASKA MICHIGAN

Barbara Pavolony Account Manager ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8536 F: 770/730-5198 E-mail: [email protected]

First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696 MINNESOTA Dwaine Voas MMIS Unit Supervisor Minnesota Dept. of Human Services 800 Minnehaha Avenue St. Paul, MN 51555

NEVADA First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-3238

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NEW HAMPSHIRE

NORTH DAKOTA

Sherrill Bryant Plan Administrator First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]

Brendan K. Joyce, Pharm. D., R.Ph. Administrator, Pharmacy Services North Dakota Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

NEW JERSEY OHIO

Edward J. Vaccaro, R.Ph. Assistant Director Office of Utilization Management Department of Medical Assistance and Human Services P.O. Box 712 Trenton, NJ 08619 T: 609/588-3475 F: 609/588-3889 E-mail: [email protected]

First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7696 OKLAHOMA EDS 2401 N.W. 23rd Street, Suite 11 Oklahoma City, OK 73107 T: 405/416-6794

NEW MEXICO ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8592 F: 770/730-5198

OREGON Jim Rowland Account Manager First Health Services Corporation 925 Commercial Street SE Salem, OR 97302 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

NEW YORK eMedNY Computer Sciences Corporation Attn: eMedNY Webmaster One CSC Way Rensselaer, NY 12144 T: 800/343-9000 E-mail: [email protected]

PENNSYLVANIA EDS 275 Grandview Avenue Camp Hill, PA 17011

NORTH CAROLINA

(All contacts with contractor must be made through State agency.)

Sharon Greeson, R.Ph. Pharmacy Program Manager EDS 4905 Waters Edge Dr. Raleigh, NC 27606 T: 919/816-4475 F: 919/816-4399 E-mail: [email protected]

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RHODE ISLAND

UTAH

EDS 1471 Elmwood Avenue Cranston, RI 02910 T: 401/784-3879

Connie Higley Information Technology Director Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6136 F: 801-538-6099 E-mail: [email protected]

SOUTH CAROLINA Rod Davis Deputy Director of Information Technology S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2610 E-mail: [email protected]

VERMONT First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7717

SOUTH DAKOTA Meredith Heerman Claims Processing Administrator Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

VIRGINIA Frank Fury Processing Administrator First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7400

TENNESSEE

WASHINGTON

Maria P. Hogan Plan Administrator First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7400 E-mail: [email protected]

Chris Johnson Claims Processing Manager Medical Assistance Administrator, DSHS P.O. Box 45509 Olympia, WA 98504-5509 T: 360/725-1239 E-mail: [email protected]

TEXAS

WEST VIRGINIA

Barbara Dean, R.Ph. Acting Director Vendor Drug Program Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78756 T: 512/491-1101 F: 512/491-1962 E-mail: [email protected]

Heather Bodiford PBM Account Manager ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 770/730-5198 E-mail: [email protected]

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Pharmaceutical Benefits 2004

WISCONSIN Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567 WYOMING ACS State Healthcare Northridge Center One, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459

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PRESCRIPTION PRICE UPDATING CONTACTS, 2004 ALABAMA

COLORADO

Allyn Williford Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5034 F: 334/353-7014

Martha Warner Pharmacy Supervisor Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-3176 F: 303/866-2573 E-mail: [email protected]

ALASKA CONNECTICUT

Dave Campana, R.Ph. Pharmacy Program Manager Division of Health Care Services 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/273-3224 F: 907/561-1684 E-mail: [email protected]

Ellen Arce, R.Ph. Pharmacy Manager EDS 1000 Stanley Drive New Britain, CT 06053 T: 860/832-5885 F: 860/832-5921 E-mail: [email protected]

ARIZONA DELAWARE

Dell Swan Pharmacy Program Administrator AHCCCS 701 East Jefferson Street MD 8000 Phoenix, AZ 85034 T: 612/417-4726 E-mail: [email protected]

Cynthia R. Denemark, R.Ph. Director of Pharmacy Services 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

ARKANSAS

DISTRICT OF COLUMBIA

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

Christine Quinn Account Manager ACS State Healthcare 750 First Street, NE Washingotn, DC 20002 T: 202/906-8304 F: 202/906-8378 E-mail: [email protected]

F: 650/588-4003

CALIFORNIA EDS Federal Corporation P.O. Box 13029 Sacramento, CA 95813-4029 T: 916/636-1000

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FLORIDA

INDIANA

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

GEORGIA

IOWA

Manny Conduah, Pharm.D. Clinical Program Manager Express Scripts, Inc. 300 Colonial Center Parkway Roswell, GA 30076 T: 770/552-3793 F: 770/992-8949 E-mail: [email protected]

Patrick Danlen POS Account Manager Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010 KANSAS

HAWAII

Mary H. Obley Pharmacist Pharmacy Program Manager Health Care Policy Division Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected]

ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 Attn: Hawaii Medicaid T: 800/358-2381 F: 770/730-5198 IDAHO Katie Ayad, C.Ph.T. Technical Records II Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1970 F: 208/364-1864 E-mail: [email protected]

KENTUCKY Unisys Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

ILLINOIS

LOUISIANA

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

Maggie Vick Unisys 8591 United Plaza Blvd., Ste. 300 Baton Rouge, LA 70809 T: 225/237-3251 F: 225/237-3334 E-mail: [email protected]

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MAINE

MISSISSIPPI

Bruce McClanahan Pharmacy Unit Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 886/796-2463 F: 207/287-8601 E-mail: [email protected] Internet address: www.maine.gov/bms

Terri R. Kirby, R.Ph. Pharmacist Division of Medicaid Robert E. Lee Building 239 North Lamar St., Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] MISSOURI

MARYLAND

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4510

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578

MONTANA MASSACHUSETTS

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEBRASKA MICHIGAN

Dyke Anderson, R.Ph. Pharmacy Consultant Department of Health and Human Services Finance and Support/Medicaid Division 301 Centennial Mall South, 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected]

First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696 MINNESOTA First DataBank 1111 Bay Hill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

NEVADA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

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Pharmaceutical Benefits 2004

NEW HAMPSHIRE NORTH DAKOTA

Sherrill Bryant Plan Administrator First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]

Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services North Dakota Department of Human Services 600 East Boulevard Avenue Dept. 325 Bismark, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

NEW JERSEY First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

OHIO First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEW MEXICO First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453

OKLAHOMA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453

NEW YORK Carl T. Cioppa, Pharm.D. Pharmacy Operations Manager Department of Health Office of Medicaid Management 99 Washington Avenue Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]

OREGON Jim Rowland Account Manager First Health Sevices Corporation 925 Commercial Street SE Salem, OR 97302 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

NORTH CAROLINA PENNSYLVANIA

Tom D’Andrea, R.Ph., M.B.A. Chief of Pharmacy and Ancillary Services Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected]

First DataBank, Inc. 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453

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Pharmaceutical Benefits 2004

RHODE ISLAND

UTAH

Paula J. Avarista, R.Ph., M.B.A. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02919 T: 401/462-6390 F: 401/462-6836 E-mail: [email protected]

RaeDell Ashley, R.Ph. Pharmacy Director Medicaid Program Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected]

SOUTH CAROLINA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

VERMONT Cathy England, Manager Rebate Administration First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7717

SOUTH DAKOTA Mark E. Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3498 F: 605/773-5246 E-mail: [email protected]

VIRGINIA Keith T. Hayashi Pharmacist I Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/225-2773 F: 804/786-0973 E-mail: [email protected]

TENNESSEE First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588/6867

WASHINGTON Tom Zuchlewski Pharmacy Rates Manager Medical Assistance Administration, DSHS P.O. Box 45510 Olympia, WA 98504-5510 T: 360/725-1837 F: 360/753-9152 E-mail: [email protected]

TEXAS Martha McNeill, R.Ph. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected]

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Pharmaceutical Benefits 2004

WEST VIRGINIA Heather Bodiford PBM Account Manager ACS State Healthcare 365 Northridge Road Northridge Center, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 770/730-5198 E-mail: [email protected] WISCONSIN First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453 F: 650/588-6867 WYOMING First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453 F: 650/588-4003

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Pharmaceutical Benefits 2004

MEDICAID DRUG REBATE CONTACTS, 2004 ALABAMA CALIFORNIA

Cyndi Crocket, Supervisor EDS 301 Technacenter Drive Montgomery, AL 36117 T: 334/215-0111

Craig Miller Chief, Drug Rebate and Vision Section Department of Health Services Medi-Cal Policy Division Pharmacy Contracting and Policy Section 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

ALASKA Amanda Burger Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2409 F: 907/561-1684 E-mail: [email protected]

COLORADO Vince Sherry Drug Rebate Manager Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-5408 F: 303/866-2573 E-mail: [email protected]

ARIZONA Dell Swan Pharmacy Program Administrator AHCCCS 701 East Jefferson Street MD 8000 Phoenix, AZ 85034 T: 612/417-4726 E-mail: [email protected]

CONNECTICUT Afrika Hinds-Ayala Health Program Associate Department of Social Services Medical Operations Unit #4 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

ARKANSAS Suzette Bridges, P.D., Administrator Pharmacy Program Department of Human Services Division of Medical Services Pharmacy Program P.O. Box 1437, Slot 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

DELAWARE Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

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Pharmaceutical Benefits 2004

DISTRICT OF COLUMBIA

IDAHO

Jeffrey Dzieweczynski, R.Ph., M.S. ACS State Healthcare 750 First Street, NE Washington, DC 20002 T: 202/906-8353 F: 202/906-8399 E-mail: [email protected]

Mary Wheatley, R.Ph. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1832 F: 208/364-1864 E-mail: [email protected]

FLORIDA Regina Wiggins Rebate Coordinator Agency for Health Care Administration 2727 Mahan Dr., MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected]

ILLINOIS Bradley Wallner, Chief Bureau of Budget and Cash Management Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62702 T: 217/524-7161 F: 217/785-4174 E-mail: [email protected]

GEORGIA Patricia Zeigler Jeter, M.P.A., R.Ph. DUR Coordinator-Rebate Pharmacist Department of Community Health Division of Medical Assistance 2 Peachtree St., NW, 37th Floor Atlanta, GA 30303-3159 T: 404/657-9181 F: 404/657-5461 E-mail: [email protected]

INDIANA Martha Kessenich Rebate Accounting Manager ACS State Healthcare 365 Northridge Rd., Suite 400 Atlanta, GA 30350 T: 770/730-3292 F: 866/759-4100 E-mail: [email protected]

HAWAII IOWA

Martha Kessenich Drug Rebate Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 Attn: Hawaii Medicaid T: 800/358-2381 F: 770/730-5198 E-mail: [email protected]

Patrick Danlen POS Account Manager Iowa Medicaid Enterprise 100 Army Post Road Des Moines, IA 50315 T: 515/725-1226 F: 515/725-1010

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

KANSAS

MARYLAND

Mary H. Obley Pharmacist Pharmacy Program Manager Health Care Policy Division Dept. of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected]

Barry Pope Rebate Pharmacist First Health Services Corporation Montgomery Park Business Center 1800 Washington Boulevard, Suite 420 Baltimore, MD 21230 T: 410/263-7048 F: 410/263-7062 MASSACHUSETTS Martha Kessenich Rebate Analyst ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 800/358-2381 F: 770/730-5198 E-mail: [email protected]

KENTUCKY Betsy Scott Department for Medicaid Services CHR Building, 6 E-B 275 E. Main Street Frankfort, KY 40621 T: 502/564-5472 F: 502/564-0223 E-mail: [email protected]

MICHIGAN Dawn Parsons Pharmacy Consultant MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]

LOUISIANA Timothy T. Williams Health Services Financing Program Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-5194 F: 225/342-1980 E-mail: [email protected]

MINNESOTA Jarvis P. Jackson, R.Ph. Drug Rebate Coordinator Department of Human Services 444 Lafayette Rd. North St. Paul, MN 55155-3853 T: 651/282-5881 F: 651/282-6744 E-mail: [email protected]

MAINE Rossi Rowe Insurance Recovery/ Drug Rebate Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1838 F: 207/287-1788 E-mail: [email protected]

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Pharmaceutical Benefits 2004

NEVADA

MISSISSIPPI

Dionne Coston, R.N. Medicaid Services Specialist Nevada Medicaid Office Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected]

Robert Reedy, C.Ph.T. DRAMS Business Analyst ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/206-2936 F: 601/206-3119 E-mail: [email protected] MISSOURI

NEW HAMPHSHIRE

Vickie L. Harper Medicaid Unit Supervisor Division of Medical Services Drug Rebate Unit 2023 St. Mary’s Boulevard P.O. Box 6500 Jefferson City, MO 65102 T: 573/526-5664 F: 573/522-4650 E-mail: [email protected]

John Cox Rebate Pharmacist First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected] NEW JERSEY

MONTANA

Joseph B. Martinez, R.Ph. Chief, Pharmaceutical Services Department of Medical Assistance and Human Services Office of Utilization Management P.O. Box 712 Trenton, NJ 08619 T: 609/588-2774 F: 609/588-3889 E-mail: [email protected]

Betty DeVaney Drug Rebate Coordinator Dept. of Public Health and Human Services Medicaid Services Bureau 1400 Broadway P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-3457 F: 406/444-1861 E-mail: [email protected]

NEW MEXICO NEBRASKA

Sherry Montoya, Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7777 F: 505/827-3196 E-mail: [email protected]

Karen Jaques Accountant II HHSS-Finance and Support 301 Centennial Mall South NSOB, 5th Floor P.O. Box 95026 Lincoln, NE 68509-5026 F: 402/471-9397 E-mail: [email protected]

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NEW YORK

OKLAHOMA

Mark-Richard A. Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Office of Medicaid Management Department of Health 99 Washington Ave. Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]

Tom Simonson Drug Rebate Manager Oklahoma Health Care Authority 4545 N. Lincoln Blvd, Suite 124 Oklahoma City, OK 73105 T: 405/522-7327 F: 405/522-3236 E-mail: [email protected] OREGON

NORTH CAROLINA

Jim Rowland Account Manager First Health Sevices Corporation 925 Commercial Street SE Salem, OR 97302 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

Tom D’Andrea, R.Ph., M.B.A. Chief of Pharmacy and Ancillary Services Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699 T: 919/855-4300 F: 919/715-1255 E-mail: [email protected]

PENNSYLVANIA Terri Cathers Director of Pharmacy Department of Public Welfare P.O. Box 2675 Harrisburg, PA 17105 T: 717/772-6195 F: 717/705-8391 E-mail: [email protected]

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Ave. Department 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

RHODE ISLAND Helen Vaughn Analyst EDS 1471 Elmwood Avenue Cranston, RI 02910 T: 401/784-3879

OHIO Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

SOUTH CAROLINA Caroline Y. Sojurner, R.Ph. Department Head Department of Pharmacy Services Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected]

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Pharmaceutical Benefits 2004

SOUTH DAKOTA

VIRGINIA

Helen Rokusek Rebate Coordinator Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3653

Keith T. Hayashi, Pharmacist I Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/225-2773 F: 804/786-0973 E-mail: [email protected]

TENNESSEE WASHINGTON

Sybil Creekmore Accounting Manager Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0018 F: 615/532-3479 E-mail: [email protected]

Connie Riddle Medical Assistance Administration, DSHS P.O. Box 45503 Lacey, WA 98504-5503 T: 360/725-1243 E-mail: [email protected] WEST VIRGINIA

TEXAS Heather Murphy Manager, Pharmacy Contracts and Rebates Vendor Drug Program Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78759 T: 512/491-1163 F: 512/491-1967 E-mail: [email protected]

Gail Goodnight, R.Ph. Rebate Coordinator Department of Health and Human Services Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5977 F: 304/558-1542 E-mail: [email protected]

UTAH

WISCONSIN

Raedell Ashley, R.Ph. Pharmacy Director Medicaid Program Division of Health Care Financing P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected]

Ellen Orsburne Medicaid Systems Analyst Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/267-7939 E-mail: [email protected]

VERMONT

WYOMING

Christine Dapkiewicz Drug Rebate Coordinator EDS 312 Hurricane Lane, Suite 100 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

Sheila McInerney TPL Manager ACS State Healthcare P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405 E-mail: [email protected]

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Pharmaceutical Benefits 2004

STATE OFFICIALS -- 2005 ALABAMA

ALASKA

ARIZONA

Governor Honorable Bob Riley State Capitol 600 Dexter Avenue Montgomery, AL 36103 T: 334/242-7100 F: 334/353-0004 E-mail: [email protected] Internet address: www.governor.state.al.us

Governor Honorable Frank Murkowski P.O. Box 110001 Juneau, AK 99811-0001 T: 907/465-3500 F: 907/465-3532 E-mail: [email protected] Internet address: www.gov.state.ak.us

Governor Honorable Janet Napolitano State Capitol 1700 W. Washington Phoenix, AZ 85007 T: 602/542-4331 F: 602/542-1381 E-mail: [email protected] Internet address: www.governor.state.az.us

Single State Agency Director Ms. Carol Herrmann Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5600 F: 334/242-0597 E-mail: [email protected] Internet address : www.medicaid.state.al.us Medicaid Director Ms. Carol Herrmann Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5600 F: 334/242-0597 E-mail: [email protected] Internet address : www.medicaid.state.al.us

Single State Agency Director Mr. Joel Gilbertson, Commissioner Department of Health and Social Services P.O. Box 110601 350 Main Street, Room 229 Juneau, AK 99811-0601 T: 907/465-3030 F: 907/465-3068 E-mail: [email protected] Internet address: www.hss.state.ak.us

Single State Agency Director Mr. Anthony D. Rodgers, Director Arizona Health Care Cost Containment System (AHCCCS) 80l East Jefferson Street Phoenix, AZ 85034 T: 602/417-4111 F: 602/252-6536 E-mail: [email protected] Internet address: www.ahcccs.state.az.us

Medicaid Director Mr. Jerry Fuller, Director Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, AK 99811-0660 T: 907/465-3030 F: 907/465-3068 E-mail: [email protected] Internet address: www.hss.state.ak.us/dhcs

Medicaid Director Mr. Anthony D. Rodgers, Director Arizona Health Care Cost Containment System (AHCCCS) 801 East Jefferson Street Phoenix, AZ 85034 T: 602/417-4111 F: 602/252-6536 E-mail: [email protected] s Internet address: www.ahcccs.state.az.us

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Pharmaceutical Benefits 2004

ARKANSAS

CALIFORNIA

COLORADO

Governor Honorable Mike Huckabee State Capitol Building Room 250 Little Rock, AR 72201 T: 501/682-2345 F: 501/682-3597 E-mail: [email protected] Internet address: www.arkansas.gov/governor

Governor Honorable Arnold Schwarzenegger State Capitol, First Floor Sacramento, CA 958l4 T: 916/445-2841 F: 916/445-4633 E-mail: [email protected] Internet address: www.governor.ca.gov/state/govsite/ gov_hompage.jsp

Governor Honorable Bill Owens State Capitol Room 136 Denver, CO 80203-1792 T: 303/866-2471 F: 303/866-2003 E-mail: [email protected] Internet address: www.colorado.gov/governor

Single State Agency Director Mr. Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 201 Little Rock, AR 72203-1437 T: 501/682-8650 F: 501/682-6836 E-mail: [email protected] Internet address: www.state.ar.us/dhs

Single State Agency Director Ms. Sandra Shewry, Director Department of Health Services 1501 Capitol Avenue Sacramento, CA 95899 T: 916/440-7400 F: 916/440-7404 E-mail: [email protected] Internet address: www.dhs.ca.gov

Medicaid Director Mr. Roy Jeffus, Director Division of Medical Services Dept. of Human Services P.O. Box 1437, Slot 1100 103 East 7th Street Little Rock, AR 72203-1437 T: 50l/682-1671 F: 501/682-1197 E-mail: [email protected] Internet address: www.medicaid.state.ar.us

Medicaid Director Mr. Stan Rosenstein Deputy Director Medical Care Services Department of Health Services 1501 Capitol Avenue, 6th Floor P.O. Box 942732 Sacramento, CA 95814 T: 916/440-7800 F: 916/440-7805 E-mail: [email protected] Internet address: www.medical.ca.gov

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Single State Agency Director Ms. Marva Livingston Hammons Executive Director Department of Human Services l575 Sherman Street Denver, CO 80203-1714 T: 303/866-5700 F: 303/866-4047 E-mail: [email protected] Internet address: www.cdhs.state.co.us Medicaid Director Ms. Vivianne M. Chaumont Director Office of Medical Assistance Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818 T: 303/866-5929 F: 303/866-2573 E-mail: [email protected] Internet address: www.chcpf.state.co.us

National Pharmaceutical Council

Pharmaceutical Benefits 2004

CONNECTICUT

DELAWARE

DISTRICT OF COLUMBIA

Governor Honorable M. Jodi Rell Executive Office of the Governor State Capitol, Room 210 Hartford, CT 06l06 T: 860/566-4840 F: 820/524-7396 E-mail: [email protected] Internet address: www.state.ct.gov/governorrel

Governor Honorable Ruth Ann Minner Tatnall Building William Penn Street Dover, DE 19901 T: 302/744-4101 F: 302/739-2775 E-mail: [email protected] Internet address: www.state.de.us/governor

Mayor Honorable Anthony A. Williams John A. Wilson Building 1350 Pennsylvania Avenue, NW Washington, DC 20004 T: 202/727-2980 F: 202/727-6561 E-mail: [email protected] Internet address: www.dc.gov

Single State Agency Director Ms. Patricia Wilson-Coker Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5008 F: 860/566-2022 E-mail: [email protected] Internet address: www.dss.state.ct.us Medicaid Director Mr. David Parella, Director Medical Care Administration Department of Social Services 25 Sigourney Street Hartford, CT 06106 T: 860/424-5116 F: 860/424-5114 E-mail: [email protected] Internet address: www.dss.state.ct.us

Single State Agency Director Mr. Vincent P. Meconi, Secretary Department of Health and Social Services 1901 North DuPont Highway New Castle, DE l9720 T: 302/255-9040 F: 302/255-4429 E-mail: [email protected] Internet address: www.state.de.us/dhss Medicaid Director Mr. Harry Hill Deputy Director Planning and Development Department of Health and Social Services Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/577-4901 F: 302/255-4425 E-mail: [email protected] Internet address: www.state.de.us/dhss

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Single State Agency Director Dr. Gregory A. Pane Department of Health 825 North Capitol Street, NE Fourth Floor Washington, DC 20002 T: 202/442-5000 F: 202/442-4795 E-mail: [email protected] Internet address: www.dchealth.dc.gov Medicaid Director Mr. Robert Maruca Senior Deputy Director Medical Assistance Administration Department of Health 825 North Capitol Street, NE Fifth Floor Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected] Internet address: www.dchealth.dc.gov

National Pharmaceutical Council

Pharmaceutical Benefits 2004

FLORIDA

GEORGIA

GUAM

Governor Honorable Jeb Bush The State Capitol Tallahassee, FL 32399-0001 T: 850/488-4441 F: 850/487-0801 E-mail: [email protected] Internet address: www.myflorida.com/b_eog/owa/b_ eog_www.html.main_page

Governor Honorable Sonny Purdue 203 State Capitol Atlanta, GA 30334 T: 404/656-l776 F: 404/657-7332 E-mail: [email protected] Internet address: www.gagovernor.org

Governor Honorable Felix Comacho Adelup Complex P.O. Box 2950 Agana, GU 96932 T: 671/479-2002 F: 671/479-2009 E-mail: [email protected] Internet address: www.gov.gu/webtax/govoff.html

Single State Agency Director Mr. Alan Levine, Secretary Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 1 Tallahassee, FL 32308 T: 850/922-3809 F: 850/488-0043 E-mail: [email protected] Internet address: www.ahca.myflorida.com Medicaid Director Mr. Thomas W. Arnold Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 T: 850/488-3560 F: 850/488-2520 E-mail: [email protected] Internet address: www.ahca.myflorida.com/Medicai d

Single State Agency Director Mr. Tim Burgess, Commissioner Department of Community of Health 2 Peachtree Street, NW Suite 4043 Atlanta, GA 30303-3159 T: 404/656-4507 F: 404/651-6880 E-mail: [email protected] Internet address: www.dch.state.ga.us Medicaid Director Mr. Mark Trail, Director Department of Community Health Medical Assistance Division 2 Peachtree Street, NW Suite 3733 Atlanta, GA 30303 T: 404/656-1502 F: 866/283-0128 E-mail: [email protected] Internet address: www.dch.state.ga.us

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Single State Agency Director Mr. PeterJohn B. Comacho, Administrator Dept. of Public Health and Social Services P.O. Box 2816 Agana, GU 96932 T: 671/735-7102 F: 671/734-5910 E: mail: [email protected] 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 T: 671/735-7282 F: 671/734-5910

National Pharmaceutical Council

Pharmaceutical Benefits 2004

HAWAII

IDAHO

ILLINOIS

Governor Honorable Linda Lingle State Capitol 415 S. Beretania Street Honolulu, HI 968l3 T: 808/586-0034 F: 808/586-0006 E-mail: [email protected] Internet address: www.gov.state.hi.us

Governor Honorable Dirk Kempthorne P.O. Box 83720 Boise, ID 83720-0034 T: 208/334-2100 F: 208/334-3454 E-mail: [email protected] Internet address: www2.state.id.us/gov/index.htm

Governor Honorable Rod Blagojevich 207 State Capitol Building Springfield, IL 62706 T: 2l7/782-6830 F: 217/782-1853 E-mail: [email protected] Internet address: www.state.il.us/gov

Single State Agency Director Mr. Karl Kurtz, Director Department of Health and Welfare 450 West State Street Boise, ID 83720-0036 T: 208/334-5500 F: 208/334-6558 E-mail: [email protected] Internet address: www.healthandwelfare.idaho.gov

Single State Agency Director Mr. Barry Maram, Director Department of Public Aid 201 South Grand Avenue, East Third Floor Springfield, IL 62794 T: 2l7/782-1200 F: 217/524-7120 E-mail: [email protected] Internet address: www.dpaillinois.com

Single State Agency Director Ms. Lillian B. Koller, Director Department of Human Services 1390 Miller Street, Room 209 Honolulu, HI 96813 T: 808/586-4997 F: 808/586/4890 E-Mail: [email protected] Internet address: www.state.hi.us/dhs Medicaid Director Ms. Angie Payne Acting Administrator Med-Quest Division Department of Human Services P.O. Box 399 Honolulu, HI 96809-0339 T: 808/692-8050 F: 808/692-8173 E-mail: [email protected] Internet address: www.medquest.us

Medicaid Director Mr. David Rogers, Administrator Division of Medicaid Department of Health and Welfare Americana Building 3232 Elder Street Boise, ID 83705 T: 208/334-5747 F: 208/364-1811 E-mail: [email protected] Internet address: www.healthandwelfare.idaho.gov

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Medicaid Director (Medical Operations) Dr. Anne Marie Murphy, Director Medicaid and SCHIP Progams Department of Public Aid 20l South Grand Avenue, East Springfield, IL 62763-0001 T: 2l7/782-7570 F: 217/524-5672 E-mail: [email protected] Internet address: www.dpaillinois.com/medical

National Pharmaceutical Council

Pharmaceutical Benefits 2004

INDIANA

IOWA

KANSAS

Governor Honorable Mitch Daniels State House, Room 206 200 W. Washington Street Indianapolis, IN 46204 T: 3l7/232-4567 F: 317/232-3443 E-mail: [email protected] Internet address: www.in.gov/gov

Governor Honorable Thomas J. Vilsack State Capitol Building Des Moines, IA 503l9 T: 5l5/28l-0561 F: 515/281-6611 E-mail: [email protected] Internet address: www.state.ia.us/governor

Governor Honorable Kathleen Sebelius 2nd Floor State Capitol Building Topeka, KS 66612-1590 T: 785/296-3232 F: 785/296-7973 E-mail: [email protected] Internet address: www.ksgovernor.org

Single State Agency Director Mr. Mitch Roob, Secretary Family and Social Services Administration Room 461, Mail Stop 25 P.O. Box 7083 402 W. Washington Street Indianapolis, IN 46207-7083 T: 317/233-4690 F: 317/233-4693 E-Mail: [email protected] Internet address: www.state.in.us/fssa

Single State Agency Director Mr. Kevin Concannon, Director Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 T: 5l5/28l-5452 F: 515/281-4980 E-mail: [email protected] Internet address: www.dhs.state.ia.us

Medicaid Director Ms. Jeanne Labrecque, Director Office of Medicaid Policy and Planning Family and Social Services Administration 402 W. Washington Street Room W382 Indianapolis, IN 46204-2739 T: 317/234-2407 F: 317/232-7382 E-mail: [email protected] Internet address: www.in.gov/fssa/servicedisabl/med icaid

Medicaid Director Mr. Eugene Gessow Medicaid Director Division of Medical Services Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 T: 5l5/725-1121 F: 515/725-1010 E-mail: [email protected] Internet address: www.dhs.state.ia.us

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Single State Agency Director Mr. Gary Daniels, Acting Secretary Kansas Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison Street, 6th Floor Topeka, KS 66612 T: 785/296-3271 F: 785/296-2173 E-mail: [email protected] Internet address: www.srskansas.org Medicaid Director Mr. Scott Brunner, Director Medical Policy/Medicaid Department of Social and Rehabilitation Services Docking State Office Building, 5th Floor 915 SW Harrison Street, Topeka, KS 66612 T: 785/296-3773 F: 785/296-0509 E-mail: [email protected] Internet address: www.srskansas.org/hcp/MPmain. html

National Pharmaceutical Council

Pharmaceutical Benefits 2004

KENTUCKY

LOUISIANA

MAINE

Governor Honorable Ernie Fletcher State Capitol Building 700 Capitol Avenue Frankfort, KY 4060l T: 502/564-2611 F: 502/564-2517 E-mail: [email protected] Internet address: www.governor.ky.gov

Governor Honorable Kathleen Blanco State Capitol P.O. Box 94004 Baton Rouge, LA 70804 T: 225/342-7015 F: 225/342-7099 E-mail: www.gov.state.la.us/gov_email.html Internet address: www.gov.state.la.us

Governor Honorable John Baldacci 1 State House Station Augusta, Maine 04333-0001 T: 207/287-3531 F: 207/287-1034 E-mail: [email protected] Internet address: www.main.gov/governor/baldacci/ index.shtml

Single State Agency Director Mr. James W. Holsinger, Jr., M.D. Secretary Cabinet for Health and Family Services 275 East Main Street, 5C-A Frankfort, KY 40621 T: 502/564-6786 F: 502/564-0274 E-mail: [email protected] Internet address: www.chs.state.ky.us Medicaid Director Ms. Shannon Turner Acting Commissioner Department for Medicaid Services Sixth Floor 275 East Main Street Frankfort, KY 40621 T: 502/564-4321 F: 502/564-0509 Internet address: www.chs.ky.gov./dms

Single State Agency Director Mr. Frederick P. Cerise, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821-0629 T: 225/342-9500 F: 225/342-9508 E-mail: [email protected] Internet address: www.dhh.state.la.us Medicaid Director Mr. Ben Bearden, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821-9030 T: 225/342-3891 F: 225/342-9508 E-mail: [email protected] Internet address: www.dhh.state.la.us/MEDICAID/ index.htm

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Single State Agency Director Mr. John R. Nichols Commissioner Department of Human Services State House Station 11 211 State Street Augusta, ME 04333-0011 T: 207/287-1921 F: 207/287-3005 E-mail: [email protected] Internet address: www.main.gov/dhs/index.htm Medicaid Director Ms. Christine Gianopoulos Acting Director Bureau of Medical Services Department of Human Services State House Station 11 442 Civic Center Drive Augusta, ME 04333-0011 T: 207/287-2674 F: 207/287-2675 E-mail: [email protected] Internet address : www.state.me.us/bms/bmshome. htm

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MARYLAND

MASSACHUSETTS

MICHIGAN

Governor Honorable Robert Ehrlich State House Annapolis, MD 21401 T: 410/974-3901 F: 410/974-3275 E-mail: [email protected] Internet address: www.gov.state.md.us

Governor Honorable Mitt Romney Executive Office, State House Room 360 Boston, MA 02133 T: 617/727-6250 F: 617/727-9725 E-mail: [email protected] Internet address: www.mass.gov

Governor Honorable Jennifer Granholm P.O. Box 30013 Lansing, MI 48909 T: 5l7/335-7858 F: 517/335-6863 E-mail: www.michigan.gov/gov Internet address: www.michigan.gov/gov

Single State Agency Director Mr. S. Anthony McCann Secretary Department of Health & Mental Hygiene Herbert R. O'Connor Building 201 West Preston Street Fifth Floor Baltimore, MD 21201 T: 410/767-6505 F: 410/161-6489 E-mail: [email protected] Internet address: www.dhmh.state.md.us Medicaid Director Mr. John Folkemer Deputy Secretary for Health Care Financing Office of Planning and Finance Medical Care Programs Department of Health & Mental Hygiene 201 West Preston Street, 2nd Floor Baltimore, MD 21201 T: 410/767-5806 F: 410/333-7505 E-mail: [email protected] Internet address: www.dhmh.state.md.us

Single State Agency Director Mr. Ronald Preston, Secretary Health and Human Services Executive Office One Ashburton Place, Room 1109 Boston, MA 02108 T: 617/727-0077 F: 617/727-5134 E-mail: [email protected] Internet address: www.masscare.org Medicaid Director Ms. Beth Waldman, Director Divison of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5690 F: 617/210-5697 E-mail: [email protected] Internet address : www.state.ma.us/dma

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Single State Agency Director Ms. Janet Olszewski Director Michigan Department of Community Health Lewis Cass Building 320 South Walnut Street Lansing, MI 48913 T: 517/335-0267 F: 517/373-4288 E-mail: [email protected] Internet address: www.michigan.gov/mdch Medicaid Director Mr. Paul Reinhart Deputy Director Michigan Department of Community Health 320 South Walnut Street Lansing, MI 48913 T: 517/241-7882 F: 517/335-5007 E-mail: [email protected] Internet address: www.michigan.gov/mdch

National Pharmaceutical Council

Pharmaceutical Benefits 2004

MINNESOTA

MISSISSIPPI

MISSOURI

Governor Honorable Tim Pawlenty 130 State Capitol St. Paul, MN 55155-1099 T: 651/296-3391 F: 651/296-2089 E-mail: [email protected] Internet address: www.governor.state.mn.us

Governor Honorable Haley Barbour State Capitol P.O. Box 139 Jackson, MS 39205 60l/359-3150 E-mail: www.governor.state.ms.us/aboutthe gov/writetoindex.html Internet address: www.governor.state.ms.us

Governor Honorable Matt Blunt State Capitol Building, Room 216 P.O. Box 720 Jefferson City, MO 65102-0720 T: 573/751-3222 F: 573/751-1495 E-mail: [email protected] Internet address: www.gov.state.mo.us

Single State Agency Director Mr. Kevin Goodno Commissioner Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3815 T: 651/296-2701 F: 651/297-3230 E-mail: [email protected] Internet address: www.dhs.state.mn.us Medicaid Director Ms. Christine Bronson Acting Medicaid Director Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55l55-3853 T: 651/296-4332 F: 651/296-5868 E-mail: [email protected] Internet address: www.dhs.state.mn.us

Single State Agency Director Mr. Donald Taylor Executive Director Department of Human Services 750 North State Street Jackson, MS 39202 T: 601/359-4500 F: 601/359-4477 E-mail: [email protected] Internet address: www.mdhs.state.ms.us

Single State Agency Director Mr. Steve Renne, Acting Director Department of Social Services 221 West High Street P.O. Box 1527 Jefferson City, MO 65102 T: 573/751-4815 F: 573/751-3203 E-mail: [email protected] Internet address: www.dss.state.mo.us

Medicaid Director Mr. Warren A. Jones, M.D. Executive Director Division of Medicaid Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201-1399 T: 601/359-6050 F: 601/359-6048 E-mail: [email protected] Internet address: www.mdhs.state.ms.us

Medicaid Director Dr. Michael Ditmore Acting Director Division of Medical Services Department of Social Services 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6922 F: 573/751-6564 E-mail: [email protected] Internet address: www.dss.state.mo.us/dms

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

MONTANA

NEBRASKA

NEVADA

Governor Honorable Brian Schweitzer Office of the Governor State Capitol P.O. Box 200801 Helena, MT 59620-0801 T: 406/444-3111 F: 406/444-4151 E-mail: [email protected] Internet address: www.governor.mt.gov

Governor Honorable Dave Heineman P.O. Box 94848 Lincoln, NE 68509-4848 T: 402/471-2244 F: 402/471-6031 E-mail: [email protected] Internet address: www.gov.nol.org

Governor Honorable Kenny C. Guinn State Capitol Carson City, NV 89710 T: 702/684-5670 F: 775/684-5683 E-mail: www.gov.state.nv.us/mail.gov.htm Internet address: www.gov.state.nv.us

Single State Agency Director Dr. Robert E. Wynia Department of Public Health and Human Services P.O. Box 4210 111 N. Sanders Helena, MT 59604-4210 T: 406/444-5622 F: 406/444-1970 E-mail: [email protected] Internet address: www.dphhs.state.mt.us Medicaid Director Mr. John Chappuis Medicaid Director Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4084 F: 406/444-1861 E-mail: [email protected] Internet address: www.dphhs.state.mt.us/hpsd/index. htm

Single State Agency Director Mr. Richard P. Nelson, Director Nebraska Department of Health and Human Services Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-8566 F: 402/471-9449 E-mail: [email protected] Internet address: www.hhs.state.ne.us/svc/svcindex. htm Medicaid Director Ms. Mary Steiner Interim Administrator Medicaid Division Nebraska Department of HHS Finance and Support P.O. Box 95007 301 Centennial Mall South, 5th Floor Lincoln, NE 68509-5007 T: 402/471-9567 F: 402/471-9092 E-mail: [email protected] Internet address: www.hhs.state.ne.us/med/medindex. htm

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Single State Agency Director Mr. Mike Wilden, Director Department of Human Resources 505 East King Street, Room 600 Carson City, NV 89710 T: 775/684-4000 F: 775/684-4010 E-mail: [email protected] Internet address: www.hr.state.nv.us Medicaid Director Mr. Charles Duarte, Administrator Division of Health Care Financing and Policy 1100 East William Street, Suite 116 Carson City, NV 89710 T: 775/684-3676 F: 775/687-3893 E-mail: [email protected] Internet address: www.dhcfp.state.nv.us

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEW HAMPSHIRE

NEW JERSEY

NEW MEXICO

Governor Honorable John Lynch Office of the Governor State House Room 208 107 North Main Street Concord, NH 03301-4990 T: 603/271-2121 F: 603/271-5686 E-mail: [email protected] Internet address: www.state.nh.us/governor

Governor Honorable Richard Codey Acting Governor 125 West State Street State House CN-001 Trenton, NJ 08625 T: 609/292-6000 F: 609/292-3454 E-mail: www.state.nj.us/governor/govmail. html Internet address: www.state.nj.us/governor

Governor Honorable Bill Richardson Office of the Governor State Capitol Suite 400 Santa Fe, NM 87501 T: 505/476-2200 F: 505/476-2226 E-mail: [email protected] Internet address: www.governor.state.nm.us

Single State Agency Director Mr. John Stephen, Commissioner Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-4331 F: 603/271-4912 E-mail: [email protected] Internet address: www.dhhs.state.nh.us/DHHS/ DHHS_SITE/default.htm Medicaid Director Mr. Stephen Norton Medicaid Director Office of Health Policy & Medicaid Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-3676 F: 603/271-8431 E-mail: [email protected] Internet address: www.dhhs.state.nh.us/DHHS/ MEDICAIDPROGRAM/ default.htm

Single State Agency Director Mr. James M. Davy, Commissioner Department of Human Services P.O. Box 700 Trenton, NJ 08625 T: 609/292-3717 F: 609/292-3824 E-mail: [email protected] Internet address: www.state.nj.us/humanservices Medicaid Director Ms. Ann Clemency Kohler, Director Division of Medical Assistance and Health Services Department of Human Services P.O. Box 712 Trenton, NJ 08625-0712 T: 609/588-2600 F: 609/588-3583 E-mail: [email protected] Internet address: www.state.nj.us/humanservices/ dmahs/index.html

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Single State Agency Director Ms. Pamela Hyde, J.D. Secretary New Mexico Human Services Department P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7750 F: 505/827-6286 E-mail: [email protected] Internet address: www.state.nm.us/hsd Medicaid Director Ms. Carolyn Ingram, Director Medical Assistance Division New Mexico Human Services Department P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3106 F: 505/827-3185 E-mail: [email protected] Internet address: www.state.nm.us/hsd/mad/index. html

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NEW YORK

NORTH CAROLINA

NORTH DAKOTA

Governor Honorable George E. Pataki Executive Chamber State Capitol Albany, NY 12224 T: 5l8/474-8390 F: 518/474-3767 E-mail: [email protected] Internet address: www.state.ny.us/governor

Governor Honorable Mike Easley Office of the Governor 116 West Jones Street 20301 Mail Service Center Raleigh, NC 27699-0301 T: 919/733-4240 T: 919/733-5811 F: 919/733-2120 F: 919/715-3175 E-mail: www.governor.state.nc.us/email.asp ?to=1 Internet address: www.governor.state.nc.us

Governor Honorable John Hoeven Department 101 600 East Boulevard Avenue Bismarck, ND 58505-0001 T: 701/328-2200 F: 701/328-2205 E-mail: [email protected] Internet address: www.governor.state.nd.us

Single State Agency Director Ms. Antonia C. Novello, M.D., M.P.H., Commissioner NYS Department of Health ESP, Corning Tower Building Albany, NY 12237 T: 518/474-2011 F: 518/474-5450 E-mail: [email protected] Internet address: www.health.state.ny.us/homens6. html Medicaid Director Ms. Kathryn Kuhmerker, Deputy Director NYS Department of Health Office of Medicaid Management Empire State Plaza Room 1466, Corning Tower Building Albany, NY 12237 T: 518/474-3018 F: 518/486-6852 E-mail: [email protected] Internet address : www.health.state.ny.us/health_care /medicaid

Single State Agency Director Ms. Carmen Hooker Odom, Secretary Department of Health and Human Services 2001 Mail Service Center Raleigh, NC 27699-2001 T: 919/733-4534 F: 919/715-4645 E-mail: [email protected] Internet address: www.dhhs.state.nc.us Medicaid Director Mr. Mark Benton, Interim Director Division of Medical Assistance Department of Health and Human Services 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/855-4100 F: 919/733-6608 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma

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Single State Agency Director Ms. Carol K. Olson, Executive Director Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-2538 F: 701/328-1545 E-mail: [email protected] Internet address: www.state.nd.us/humanservices.nsf Medicaid Director Mr. David J. Zentner Director Division of Medical Services Department of Human Services 600 East Boulevard Avenue Dept. 325 Bismarck, ND 58505-0261 T: 701/328-2321 F: 701/328-1544 E-mail: [email protected] Internet address: www.state.nd.us/humanservices/ services/medicalserv

National Pharmaceutical Council

NORTHERN MARIANA ISLANDS Governor Honorable Juan N. Babauta Office of the Governor Commonwealth of the Northern Mariana Islands Juan S. Atalig Memorial Building Isa Drive, Capitol Hill Caller Box 10007 Saipan, MP 96950 670/322-5091 Single State Agency Director Dr. James Hofschneider 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 670/234-8950 Medicaid Director Ms. Maria Sablan Medical Administrator Department of Public Health and Environmental Services Commonwealth of the Northern Mariana Islands P.O. Box 409 CK Saipan, MP 96950 T: 670/664-4880 F: 670/664-4885

Pharmaceutical Benefits 2004

OHIO

OKLAHOMA

Governor Honorable Bob Taft 77 South High Street, 30th Floor Columbus, OH 43215-6117 T: 614/466-3555 F: 614/466-9354 E-mail: [email protected] Internet address: www.state.oh.us/gov

Governor Honorable Brad Henry 212 State Capitol 2300 N. Lincoln Boulevard Oklahoma City, OK 73105 T: 405/521-2342 F: 405/521-3353 E-mail: [email protected] Internet address: www.governor.state.ok.us

Single State Agency Director Ms. Barbara Riley, Director Ohio Department of Job and Family Services 30 East Broad Street, 32nd Floor Columbus, OH 43215-3414 T: 614/466-6282 F: 614/466-2815 E-mail: [email protected] Internet address: www.jfs.ohio.gov

Single State Agency Director Mr. Mike Fogarty, J.D. Chief Executive Officer Oklahoma Health Care Authority 4545 North Lincoln Boulevard Suite 124 Oklahoma City, OK 73105 T: 405/522-7300 F: 405/522-7187 E-mail: [email protected] Internet address: www.ohca.state.ok.us

Medicaid Director Ms. Barbara Coulter Edwards Deputy Director Ohio Health Plans Ohio Department of Job and Family Services 30 East Broad Street, 31st Floor Columbus, OH 43215-3414 T: 614/466-0140 F: 614/752-3986 E-mail: [email protected] Internet address : www.jfs.ohio.gov.ohp

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Medicaid Director Ms. Lynn Mitchell, M.D., M.P.H. Medical Director Oklahoma Health Care Authority 4545 North Lincoln Boulevard Suite 124 Oklahoma City, OK 73105 T: 405/522-7365 F: 405/530-3218 E-mail: [email protected] Internet address: www.ohca.state.ok.us

National Pharmaceutical Council

Pharmaceutical Benefits 2004

OREGON

PENNSYLVANIA

PUERTO RICO

Governor Honorable Ted Kulongoski State Capitol 900 Court Street NE Salem, OR 97310-4047 T: 503/378-3111 F: 503/378-4863 E-mail: www.governor.state.or.us/ Contact.htm Internet address: www.governor.state.or.us

Governor Honorable Ed Rendell 25 Main Capitol Building Harrisburg, PA 17120 T: 717/787-2500 F: 717/772-8284 E-mail: www.state.pa.us/pa_exec/governor/ govmail.html Internet address: www.state.pa.us/governor

Governor Honorable Anibal Acevedo-Vila Office of the Governor La Fortaleza P.O. Box 82 San Juan, PR 00901 809/721-7000

Single State Agency Director Mr. Gary Weeks, Director Department of Human Resources 500 Summer Street, NE Human Resources Building, E15 Salem, OR 97301 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] Internet address: www.dhs.state.or.us

Single State Agency Director Ms. Estelle B. Richman, Secretary Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-2600 F: 717/772-2062 E-mail: ra-dpwsecretarynet @state.pa.us Internet address: www.dpw.state.pa/us

Medicaid Director Mr. Barney H. Speight Administrator Office of Medical Assistance Programs Department of Human Services 500 Summer Street, NE, E49 Salem, OR 97301 T: 503/373-7689 F: 503/373-7823 E-mail: [email protected] Internet address: www.dhs.state.or.us/healthplan

Medicaid Director Mr. David S. Feinberg Deputy Secretary Office of Medical Assistance Programs Department of Public Welfare Health and Welfare Building, Room 515 P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-1870 F: 717/787-4639 E-mail: [email protected] Internet address: www.dpw.state.pa.us/omap

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Single State Agency Director Mr. John Rullan, M.D. Secretary Department of Health G.P.O. Box 70184 San Juan, PR 00936 787/7274-7676 Medicaid Director Mr. William Gonzalez, Director Office of Economic Assistance to The Medically Indigent Department of Health G.P.O. Box 70184 San Juan, PR 00936 T: 787/765-1230, ext. 200 F: 787/250-0990 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2004

RHODE ISLAND

SOUTH CAROLINA

SOUTH DAKOTA

Governor Honorable Don Carcieri 222 State House Providence, RI 02903-1196 T: 401/222-2080 F: 401/222-8096 E-mail: [email protected] Internet address: www.governor.state.ri.us

Governor Honorable Mark Sanford P.O. Box 12267 Columbia, SC 29211 T: 803/734-2100 F: 803/734-5167 E-mail: [email protected] Internet address: www.state.sc.us/governor

Governor Honorable Mike Rounds 500 East Capitol Pierre, SD 57501 T: 605/773-3212 F: 605/773-4711 E-mail: [email protected] Internet address: www.state.sd.us/governor

Single State Agency Director Ms. Jane Hayward, Director Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-2121 F: 401/462-3677 E-mail: [email protected] Internet address: www.dhs.state.ri.us Medicaid Director Mr. John C. Young, C.P.M. Associate Director Division of Medical Services Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-3575 F: 401/462-6338 E-mail: [email protected] Internet address: www.dhs.state.ri.us

Single State Agency Director Mr. Robert Kerr, Director Department of Health and Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Internet address: www.dhhs.state.sc.us Medicaid Director Mr. Robert Kerr, Director Department of Health and Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Internet address: www.dhhs.state.sc.us

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Single State Agency Director Mr. James W. Ellenbecker, Secretary Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 T: 605/773-3165 F: 605/773-4855 E-mail: [email protected] Internet address: www.state.sd.us/social Medicaid Director Mr. Larry Iverson Division Director Medical Services Department of Social Services Richard F. Kneip Building 700 Governors Drive Pierre, SD 57501-2291 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected] Internet address: www.state.sd.us/social/medical

National Pharmaceutical Council

Pharmaceutical Benefits 2004

TENNESSEE

TEXAS

UTAH

Governor Honorable Phil Bredesen State Capitol, First Floor Nashville, TN 37243-0001 T: 615/741-2001 F: 615/532-9711 E-mail: [email protected] Internet address: www.state.tn.us/governor

Governor Honorable Rick Perry State Capitol P.O. Box 12428 Austin, TX 78711 T: 5l2/463-2000 F: 512/463-1849 E-mail: www.governor.state.tx.us/contact Internet address: www.governor.state.tx.us

Governor Honorable John Huntsman Office of the Governor Utah East Office Building Suite E220 Salt Lake City, UT 84114 T: 801/538-1000 F: 801/538-1528 E-mail: [email protected] Internet address: www.utah.gov/governor

Single State Agency Director Mr. Albert Hawkins, Commissioner Health and Human Services Commission 4900 N. Lamar Boulevard P.O. Box 13247 Austin, TX 78751 T: 5l2/424-6502 F: 512/424-6587 E-mail: [email protected] Internet address: www.hhsc.state.tx.us

Single State Agency Director Mr. David Sundwall, M.D. Executive Director Department of Health P.O. Box 141000 Salt Lake City, UT 84114-1000 T: 801/538-6111 F: 801/538-6306 E-mail: [email protected] Internet address: www.health.utah.gov

Single State Agency Director Ms. Gina Lodge, Commissioner Department of Human Services 400 Deaderick Street, 15th Floor Nashville, TN 37248-0001 T: 615/313-4700 F: 615/741-4165 E-mail: [email protected] Internet address: www.state.tn.us/humanserv Medicaid Director Ms. Mary-Anne Rudolph, Director Medicaid Policy Unit Citizen’s Plaza Building, 12th Floor 400 Deaderick Street Nashville, TN 37248 T: 615/313-4873 F: 615/313-6639 E-mail: [email protected] Internet address: www.state.tn.us/humanserv/medi. htm

Medicaid Director Mr. David Balland Interim Director Health and Human Services Commission 4900 N. Lamar Boulevard, 4th Floor P.O. Box 13247 Austin, TX 78751 T: 512/491-1463 F: 512/424-6587 E-mail: [email protected] Internet address: www.hhsc.tx.us/medicaid

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Medicaid Director Mr. Michael Deily, Director Department of Health Division of Health Care Financing P.O. Box 14301 Salt Lake City, UT 84114-3101 T: 801/538-6406 F: 801/538-6099 E-mail: [email protected] Internet address: www.health.utah.gov/medicaid

National Pharmaceutical Council

Pharmaceutical Benefits 2004

VERMONT

VIRGINIA

VIRGIN ISLANDS

Governor Honorable James Douglas 109 State Street Montpelier, VT 05609 T: 802/828-3333 F: 802/828-3339 Internet address: www.gov.state.vt.us

Governor Honorable Mark Warner State Capitol Building, Third Floor Richmond, VA 232l9 T: 804/786-2211 F: 804/692-0121 E-mail: www.governor.state.va.us/contact/ email_form.html Internet address: www.governor.state.va.us

Governor Honorable Charles Turnbull Government House 21-22 Kongens Gada Street Charlotte Amalie St. Thomas, VI 00802 T: 340/774-0001 F: 340/776-4912 E-mail: [email protected] Internet address: www.gov.vi

Single State Agency Director Mr. Michael K. Smith, Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05671-0201 T: 802/241-2220 F: 802/241-2979 E-mail: [email protected] Internet address: www.ahs.state.vt.us Medicaid Director Mr. Joshua Slen, Medicaid Director Agency of Human Services Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676-1201 T: 802/879-5900 F: 802/879-5962 E-mail: [email protected] Internet address: www.dsw.state.vt.us

Single State Agency Director Ms. Jane H. Woods, Secretary Office of The Secretary of Health and Human Resources 202 N. Ninth Street, Suite 622 P.O. Box 1475 Richmond, VA 23219 T: 804/786-7765 F: 804/371-6984 E-mail: [email protected] Internet address : www.hhr.state.va.us Medicaid Director Mr. Patrick Finnerty, Director Department of Medical Assistance Services 600 East Broad Street Suite 1300 Richmond, VA 23219 T: 804/786-4231 F: 804/371-4981 E-mail: [email protected] Internet address: www.dmas.state.va.us

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Single State Agency Director Ms. Darlene A Carty Commissioner of Health Virgin Islands Department of Health 48 Sugar Estate St. Thomas, VI 00802 T: 340/774-0117 F: 340/777-4001 E-mail: [email protected] Medicaid Director Ms. Jane Laws, Executive Director Bureau of Health Insurance and Medical Assistance Department of Health 3730 Altona, Suite 302 Frostco Center Charlotte Amalie St. Thomas, VI 00802 T: 340/774-4624 F: 340/774-4918 E-mail: [email protected]

National Pharmaceutical Council

Pharmaceutical Benefits 2004

WASHINGTON

WEST VIRGINIA

WISCONSIN

Governor Honorable Christine Gregoire Office of the Governor P.O. Box 40002 Olympia, WA 98504-0002 T: 360/902-4111 F: 360-753-4110 E-mail: www.governor.wa.gov/contact.gov email.htm Internet address: www.governor.wa.gov

Governor Honorable Joe Manchin III State Capitol Charleston, WV 25305-0370 T: 304/558-2000 F: 304/342-7025 E-mail: [email protected] Internet address: www.state.wv.us/governor

Governor Honorable Jim Doyle Office of The Governor 115 East State Capitol Madison, WI 53702 T: 608/266-1212 F: 608/267-8983 E-mail: [email protected] Internet address: www.wisgov.state.wi.us

Single State Agency Director Ms. Robin Arnold-Williams Secretary Department of Social and Health Services P.O. Box 45010 Olympia, WA 98504-5010 T: 360/902-7800 F: 360/902-7848 E-mail: [email protected] Internet address: www.wa.gov/dshs Medicaid Director Mr. Doug Porter Assistant Secretary Medical Assistance Administration P.O. Box 45100 Olympia, WA 98504-5100 T: 360/902-1863 F: 360/902-7855 E-mail: [email protected] Internet address: www.fortress.wa.gov/dshs/maa

Single State Agency Director Ms. Martha Yeager Walker Secretary Department of Health and Human Resources Building 3, State Capitol Complex Room 206 Charleston, WV 25305 T: 304/558-0684 F: 304/558-1130 E-mail: [email protected] Internet address: www.wvd.hhr.org Medicaid Director Ms. Nancy Atkins, Commissioner Bureau for Medical Services Department of Health and Human Resources 7012 MacCorkle Avenue, SE Charleston, WV 25301 T: 304/558-1700 F: 304/558-1509 E-mail: [email protected] Internet address: www.wvdhhr.org/bms

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Single State Agency Director Ms. Helene Nelson, Secretary Department of Health and Family Services One West Wilson Street, Room 650 Madison, WI 53702 T: 608/266-9622 F: 608/266-7882 E-mail: [email protected] Internett address: www.dhfs.state.wi.us Medicaid Director Mr. Mark B. Moody, Administrator Division of Health Care Financing One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-2522 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us

National Pharmaceutical Council

Pharmaceutical Benefits 2004

WYOMING Governor Honorable Dave Freudenthal State Capitol, Room 124 Cheyenne, WY 82002-0010 T: 307/777-7434 F: 307/632-3909 E-mail: [email protected] Internet address: www.state.wy.us Single State Agency Director Ms. Deb Fleming, Ph.D., Director Department of Health 117 Hathaway Building Cheyenne, WY 82002 T: 307/777-7656 F: 307/777-7439 E-mail: [email protected] Internet address: www.wdhfs.state.wy.us Medicaid Director Ms. Iris Oleske, State Medicaid Agent Department of Health 147 Hathaway Building Cheyenne, WY 82002 T: 307/777-7531 F: 307/777-6964 E-mail: [email protected] Internet address: wdhfs.state.wy.us

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) REGIONAL OFFICES ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID Region I Boston Regional Office

Region II New York Regional Office

Region III Philadelphia Regional Office

Region IV Atlanta Regional Office

Region V Chicago Regional Office

Region VI Dallas Regional Office

Region VII Kansas City Regional Office

Region VIII Denver Regional Office

Region IX San Francisco Regional Office

Region X Seattle Regional Office

Peggy Leoni John F. Kennedy Federal Bldg. Government Center, Room 2325 Boston, MA 02203-0003 617/565-1299 Sue Kelly 26 Federal Plaza Room 3811 New York, NY 10278-0063 212/264-2058 Sue Cuerdon The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 215/861-4261 Hugh Webster (Acting) Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 404/562-7432 Cheryl Harris 233 North Michigan Avenue Suite 600 Chicago, IL 60601-5519 312/353-2702 Andrew Fredrickson 1301 Young Street, Room 714 Dallas, TX 75202 214/767-6385 James Scott Richard Bolling Federal Building 601 East 12th Street, Room 235 Kansas City, MO 64106-2808 816/426-6417 Diane Livesay Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 303/844-7057 Linda Minamoto 75 Hawthorne Street, 4th & 5th Floors San Francisco, CA 94105-3901 415/744-3568 Karen O’Connor 2201 6th Avenue Mail Stop RX-43 Seattle, WA 98121-2500 206/615-2330

Source: CMS, Central Office, Centers for Medicaid and State Operations, as of April 2005.

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Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

New Jersey, New York, Puerto Rico, Virgin Islands

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Iowa, Kansas, Missouri, Nebraska

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Arizona, California, Hawaii, Guam Nevada, and Pacific Islands

Alaska, Idaho, Oregon, Washington

National Pharmaceutical Council

Pharmaceutical Benefits 2004

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) NATIONAL ACCOUNT REPRESENTATIVES STATE

CENTRAL OFFICE

REGIONAL OFFICE

Alabama

Virginia Wanamaker Deputy Director Division of Laboratory Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-7304 E-mail: [email protected]

Jay Gavens Financial Analyst Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7430 E-mail: [email protected]

Alaska

Richard Strauss Director Division of Financial Management Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-2019 E-mail: [email protected]

Elizabeth Trias Health Insurance Specialist Medicaid Branch, Region X 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2400 E-mail: [email protected]

American Samoa

Linda Murphy Health Insurance Specialist Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0435 E-mail: [email protected]

Mary Rydell Pacific Area Representative P.O. Box 50081 300 Ala Moana Blvd., 6-225 Honolulu, HI 96850 T: 808/541-2732 E-mail: [email protected]

Arizona

Angela Brice-Smith Deputy Director Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4340 E-mail: [email protected]

Ronald Reepen Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3601 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Arkansas

Marty Svolos Director Division of Eligibility, Enrollment and Outreach Family and Children's Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4582 E-mail: [email protected]

J. P. Peters Health Insurance Specialist 1301 Young Street, Room 833 Dallas, TX 75202 T: 214/767-2628 E-mail: [email protected]

California

Bill Lasowski Financial Advisor Office of the Center Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-2003 E-mail: [email protected]

Pat Daley Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3592 E-mail: [email protected]

Colorado

Edward Gendron Director Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1064 E-mail: [email protected]

Cynthia Gillaspie Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-4725 E-mail: [email protected]

Connecticut

Edward Hutton Technical Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6616 E-mail: [email protected]

Irvin Rich JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1247 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Delaware

Denise Bazemore Technical Director Division of State Systems Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4449 E-mail: [email protected]

Paul Hughes Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4171 E-mail: [email protected]

District of Columbia

Rick Fenton Deputy Director Family and Children's Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5920 E-mail: [email protected]

Marguerite Clark Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4199 E-mail: [email protected]

Florida

Jim Frizzera Co-Lead, National Institutional Reimbursement Team Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-9535 E-mail: [email protected]

Roberta Kelley Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7338 E-mail: [email protected]

Georgia

Jerry Zelinger Medical Advisor Division of Benefits, Coverage and Payment Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5929 E-mail: [email protected]

Hugh Webster Chief Medicaid Financial Management Branch Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7432 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Guam

Paul Miner Technical Director Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5937 E-mail: [email protected]

Eddie Martin Accountant 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3588 E-mail: [email protected]

Hawaii

Larry Reed Co-Lead, Pharmacy Team Family and Children's Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3325 E-mail: [email protected]

Susan Castleberry Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3599 E-mail: [email protected]

Idaho

Georgia Johnson Technical Director Division of Continuing Care Providers Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6859 E-mail: [email protected]

David Meacham Health Insurance Specialist 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2356 E-mail: [email protected]

Illinois

Mary Beth Hance Director Policy Coordination and Planning Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4299 E-mail: [email protected]

Alice Holden 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-1582 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Indiana

Kristin Fan Supervisory Health Insurance Specialist Division of Reimbursement and State Finance Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4581 E-mail: [email protected]

Leslie Campbell Indiana State Representative 233 N. Michigan Avenue Suite 600 Chicago, IL 6061 T: 312/353-1557 E-mail: [email protected]

Iowa

Mary Jean Duckett Director Division of Benefits, Coverage and Payment Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3294 E-mail: [email protected]

James G. Scott Branch Manager DMCH, PSB Richard Bolling Federal Building 601 East 12th Street, Room 235 Kansas City, MO 64106-2808 T: 816/426-6417 E-mail: [email protected]

Kansas

Frank Sokolik Director Division of Acute Care Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-7089 E-mail: [email protected]

Tim Watson Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-6462 E-mail: [email protected]

Kentucky

Jack Williams Director Division of National Systems Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6743

Renard Murray Associate Regional Administrator Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7417 E-mail: [email protected]

E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Louisiana

Jean Sheil Director Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1285 E-mail: [email protected]

Robert Cowan Financial Operations Specialist 1301 Young Street, Room 714 Dallas, TX 75202 T: 214/767-6485 E-mail: [email protected]

Maine

Roger Buchanan Director Division of Informational Analysis and Technical Assistance Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0780 E-mail: [email protected]

Richard Pecorella JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1244 E-mail: [email protected]

Maryland

Kathy Rama Technical Director Division of Advocacy and Special Issues Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6659 E-mail: [email protected]

James Hake Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4196 E-mail: [email protected]

Massachusetts

Tom Hamilton Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6763 E-mail: [email protected]

Alan P. Bryan Health Insurance Specialist JFK Federal Building Government Center, Room 2275 Boston, MA 02203-0003 T: 617/565-1246 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Michigan

Lillian Gibbons Senior Advisor Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-8705 E-mail: [email protected]

Ruth Hughes 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-1670 E-mail: [email protected]

Minnesota

Terry Pratt Director Division of Integrated Health Systems Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-9499 E-mail: [email protected]

Doris Ross 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-9843 E-mail: [email protected]

Mississippi

Diona Kristian Technical Director Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3283 E-mail: [email protected]

Selwyn White Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7427 E-mail: [email protected]

Missouri

Peggy Clark Technical Director Division of Integrated Health Systems Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5321 E-mail: [email protected]

Jackie Glaze Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-6458 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Montana

Kathleen Farrell Special Assistant Office of the Center Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1236 E-mail: [email protected]

Betty Strecker Colorado State Bank Building 1600 Broadway Suite 700 Denver, CO 80202-4367 T: 303/844-7028 E-mail: [email protected]

Nebraska

Tracey Mummert Special Assistant Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3398 E-mail: [email protected]

Diana Townsend Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-6456 E-mail: [email protected]

Nevada

Judy Yost Director Division of Laboratory Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3407 E-mail: [email protected]

Barbie Robinson Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3591 E-mail: [email protected]

New Hampshire

Jan Tarantino Deputy Director Division of Continuing Care Providers Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0905 E-mail: [email protected]

Harold Finn JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1225 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

New Jersey

Fred Gladden Technical Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3033 E-mail: [email protected]

Julie Alberino 26 Federal Plaza Room 3800 New York, NY 10278-0063 T: 212/264-3904 E-mail: [email protected]

New Mexico

David Escobedo Supervisory Health Insurance Specialist Survey and Administrative Budget Staff Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5401 E-mail: [email protected]

Jack Allen Health Insurance Specialist 1301 Young Street, Room 827 Dallas, TX 75202 T: 214/767-4425 E-mail: [email protected]

New York

Carmen Keller Acting Deputy Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3230 E-mail: [email protected]

Sue Kelly 26 Federal Plaza Room 3800 New York, NY 10278-0063 T: 212/264-2058 E-mail: [email protected]

North Carolina

Joe Razes Technical Director Division of Advocacy and Special Issues Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6126 E-mail: [email protected]

Donna Cross State Representative for North Carolina Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7406 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

North Dakota

James Merrill Life Safety Code Specialist Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6998 E-mail: [email protected]

Bernadette Quevedo-Mendoza State Program Coordinator Office of the Regional Administrator, CMS Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7121 E-mail: [email protected]

Northern Mariana Islands

Edward Mortimore Technical Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3509 E-mail: [email protected]

H. Stephen Deering Deputy Regional Administrator, CMS 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3501 E-mail: [email protected]

Ohio

Deirdre Duzor Co-Lead, Pharmacy Team Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4626 E-mail: [email protected]

Gwendolyn Sampson 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-9861 E-mail: [email protected]

Oklahoma

Melissa Hulbert Director Division of Continuing Care Providers Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6568 E-mail: [email protected]

Ford Blunt Health Insurance Specialist 1301 Young Street, Room 827 Dallas, TX 75202 T: 214/767-6381 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Oregon

Alissa DeBoy Special Assistant Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6041 E-mail: [email protected]

Barbara Subert Health Insurance Specialist Medicaid Branch, Region X 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2390 E-mail: [email protected]

Pennsylvania

Cheryl Austein-Casnoff Director Division of State Children’s Health Insurance Family and Children's Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4196 E-mail: [email protected]

Michael Cruse Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4216 E-mail: [email protected]

Puerto Rico

Cindy Melanson Health Program Evaluator Division of Acute Care Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0310 E-mail: [email protected]

Frank Fournier La Torre de Plaza Las Americas Suite 1116 525 F.SD. Roosevelt Ave. San Juan, PR 000919-8024 T: 787/771-3687 E-mail: [email protected]

Rhode Island

Rick Friedman Director Division of State Systems Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4451 E-mail: [email protected]

Elena Nicolella Health Insurance Specialist JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1243 E-mail: [email protected]

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

South Carolina

Helaine Jeffers Deputy Director Division of Acute Care Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5648 E-mail: [email protected]

Jessie Spillers 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7418 E-mail: [email protected]

South Dakota

David Eddinger Technical Director Division of Laboratory Systems Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3429 E-mail: [email protected]

Cynthia Riddle State Program Coordinator Office of the Regional Administrator Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7116 E-mail: [email protected]

Tennessee

Mike Fiore Acting Director Division of Benefits, Coverage and Payment Disabled and Elderly Health Programs Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0623 E-mail: [email protected]

Dorothy Smith Health Insurance Specialist Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7159 E-mail: [email protected]

Texas

Marlene Jones Lead Health Insurance Specialist Policy Coordination and Planning Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3290 E-mail: [email protected]

Joe Reeder Health Insurance Specialist 1301 Young Street, Room 714 Dallas, TX 75202 T: 214/767-4419 E-mail: [email protected]

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Utah

Aaron Blight Acting Director Division of Benefits, Coverage and Payment Family and Children’s Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-9560 E-mail: [email protected]

Tilly Rollin Utah State Program Coordinator Office of the Regional Administrator Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7111 E-mail: [email protected]

Vermont

Clarke Cagey Special Assistant Office of the Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3135 E-mail: [email protected]

Chong B. Tieng Health Insurance Specialist JFK Federal Building Government Center, Room 2275 Boston, MA 02203-0003 T: 617/565-9157 E-mail: [email protected]

Virginia

Ginni Hain Director Division of Eligibility, Enrollment and Outreach Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6036 E-mail: [email protected]

Jake Hubik Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4181 E-mail: [email protected]

Virgin Islands

Cindy Graunke Director Division of Nursing Homes Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6782 E-mail: [email protected]

Ricardo Holligan 26 Federal Plaza Room 3811 New York, NY 10278-0063 T: 212/264-3978 E-mail: [email protected]

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Washington

Gale Arden Director Private Health Insurance Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6810 E-mail: [email protected]

Carol Crimi Health Insurance Specialist Medicaid Branch Division of Medicaid and State Operations 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2515 E-mail: [email protected]

West Virginia

Joan Simmons Deputy Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3409 E-mail: [email protected]

Donna Fischer Health Insurance Specialist The Public Ledger Building, Suite 230 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4221 E-mail: [email protected]

Wisconsin

Glenn Stanton Deputy Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6768 E-mail: [email protected]

Pam Carson 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-0108 E-mail: [email protected]

Wyoming

George Karahalis Director, Training Staff Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3486 E-mail: [email protected]

Robert Tonsberg Epidemiologist, Sr. Health Services Office Manager Office of the Regional Administrator Colorado State Bank Bldg. 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-1981 E-mail: [email protected]

Source: CMS Website at www.cms.hhs.gov/states/natreps.pdf Central Office CMSO staff: Information as of April 2005.

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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) CENTER FOR MEDICAID AND STATE OPERATIONS (CMSO) CENTRAL OFFICE STAFF 7500 Security Boulevard Baltimore, MD 21244-1850 410/786-3000 Director Dennis Smith 410/786-3870

Acting Deputy Director Carmen Keller 410/786-3230

Appeals and Grievances Bob Tomlinson (Fee-for-Service) 410/786-4463

Financial Advisor Bill Lasowski 410/786-3870 Eligibility Marty Svolos (Families & Children) 410/786-4582 Roy Trudel (Disabled/Elderly) 410/786-3417

Assignment of Rights to Benefits Cheryl Camillo 410/786-1068 Budget Information for State Agencies John Hoover 410/786-2020

Family/Children 1915(b) Waivers; 1115 Demonstrations; and the Health Insurance Flexibility & Accountability Initiative (HIFA) Bruce Greenstein 410/786-3283

Children’s Health Insurance Kathleen Farrell 410/786-1236

HCFA 2082 Statistical Report Cindy Foltz 410/786-0253

Coordination of Benefits Sarah deLone (Disabled & Elderly) 410/786-7010 Marty Svolos (Families & Children) 410/786-4582

Home and Community Based Waiver Program Reviews; Independence Plus Initiative Susie Bosstick 410/786/1301 Deidra Abbott 410/786/0690

Data Inquiries Dennis Franz 410/786-6117

Managed Care Enrollment Report Carolyn Lawson 410/786/0704

Department Appeals Board Decisions Ed Davis 410/786-3280

Medicaid Statistical Information System (MSIS) Ron North410/786-5651

Disabled/Elderly 1915(b) Waivers; 1115 Demonstrations; And PACE Program Terri Pratt 410/786-5831 Drug Rebate Agreement/Data Vince Powell 410/786-3314

Pharmacy Issues (Coverage, Payment & Rebate Program) Larry Reed 410/786-3325 Deirdre Duzor 410/786-4626 National Institutional Reimbursement Team Bob Reed 206/615-2596

Drug Utilization Review Christina Lyon 410/786-3332

Non-Institutional Payment Team Linda Tavener 410/786-3838

Source: CMS Central Office, CMSO: April 2005.

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Appendix B: Medicaid Program Statistics CMS MSIS Tables

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Medicaid Program Statistics -- MSIS Report The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through September 30). The data reported for a given year represent recipients of service and the amount of payments for claims adjudicated during the year. The data reflect bills adjudicated during the year rather than the services used during the year. Historically, States summarized and reported the data processed through their Medicaid claims processing and payment operations unless they opted to participate in the Medicaid Statistical Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary program and those States participating in the MSIS project provide data tapes from their claims processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted electronically in the MSIS format. The MSIS Report is the primary CMS source on recipients’ use of services and the associated payments for these services. However, the new reporting requirements have resulted in a lag in the timely release of MSIS summary tables. The most recent MSIS service utilization information available from CMS is for FY 2002. In addition, Puerto Rico and the U.S. territories have been excluded from the tables and the National totals. In an effort to provide more recent recipient information as well as to maintain continuity with previous version of the Compilation, we have compiled ten tables from the MSIS data system for inclusion in this Appendix. The first two tables provide national level summary information on total expenditures and total number of recipients by type of service for FY 2001 and FY 2002. The remaining tables present State-by-State and national level data, including some trend information, on total Medicaid recipients, total Medicaid payments, number of prescription drug recipients, and Medicaid prescription drug payments. Additionally, there are three tables at the end of the Appendix that correspond to FY 2002 tables presented in Section 2.

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Pharmaceutical Benefits 2004

Total U.S. Medical Assistance Recipients By Type of Service FY 2001

Percent of Total*

FY 2002

Percent of Total*

Percent Change 2001-2002

Capitated Payment Services

23,355,569

50.6%

25,863,748

52.0%

15.8%

Pharmaceuticals

21,910,532

47.5%

24,424,493

49.1%

12.4%

Physicians

20,021,029

43.4%

22,102,682

44.4%

10.9%

Service

Hospital Outpatient

13,731,009

29.7%

14,861,211

29.9%

9.5%

Lab/X-ray

12,339,065

26.7%

14,067,422

28.3%

14.6%

Other Care

9,897,625

21.4%

11,195,848

22.5%

16.2%

Clinic

8,463,753

18.3%

9,498,844

19.1%

13.5%

Dental

7,018,692

15.2%

7,885,538

15.8%

14.1%

PCCM Services

6,337,864

13.7%

7,177,583

14.4%

16.4%

Personal Support Services

4,977,823

10.8%

5,688,386

11.4%

15.6%

Other Practitioners

5,102,653

11.1%

5,570,691

11.2%

10.5%

Hospital Inpatient

4,879,194

10.6%

5,051,356

10.2%

4.8%

Nursing Facility

1,702,251

3.7%

1,765,700

3.5%

7.8%

Home Health Care

1,013,796

2.2%

1,065,050

2.1%

7.7%

116,610 91,029

0.3% 0.2%

117,497 99,403

0.2% 0.2%

1.7% 11.5%

ICF-Mentally Retarded Mental Health Facility Total Unduplicated Recipients*

46,163,776

49,754,619

11.1%

*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these national totals. Source: CMS, MSIS Report, FY 2001 and FY 2002.

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Total U.S. Medical Assistance Payments By Type of Service FY 2001

Percent of Total*

FY 2002

Percent of Total*

Percent Change 2001-2002

Nursing Facility

$37,322,711,413

20.0%

$39,282,167,886

18.4%

6.0%

Capitated Payment Services

$29,368,456,447

15.7%

$33,634,458,789

15.8%

21.2%

Hospital Inpatient

$25,943,089,983

13.9%

$29,127,066,408

13.6%

14.0%

Pharmaceuticals

$23,764,446,937

12.7%

$28,408,181,719

13.3%

19.8%

Other Care

$16,756,580,093

9.0%

$20,042,516,439

9.4%

21.6%

Personal Support Services

$13,134,684,443

7.0%

$15,363,088,322

7.2%

18.1%

$9,700,947,510

5.2%

$10,681,301,264

5.0%

10.7%

Service

ICF-Mentally Retarded Hospital Outpatient

$7,496,052,121

4.0%

$8,470,604,661

4.0%

12.8%

Physicians

$7,438,667,704

4.0%

$8,354,616,947

3.9%

12.6%

Clinic

$5,602,689,477

3.0%

$6,693,856,507

3.1%

20.0%

Home Health Care

$3,520,674,702

1.9%

$3,924,725,800

1.8%

12.0%

Dental

$1,896,588,616

1.0%

$2,308,811,686

1.1%

24.0%

Lab/X-Ray

$1,622,597,746

0.9%

$2,157,359,177

1.0%

34.2%

Mental Health Facility

$1,959,318,414

1.0%

$2,122,406,677

1.0%

9.0%

Unknown

$437,818,978

0.2%

$1,878,534,734

0.9%

31.6%

Other Practitioners

$761,679,926

0.4%

$841,952,557

0.4%

11.9%

PCCM Services

$186,779,869

0.1%

$199,663,705

0.1%

9.7%

Total Payments

$186,913,784,379

$213,491,313,278

14.9%

*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these national totals. Source: CMS, MSIS Report, FY 2001 and FY 2002.

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Pharmaceutical Benefits 2004

2002 Baseline Data 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 Payments $213,491,313,278 $3,204,063,602 $686,795,186 $2,881,870,077 $2,015,436,554 $23,636,239,505 $2,166,199,614 $3,245,142,644 $651,384,655 $1,027,022,357 $9,827,003,688 $4,796,005,361 $695,279,178 $791,863,699 $9,121,713,188 $3,725,257,965 $1,855,817,441 $1,501,270,019 $3,459,365,581 $3,234,421,939 $1,716,581,955 $3,662,089,984 $6,387,100,271 $5,918,817,382 $4,439,493,794 $2,499,640,805 $4,071,544,403 $532,886,400 $1,255,039,718 $723,956,752 $745,754,084 $5,497,284,438 $1,796,901,383 $31,488,930,244 $6,041,011,008 $422,745,114 $9,186,330,669 $2,238,213,087 $2,136,400,869 $8,523,928,057 $1,251,440,036 $3,382,950,504 $503,947,234 $4,747,549,898 $11,121,020,040 $1,215,620,497 $607,249,969 $3,017,869,649 $4,373,171,467 $1,577,697,829 $3,605,541,906 $280,451,579

Drug Payments $28,408,181,719 $454,370,478 $83,324,085 $4,338,712 $279,644,642 $3,402,508,001 $202,286,461 $356,980,484 $100,112,623 $68,050,981 $1,736,991,594 $749,552,199 $81,453,811 $121,780,793 $1,222,947,241 $636,357,519 $277,753,942 $220,800,602 $661,409,737 $682,557,080 $250,331,526 $320,313,995 $952,790,939 $674,898,273 $294,838,630 $568,084,274 $799,910,014 $77,980,883 $196,526,107 $90,134,969 $98,836,636 $686,301,522 $92,674,018 $3,413,404,507 $1,069,140,895 $51,749,961 $1,330,569,382 $267,549,002 $269,936,847 $719,243,402 $126,331,040 $456,976,916 $63,654,623 $573,588,021 $1,591,828,224 $140,520,420 $115,623,970 $453,663,058 $549,216,380 $274,613,136 $455,720,622 $38,008,542

Source: CMS, MSIS Report, FY 2002.

B-7

Total Recipients 49,754,619 765,328 109,641 878,362 579,278 9,301,001 425,878 479,051 167,162 193,494 2,676,235 1,637,329 199,966 176,499 1,731,398 849,427 352,635 289,349 808,294 898,824 275,826 692,539 1,065,636 1,449,915 620,652 712,457 1,036,150 103,617 255,771 202,306 104,138 954,491 798,665 3,920,718 1,355,269 70,132 1,656,124 631,498 621,462 1,627,261 199,014 809,136 117,631 1,732,381 2,952,569 274,707 153,731 665,203 1,039,070 362,030 716,298 59,071

Drug Recipients 24,424,493 500,789 70,550 7,805 356,233 2,651,229 153,520 123,704 125,461 45,216 1,245,841 1,076,904 39,320 125,537 1,199,933 490,386 245,711 157,618 489,416 689,973 224,664 181,101 659,626 577,785 190,577 526,923 493,230 67,365 194,889 71,950 78,861 296,059 122,098 2,567,595 949,795 44,428 997,246 276,111 242,865 464,848 53,729 576,136 64,948 916,968 2,153,316 152,268 112,227 319,196 423,758 276,338 309,795 42,652

Drug $ as a % of Total $ 13.3% 14.2% 12.1% 0.2% 13.9% 14.4% 9.3% 11.0% 15.4% 6.6% 17.7% 15.6% 11.7% 15.4% 13.4% 17.1% 15.0% 14.7% 19.1% 21.1% 14.6% 8.7% 14.9% 11.4% 6.6% 22.7% 19.6% 14.6% 15.7% 12.5% 13.3% 12.5% 5.2% 10.8% 17.7% 12.2% 14.5% 12.0% 12.6% 8.4% 10.1% 13.5% 12.6% 12.1% 14.3% 11.6% 19.0% 15.0% 12.6% 17.4% 12.6% 13.6%

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Payments and Recipients, 2002 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 Payments $213,491,313,278 $3,204,063,602 $686,795,186 $2,881,870,077 $2,015,436,554 $23,636,239,505 $2,166,199,614 $3,245,142,644 $651,384,655 $1,027,022,357 $9,827,003,688 $4,796,005,361 $695,279,178 $791,863,699 $9,121,713,188 $3,725,257,965 $1,855,817,441 $1,501,270,019 $3,459,365,581 $3,234,421,939 $1,716,581,955 $3,662,089,984 $6,387,100,271 $5,918,817,382 $4,439,493,794 $2,499,640,805 $4,071,544,403 $532,886,400 $1,255,039,718 $723,956,752 $745,754,084 $5,497,284,438 $1,796,901,383 $31,488,930,244 $6,041,011,008 $422,745,114 $9,186,330,669 $2,238,213,087 $2,136,400,869 $8,523,928,057 $1,251,440,036 $3,382,950,504 $503,947,234 $4,747,549,898 $11,121,020,040 $1,215,620,497 $607,249,969 $3,017,869,649 $4,373,171,467 $1,577,697,829 $3,605,541,906 $280,451,579

Source: CMS, MSIS Report, FY 2002.

B-8

Total Recipients 49,754,619 765,328 109,641 878,362 579,278 9,301,001 425,878 479,051 167,162 193,494 2,676,235 1,637,329 199,966 176,499 1,731,398 849,427 352,635 289,349 808,294 898,824 275,826 692,539 1,065,636 1,449,915 620,652 712,457 1,036,150 103,617 255,771 202,306 104,138 954,491 798,665 3,920,718 1,355,269 70,132 1,656,124 631,498 621,462 1,627,261 199,014 809,136 117,631 1,732,381 2,952,569 274,707 153,731 665,203 1,039,070 362,030 716,298 59,071

Payments Per Recipient $4,291 $4,187 $6,264 $3,281 $3,479 $2,541 $5,086 $6,774 $3,897 $5,308 $3,672 $2,929 $3,477 $4,487 $5,268 $4,386 $5,263 $5,188 $4,280 $3,599 $6,223 $5,288 $5,994 $4,082 $7,153 $3,508 $3,929 $5,143 $4,907 $3,579 $7,161 $5,759 $2,250 $8,031 $4,457 $6,028 $5,547 $3,544 $3,438 $5,238 $6,288 $4,181 $4,284 $2,740 $3,767 $4,425 $3,950 $4,537 $4,209 $4,358 $5,034 $4,748

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Drug Payments and Recipients, 2002 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 $28,408,181,719 $454,370,478 $83,324,085 $4,338,712 $279,644,642 $3,402,508,001 $202,286,461 $356,980,484 $100,112,623 $68,050,981 $1,736,991,594 $749,552,199 $81,453,811 $121,780,793 $1,222,947,241 $636,357,519 $277,753,942 $220,800,602 $661,409,737 $682,557,080 $250,331,526 $320,313,995 $952,790,939 $674,898,273 $294,838,630 $568,084,274 $799,910,014 $77,980,883 $196,526,107 $90,134,969 $98,836,636 $686,301,522 $92,674,018 $3,413,404,507 $1,069,140,895 $51,749,961 $1,330,569,382 $267,549,002 $269,936,847 $719,243,402 $126,331,040 $456,976,916 $63,654,623 $573,588,021 $1,591,828,224 $140,520,420 $115,623,970 $453,663,058 $549,216,380 $274,613,136 $455,720,622 $38,008,542

Total Drug Recipients 24,424,493 500,789 70,550 7,805 356,233 2,651,229 153,520 123,704 125,461 45,216 1,245,841 1,076,904 39,320 125,537 1,199,933 490,386 245,711 157,618 489,416 689,973 224,664 181,101 659,626 577,785 190,577 526,923 493,230 67,365 194,889 71,950 78,861 296,059 122,098 2,567,595 949,795 44,428 997,246 276,111 242,865 464,848 53,729 576,136 64,948 916,968 2,153,316 152,268 112,227 319,196 423,758 276,338 309,795 42,652

Source: CMS, MSIS Report, FY 2002.

B-9

Drug Payments Per Recipient $1,163 $907 $1,181 $556 $785 $1,283 $1,318 $2,886 $798 $1,505 $1,394 $696 $2,072 $970 $1,019 $1,298 $1,130 $1,401 $1,351 $989 $1,114 $1,769 $1,444 $1,168 $1,547 $1,078 $1,622 $1,158 $1,008 $1,253 $1,253 $2,318 $759 $1,329 $1,126 $1,165 $1,334 $969 $1,111 $1,547 $2,351 $793 $980 $626 $739 $923 $1,030 $1,421 $1,296 $994 $1,471 $891

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Drug Payment Trends, Percent Change 2001-2002 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

2001 $23,764,446,937 $392,482,787 $66,767,949 $4,667,946 $248,390,866 $2,808,441,711 $178,062,912 $304,481,051 $81,623,058 $62,296,126 $1,490,095,934 $702,719,257 $71,231,541 $105,497,059 $934,231,380 $562,126,868 $231,010,303 $189,946,034 $599,970,167 $556,393,280 $204,014,566 $267,759,816 $796,340,945 $604,782,305 $265,097,886 $494,809,464 $682,958,006 $69,741,505 $161,820,256 $63,364,124 $90,927,594 $649,649,655 $70,202,173 $2,782,394,132 $971,104,266 $43,288,363 $1,118,119,811 $216,827,265 $222,391,952 $690,558,773 $104,918,227 $438,502,264 $52,610,673 $0 $1,327,254,967 $117,477,586 $105,993,594 $419,148,437 $464,082,836 $256,395,319 $389,373,742 $32,100,206

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

B-10

2002 $28,408,181,719 $454,370,478 $83,324,085 $4,338,712 $279,644,642 $3,402,508,001 $202,286,461 $356,980,484 $100,112,623 $68,050,981 $1,736,991,594 $749,552,199 $81,453,811 $121,780,793 $1,222,947,241 $636,357,519 $277,753,942 $220,800,602 $661,409,737 $682,557,080 $250,331,526 $320,313,995 $952,790,939 $674,898,273 $294,838,630 $568,084,274 $799,910,014 $77,980,883 $196,526,107 $90,134,969 $98,836,636 $686,301,522 $92,674,018 $3,413,404,507 $1,069,140,895 $51,749,961 $1,330,569,382 $267,549,002 $269,936,847 $719,243,402 $126,331,040 $456,976,916 $63,654,623 $573,588,021 $1,591,828,224 $140,520,420 $115,623,970 $453,663,058 $549,216,380 $274,613,136 $455,720,622 $38,008,542

Percent Change 19.54% 15.77% 24.80% -7.05% 12.58% 21.15% 13.60% 17.24% 22.65% 9.24% 16.57% 6.66% 14.35% 15.44% 30.90% 13.21% 20.23% 16.24% 10.24% 22.68% 22.70% 19.63% 19.65% 11.59% 11.22% 14.81% 17.12% 11.81% 21.45% 42.25% 8.70% 5.64% 32.01% 22.68% 10.10% 19.55% 19.00% 23.39% 21.38% 4.15% 20.41% 4.21% 20.99% 19.93% 19.61% 9.09% 8.23% 18.34% 7.11% 17.04% 18.41%

National Pharmaceutical Council

Pharmaceutical Benefits 2004

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

2002 Payments $3,413,404,507 $3,402,508,001 $1,736,991,594 $1,591,828,224 $1,330,569,382 $1,222,947,241 $1,069,140,895 $952,790,939 $799,910,014 $749,552,199 $719,243,402 $686,301,522 $682,557,080 $674,898,273 $661,409,737 $636,357,519 $573,588,021 $568,084,274 $549,216,380 $456,976,916 $455,720,622 $454,370,478 $453,663,058 $356,980,484 $320,313,995 $294,838,630 $279,644,642 $277,753,942 $274,613,136 $269,936,847 $267,549,002 $250,331,526 $220,800,602 $202,286,461 $196,526,107 $140,520,420 $126,331,040 $121,780,793 $115,623,970 $100,112,623 $98,836,636 $92,674,018 $90,134,969 $83,324,085 $81,453,811 $77,980,883 $68,050,981 $63,654,623 $51,749,961 $38,008,542 $4,338,712

Ranking 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 51

% of 2002 Total Medicaid Drug Payments 12.02% 11.98% 6.11% 5.60% 4.68% 4.30% 3.76% 3.35% 2.82% 2.64% 2.53% 2.42% 2.40% 2.38% 2.33% 2.24% 2.02% 2.00% 1.93% 1.61% 1.60% 1.60% 1.60% 1.26% 1.13% 1.04% 0.98% 0.98% 0.97% 0.95% 0.94% 0.88% 0.78% 0.71% 0.69% 0.49% 0.44% 0.43% 0.41% 0.35% 0.35% 0.33% 0.32% 0.29% 0.29% 0.27% 0.24% 0.22% 0.18% 0.13% 0.02%

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

B-11

2001 Payments $2,782,394,132 $2,808,441,711 $1,490,095,934 $1,327,254,967 $1,118,119,811 $934,231,380 $971,104,266 $796,340,945 $682,958,006 $702,719,257 $690,558,773 $649,649,655 $556,393,280 $604,782,305 $599,970,167 $562,126,868 $0 $494,809,464 $464,082,836 $438,502,264 $389,373,742 $392,482,787 $419,148,437 $304,481,051 $267,759,816 $265,097,886 $248,390,866 $231,010,303 $256,395,319 $222,391,952 $216,827,265 $204,014,566 $189,946,034 $178,062,912 $161,820,256 $117,477,586 $104,918,227 $105,497,059 $105,993,594 $81,623,058 $90,927,594 $70,202,173 $63,364,124 $66,767,949 $71,231,541 $69,741,505 $62,296,126 $52,610,673 $43,288,363 $32,100,206 $4,667,946

Ranking 2 1 3 4 5 7 6 8 11 9 10 12 16 13 14 15 51 17 18 19 22 21 20 23 24 25 27 28 26 29 30 31 32 33 34 35 38 37 36 40 39 42 45 44 41 43 46 47 48 49 50

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Payments, 2002 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

Drug Payments $28,408,181,719 $454,370,478 $83,324,085 $4,338,712 $279,644,642 $3,402,508,001 $202,286,461 $356,980,484 $100,112,623 $68,050,981 $1,736,991,594 $749,552,199 $81,453,811 $121,780,793 $1,222,947,241 $636,357,519 $277,753,942 $220,800,602 $661,409,737 $682,557,080 $250,331,526 $320,313,995 $952,790,939 $674,898,273 $294,838,630 $568,084,274 $799,910,014 $77,980,883 $196,526,107 $90,134,969 $98,836,636 $686,301,522 $92,674,018 $3,413,404,507 $1,069,140,895 $51,749,961 $1,330,569,382 $267,549,002 $269,936,847 $719,243,402 $126,331,040 $456,976,916 $63,654,623 $573,588,021 $1,591,828,224 $140,520,420 $115,623,970 $453,663,058 $549,216,380 $274,613,136 $455,720,622 $38,008,542

Total Payments $213,491,313,278 $3,204,063,602 $686,795,186 $2,881,870,077 $2,015,436,554 $23,636,239,505 $2,166,199,614 $3,245,142,644 $651,384,655 $1,027,022,357 $9,827,003,688 $4,796,005,361 $695,279,178 $791,863,699 $9,121,713,188 $3,725,257,965 $1,855,817,441 $1,501,270,019 $3,459,365,581 $3,234,421,939 $1,716,581,955 $3,662,089,984 $6,387,100,271 $5,918,817,382 $4,439,493,794 $2,499,640,805 $4,071,544,403 $532,886,400 $1,255,039,718 $723,956,752 $745,754,084 $5,497,284,438 $1,796,901,383 $31,488,930,244 $6,041,011,008 $422,745,114 $9,186,330,669 $2,238,213,087 $2,136,400,869 $8,523,928,057 $1,251,440,036 $3,382,950,504 $503,947,234 $4,747,549,898 $11,121,020,040 $1,215,620,497 $607,249,969 $3,017,869,649 $4,373,171,467 $1,577,697,829 $3,605,541,906 $280,451,579

Source: CMS, MSIS Report, FY 2002.

B-12

Percent of Total Payments 13.3% 14.2% 12.1% 0.2% 13.9% 14.4% 9.3% 11.0% 15.4% 6.6% 17.7% 15.6% 11.7% 15.4% 13.4% 17.1% 15.0% 14.7% 19.1% 21.1% 14.6% 8.7% 14.9% 11.4% 6.6% 22.7% 19.6% 14.6% 15.7% 12.5% 13.3% 12.5% 5.2% 10.8% 17.7% 12.2% 14.5% 12.0% 12.6% 8.4% 10.1% 13.5% 12.6% 12.1% 14.3% 11.6% 19.0% 15.0% 12.6% 17.4% 12.6% 13.6%

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Drugs as a Percentage of Total Payments, 1996 – 2002* 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

1996 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%

1997 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%

1998 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%

1999 10.8% 16.6% 9.9% 0.1% 13.4% 11.9% 8.0% 8.3% 11.6% 5.9% 16.3% 14.3% 8.4% 13.2% 10.6% 13.7% 12.4% 12.7% 13.8% 16.0% 12.1% 6.7% 12.0% 6.8% 6.1% 17.2% 17.2% 13.4% 13.2% 8.8% 12.3% 11.2% 4.2% 7.6% 14.3% 9.1% 12.0% 11.7% 7.7% 9.9% 8.5% 10.5% 10.0% 0.0% 11.7% 10.5% 16.0% 14.9% 11.8% 14.6% 12.4% 11.2%

2000 11.8% 13.9% 11.3% 0.1% 13.6% 13.5% 8.5% 9.3% 12.5% 7.0% 18.4% 16.2% 9.8% 14.1% 10.8% 15.6% 13.2% 13.7% 15.9% 18.2% 13.4% 7.4% 12.6% 7.7% 6.8% 20.5% 18.4% 14.0% 14.1% 10.0% 12.4% 12.4% 4.6% 9.1% 16.4% 10.6% 12.4% 11.1% 9.5% 8.4% 8.4% 12.1% 11.1% 0.0% 12.1% 10.5% 19.2% 15.4% 16.0% 15.5% 11.8% 12.8%

2001 12.7% 13.3% 11.9% 0.2% 14.4% 14.1% 9.1% 10.3% 13.6% 7.5% 17.4% 17.3% 12.0% 14.8% 11.5% 16.7% 13.9% 13.9% 18.5% 19.3% 14.0% 8.1% 13.8% 11.4% 7.0% 22.7% 18.8% 14.7% 14.8% 10.6% 13.2% 12.9% 4.7% 10.0% 17.6% 11.5% 13.9% 10.8% 11.8% 9.0% 9.6% 14.2% 12.3% 0.0% 13.8% 11.0% 19.6% 15.4% 17.1% 16.4% 12.2% 13.3%

2002 13.3% 14.2% 12.1% 0.2% 13.9% 14.4% 9.3% 11.0% 15.4% 6.6% 17.7% 15.6% 11.7% 15.4% 13.4% 17.1% 15.0% 14.7% 19.1% 21.1% 14.6% 8.7% 14.9% 11.4% 6.6% 22.7% 19.6% 14.6% 15.7% 12.5% 13.3% 12.5% 5.2% 10.8% 17.7% 12.2% 14.5% 12.0% 12.6% 8.4% 10.1% 13.5% 12.6% 12.1% 14.3% 11.6% 19.0% 15.0% 12.6% 17.4% 12.6% 13.6%

*Hawaii did not report on time for FY 1997 and FY 1999 and was excluded from the national totals for those years. Hawaii also did not report for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report. Oklahoma did not report for FY 1998 and was excluded from the national total for that year. Source: CMS, HCFA-2082 Reports, FY 1996 - FY 1998 and MSIS Reports, FY 1999 – FY 2002.

B-13

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Drug Recipients * State 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

1996 1997 1998 1999 2000 22,575,656 20,943,872 19,324,605 19,428,344 20,324,675 412,511 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

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

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

405,330 52,070 5,545 280,552 2,252,441 151,537 108,754 73,093 37,862 991,927 843,353 35,837 81,980 966,790 361,661 213,144 153,054 366,051 551,698 143,548 159,779 671,741 436,848 184,075 375,573 412,597 59,182 155,136 48,534 71,039 301,022 55,018 2,024,870 812,234 37,780 796,720 222,456 174,931 520,221 49,277 446,893 50,780 0 1,853,348 130,682 89,547 377,588 301,907 274,894 224,165 33,280

438,529 60,273 7,034 290,749 2,491,537 160,265 113,101 78,167 38,129 1,078,631 882,309 37,316 92,776 1,013,387 420,071 212,178 158,334 425,721 581,356 149,262 163,410 671,716 435,723 179,879 415,925 447,068 58,918 166,031 51,170 73,313 299,356 67,239 2,173,856 827,389 38,964 777,632 221,985 193,924 416,498 49,809 474,470 53,666 0 1,852,828 133,224 103,635 344,877 339,611 262,675 267,417 33,342

2001 21,910,532

2002 24,424,493

464,695 65,278 9,761 321,920 2,489,050 143,167 116,785 85,350 35,324 1,165,866 978,404 39,288 112,357 1,068,687 464,975 221,690 158,515 476,774 628,574 194,288 171,747 671,756 551,680 187,854 478,409 472,645 63,352 178,634 58,699 73,489 305,962 75,892 2,458,197 907,741 39,758 934,632 252,025 223,580 461,114 50,411 542,768 58,212 0 1,917,398 136,719 109,578 334,008 385,408 269,174 262,238 36,704

500,789 70,550 7,805 356,233 2,651,229 153,520 123,704 125,461 45,216 1,245,841 1,076,904 39,320 125,537 1,199,933 490,386 245,711 157,618 489,416 689,973 224,664 181,101 659,626 577,785 190,577 526,923 493,230 67,365 194,889 71,950 78,861 296,059 122,098 2,567,595 949,795 44,428 997,246 276,111 242,865 464,848 53,729 576,136 64,948 916,968 2,153,316 152,268 112,227 319,196 423,758 276,338 309,795 42,652

Note: Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. *Hawaii did not report on time for FY 1997. They are excluded from the national total for that year. Oklahoma did not report for FY 1998. They are

excluded from the national total for that year. ^Until 2002, Tennessee did not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these plans. Source: CMS, HCFA-2082 Report, FY 1996 - FY1998 and MSIS Report, FY 1999 – FY 2002.

B-14

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles by Basis of Eligibility, 2002 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 Eligibles 51,552,491 845,125 121,400 1,053,602 608,017 9,336,447 438,670 487,989 147,197 204,591 2,691,502 1,459,631 195,684 196,406 2,076,146 881,942 358,708 305,110 769,826 990,286 346,449 752,065 1,204,312 1,527,627 680,627 707,986 1,098,525 106,229 266,245 203,251 115,517 982,676 462,878 4,139,898 1,389,455 71,619 1,754,379 677,788 637,140 1,710,999 204,789 895,863 113,925 1,700,384 3,202,171 233,156 156,958 727,784 1,104,813 362,264 776,638 69,802

Aged 4,759,065 98,709 6,569 43,667 50,510 664,023 47,555 61,797 10,769 13,747 255,655 108,680 17,396 12,968 279,046 78,441 41,577 30,702 72,121 105,311 71,964 55,354 116,164 99,714 69,759 74,033 98,744 10,102 23,526 19,562 12,654 111,710 23,371 398,070 178,258 10,032 144,622 63,837 44,325 212,480 19,667 78,066 10,139 90,398 383,307 12,102 19,661 98,274 79,445 29,678 95,507 5,297

Blind/ Disabled 8,055,109 191,405 12,271 109,978 108,792 989,758 66,257 60,596 17,642 43,794 522,310 232,728 23,627 26,651 300,341 116,543 60,717 52,879 207,955 177,258 119,321 121,570 243,326 297,112 93,872 161,410 150,368 17,688 29,885 33,202 14,611 178,819 55,032 688,012 236,259 9,841 279,463 81,293 68,379 386,422 38,418 122,846 16,420 340,155 379,541 28,075 19,109 139,382 145,928 89,755 139,297 8,796

Children 24,583,011 411,324 73,962 505,858 304,343 3,462,819 219,718 255,429 64,174 88,534 1,331,626 844,963 86,034 124,773 1,016,068 521,163 175,535 161,499 370,090 588,077 97,156 415,260 482,300 804,779 333,759 384,360 566,155 52,662 150,254 95,730 68,911 462,890 290,553 1,737,279 699,139 31,859 924,487 432,322 247,763 779,880 88,794 463,859 67,273 723,890 1,870,141 130,577 66,331 378,035 579,607 176,277 335,343 39,397

Adults 13,245,645 137,462 26,602 386,179 138,152 4,058,935 87,722 102,704 52,705 51,827 538,542 252,563 62,685 29,809 395,940 152,889 70,565 47,647 110,257 110,170 55,101 142,405 361,857 285,805 174,200 84,985 258,115 21,852 51,584 46,638 16,632 207,270 90,085 1,241,408 259,289 18,097 371,476 93,949 261,511 283,257 52,218 222,576 18,157 531,554 534,638 55,627 49,235 97,000 283,313 59,878 188,479 14,099

Foster Care BOE Children Unknown 901,951 1,779 6,224 1 1,938 0 7,920 0 6,206 14 157,995 0 17,297 97 7,372 0 1,876 0 6,689 0 43,369 0 19,550 0 5,942 0 2,205 0 84,506 0 12,730 0 10,314 0 12,383 0 9,403 0 9,470 0 2,907 0 17,373 103 665 0 40,006 211 8,983 0 3,159 39 25,143 0 3,829 9 10,267 661 8,119 0 2,709 0 21,926 0 3,771 19 75,129 0 16,510 0 1,790 0 33,937 394 6,387 0 14,987 175 48,635 0 5,522 0 8,423 16 1,922 0 14,368 19 34,544 0 6,676 0 2,610 12 14,946 1 16,520 0 6,676 0 17,910 8 2,213 0

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. Source: CMS, MSIS Report, FY 2002.

B-15

BCCA Woman 5,931 0 58 0 0 2917 24 91 31 0 0 1147 0 0 245 176 0 0 0 0 0 0 0 0 54 0 0 87 68 0 0 61 47 0 0 0 0 0 0 325 170 77 14 0 0 99 0 146 0 0 94 0

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Total Medicaid Eligibles Per 1000 Population, 2002 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 287,973,924 4,478,896 641,482 5,441,125 2,706,268 35,001,986 4,501,051 3,458,587 805,945 566,157 16,691,701 8,544,005 1,240,663 1,343,124 12,586,447 6,156,913 2,935,840 2,711,769 4,089,822 4,476,192 1,294,894 5,450,525 6,421,800 10,043,221 5,024,791 2,866,733 5,669,544 910,372 1,727,564 2,167,455 1,274,405 8,575,252 1,852,044 19,134,293 8,305,820 636,911 11,408,699 3,489,700 3,520,355 12,328,827 1,068,326 4,103,770 760,437 5,789,796 21,736,925 2,318,789 616,408 7,287,829 6,067,060 1,804,884 5,439,692 498,830

Total Eligibles 51,552,491 845,125 121,400 1,053,602 608,017 9,336,447 438,670 487,989 147,197 204,591 2,691,502 1,459,631 195,684 196,406 2,076,146 881,942 358,708 305,110 769,826 990,286 346,449 752,065 1,204,312 1,527,627 680,627 707,986 1,098,525 106,229 266,245 203,251 115,517 982,676 462,878 4,139,898 1,389,455 71,619 1,754,379 677,788 637,140 1,710,999 204,789 895,863 113,925 1,700,384 3,202,171 233,156 156,958 727,784 1,104,813 362,264 776,638 69,802

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2002.

B-16

Eligibles per 1000 Population 179.0 188.7 189.2 193.6 224.7 266.7 97.5 141.1 182.6 361.4 161.2 170.8 157.7 146.2 164.9 143.2 122.2 112.5 188.2 221.2 267.6 138.0 187.5 152.1 135.5 247.0 193.8 116.7 154.1 93.8 90.6 114.6 249.9 216.4 167.3 112.4 153.8 194.2 181.0 138.8 191.7 218.3 149.8 293.7 147.3 100.6 254.6 99.9 182.1 200.7 142.8 139.9

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Medicaid Total Net Expenditures and Eligibles, 2002 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 Net Medical Assistance Expenditures

Total Eligibles

Average Per Eligible

$245,697,620,676 $3,093,270,640 $685,772,985 $3,541,598,721 $2,237,817,554 $26,890,540,967 $2,323,068,699 $3,456,338,545 $634,046,351 $1,021,772,693 $9,871,508,234 $6,241,211,454 $740,007,314 $773,534,776 $8,809,060,004 $4,448,318,143 $2,575,146,342 $1,836,717,196 $3,763,204,047 $4,885,971,853 $1,430,109,134 $3,613,476,100 $8,063,005,258 $7,562,053,407 $4,414,511,470 $2,877,013,521 $5,360,607,640 $571,456,455 $1,339,132,070 $808,198,344 $1,016,094,814 $7,745,877,997 $1,776,811,688 $36,295,107,368 $6,723,598,560 $461,401,546 $9,658,040,587 $2,260,403,490 $2,571,560,664 $12,130,925,035 $1,358,500,649 $3,292,901,444 $549,884,391 $5,787,079,096 $13,523,486,149 $984,160,785 $660,731,979 $3,812,166,436 $5,168,511,470 $1,584,166,286 $4,193,175,197 $274,565,128

51,552,491 845,125 121,400 1,053,602 608,017 9,336,447 438,670 487,989 147,197 204,591 2,691,502 1,459,631 195,684 196,406 2,076,146 881,942 358,708 305,110 769,826 990,286 346,449 752,065 1,204,312 1,527,627 680,627 707,986 1,098,525 106,229 266,245 203,251 115,517 982,676 462,878 4,139,898 1,389,455 71,619 1,754,379 677,788 637,140 1,710,999 204,789 895,863 113,925 1,700,384 3,202,171 233,156 156,958 727,784 1,104,813 362,264 776,638 69,802

$4,766 $3,660 $5,649 $3,361 $3,681 $2,880 $5,296 $7,083 $4,307 $4,994 $3,668 $4,276 $3,782 $3,938 $4,243 $5,044 $7,179 $6,020 $4,888 $4,934 $4,128 $4,805 $6,695 $4,950 $6,486 $4,064 $4,880 $5,379 $5,030 $3,976 $8,796 $7,882 $3,839 $8,767 $4,839 $6,442 $5,505 $3,335 $4,036 $7,090 $6,634 $3,676 $4,827 $3,403 $4,223 $4,221 $4,210 $5,238 $4,678 $4,373 $5,399 $3,933

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. Source: CMS, CMS-64 Report, FY 2002 and CMS-MSIS Report, 2002.

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Appendix C: Medicaid Rebate Law

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TITLE 42 - THE PUBLIC HEALTH AND WELFARE CHAPTER 7 - SOCIAL SECURITY SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Sec. 1396r-8. Payment for covered outpatient drugs1 (a) Requirement for rebate agreement (1) In general In order for payment to be available under section 1396b(a) of this title or under part B of title XVIII for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after November 4, 1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be retroactively calculated as if the agreement between the manufacturer and the State had been entered into on January 1, 1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an agreement, subsequently entered into, shall become effective as of the date on which the agreement is entered into or, at State option, on any date thereafter on or before the first day of the calendar quarter that begins more than 60 days after the date of the agreement is entered into. (2) Effective date Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991. (3) Authorizing payment for drugs not covered under rebate agreements Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single source drug or innovator multiple source drug if (A)(i) the State has made a determination that the availability of the drug is essential to the health of beneficiaries under the State Plan for medical assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and (iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in accordance with a prior authorization program described in subsection (d) of this section, or (II) the Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances. (4) Effect on existing agreements In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990, such agreement, for the initial agreement period specified therein, shall be considered to be a rebate agreement in compliance with this section with respect to that State, if the State agrees to report to the Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum aggregate rebate of 10 percent of the State’s total expenditures under the State Plan for coverage of the manufacturer’s drugs under this subchapter. If, after the initial agreement period, the State establishes to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for rebates that are at least as large as the rebates otherwise required under this section, and the State agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to be a rebate agreement in compliance with the section for the renewal periods of such agreement. (5) Limitation on prices of drugs purchased by covered entities (A) Agreement with Secretary 1

This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.

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A manufacturer meets the requirements of this paragraph if the manufacturer has entered into an agreement with the Secretary that meets the requirements of section 256b of this title with respect to covered outpatient drugs purchased by a covered entity on or after the first day of the first month that begins after November 4, 1992. (B) “Covered entity” defined In this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of this title. (C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within 12 months of November 4, 1992, the following requirements shall apply: (i) Entities Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title when it is seeking reimbursement from the State Plan for medical assistance described in section 1396d(a)(12) of this title with respect to a unit of any covered outpatient drug which is subject to an agreement under section 256b(a) of this title. (ii) State agency Each such single State agency shall provide a means by which a covered entity shall indicate on any drug reimbursement claims form (or format, where electronic claims management is used) that a unit of the drug that is the subject of the form is subject to an agreement under section 256b of this title, and not submit to any manufacturer a claim for a rebate payment under subsection (b) of this section with respect to such a drug. (D) Effect of subsequent amendments In determining whether an agreement under subparagraph (A) meets the requirements of section 256b of this title, the Secretary shall not take into account any amendments to such section that are enacted after November 4, 1992. (E) Determination of compliance A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of section 256b of this title (as in effect immediately after November 4, 1992) and would have entered into an agreement under such section (as such section was in effect at such time), but for a legislative change in such section after November 4, 1992. (6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certain other Federal agencies (A) In general A manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisions of section 8126 of title 38, including the requirement of entering into a master agreement with the Secretary of Veterans Affairs under such section. (B) Effect of subsequent amendments In determining whether a master agreement described in subparagraph (A) meets the requirements of section 8126 of title 38, the Secretary shall not take into account any amendments to such section that are enacted after November 4, 1992. (C) Determination of compliance A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of section 8126 of title 38, (as in effect immediately C-4

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after November 4, 1992) and would have entered into an agreement under such section (as such section was in effect at such time), but for a legislative change in such section after November 4, 1992. (b) Terms of rebate agreement (1) Periodic rebates (A) In general A rebate agreement under this subsection shall require the manufacturer to provide, to each State Plan approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for which payment was made under the State Plan for such period. Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2) for the period involved. (B) Offset against medical assistance Amounts received by a State under this section (or under an agreement authorized by the Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) in any quarter shall be considered to be a reduction in the amount expended under the State Plan in the quarter for medical assistance for purposes of section 1396b(a)(1) of this title. (2) State provision of information (A) State responsibility Each State agency under this subchapter shall report to each manufacturer not later than 60 days after the end of each rebate period and in a form consistent with a standard reporting format established by the Secretary, information on the total number of units of each dosage form and strength and package size of each covered outpatient drug dispensed after December 31, 1990, for which payment was made under the plan during the period, and shall promptly transmit a copy of such report to the Secretary. (B) Audits A manufacturer may audit the information provided (or required to be provided) under subparagraph (A). Adjustments to rebates shall be made to the extent that information indicates that utilization was greater or less than the amount previously specified. (3) Manufacturer provision of price information (A) In general. -- Each manufacturer with an agreement in effect under this section shall report to the Secretary – (i) not later than 30 days after the last day of each rebate period under the agreement (beginning on or after January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the agreement; (ii) not later than 30 days after the date of entering into an agreement under this section on the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 for each of the manufacturer’s covered outpatient drugs; and (iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with reporting required under clause (i) and by National Drug Code (including package size)— (I) the manufacturer’s average sales price (as defined in section 1847A(c)) and the total number of units specified under section 1847A(b)(2)(A); C-5

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(II) if required to make payment under section 1847A, the manufacturer’s wholesale acquisition cost, as defined in subsection (c)(6) of such section; and (III) information on those sales that were made at a nominal price or otherwise described in section 1847A(c)(2)(B); for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1842 (o)(1) or section 1881(b)(13)(A)(ii). Information reported under this subparagraph is subject to audit by the Inspector General of the Department of Health and Human Services. (B) Verification surveys of average manufacturer price and manufacturer’s average sales price The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices and manufacturer’s average sales prices (including wholesale acquisition cost) if required to make payment reported under subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drug refuses a request for information about charges or prices by the Secretary in connection with a survey under this subparagraph or knowingly provides false information. The provisions of section 1320a-7a of this title (other than subsections (a) (with respect to amounts of penalties or additional assessments) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title. (C) Penalties (i) Failure to provide timely information In the case of a manufacturer with an agreement under this section that fails to provide information required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by $10,000 for each day in which such information has not been provided and such amount shall be paid to the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the agreement shall be suspended for services furnished after the end of such 90-day period and until the date such information is reported (but in no case shall such suspension be for a period of less than 30 days). (ii) False information Any manufacturer with an agreement under this section that knowingly provides false information is subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions of section 1320a-7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title. (D) Confidentiality of information Notwithstanding any other provision of law, information disclosed by manufacturers or wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section (other than the wholesale acquisition cost for purposes of carrying out section 1847A) is confidential and shall not be disclosed by the Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of a specific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler, except(i) as the Secretary determines to be necessary to carry out this section, to carry out section 1847A (including the determination and implementation of the payment amount), or to carry out section 1847B, C-6

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(ii) to permit the Comptroller General to review the information provided, and (iii) to permit the Director of the Congressional Budget Office to review the information provided. The previous sentence shall also apply to information disclosed under section 1860D-2(d)(2) or 1860D-4(c)(2)(E) and drug pricing data reported under the first sentence of section 1860D31(i)(1). (4) Length of agreement (A) In general A rebate agreement shall be effective for an initial period of not less than 1 year and shall be automatically renewed for a period of not less than one year unless terminated under subparagraph (B). (B) Termination (i) By the Secretary The Secretary may provide for termination of a rebate agreement for violation of the requirements of the agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a hearing concerning such a termination, but such hearing shall not delay the effective date of the termination. (ii) By a manufacturer A manufacturer may terminate a rebate agreement under this section for any reason. Any such termination shall not be effective until the calendar quarter beginning at least 60 days after the date the manufacturer provides notice to the Secretary. (iii) Effectiveness of termination Any termination under this subparagraph shall not affect rebates due under the agreement before the effective date of its termination. (iv) Notice to States In the case of a termination under this subparagraph, the Secretary shall provide notice of such termination to the States within not less than 30 days before the effective date of such termination. (v) Application to terminations of other agreements The provisions of this subparagraph shall apply to the terminations of agreements described in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title 38. (C) Delay before reentry (c) In the case of any rebate agreement with a manufacturer under this section which is terminated, another such agreement with the manufacturer (or a successor manufacturer) may not be entered into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the Secretary finds good cause for an earlier reinstatement of such an agreement. Determination of amount of rebate (1) Basic rebate for single source drugs and innovator multiple source drugs (A) In general Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a single source drug or an innovator multiple source drug shall be equal to the product of C-7

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(i) the total number of units of each dosage form and strength paid for under the State Plan in the rebate period (as reported by the State); and (ii) subject to subparagraph (B)(ii), the greater of (I) the difference between the average manufacturer price and the best price (as defined in subparagraph (C)) for the dosage form and strength of the drug, or (II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer price, for the rebate period. (B) Range of rebates required (i) Minimum rebate percentage For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate periods beginning (I) after December 31, 1990, and before October 1, 1992, is 12.5 percent; (II) after September 30, 1992, and before January 1, 1994, is 15.7 percent; (III) after December 31, 1993, and before January 1, 1995, is 15.4 percent; (IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and (V) after December 31, 1995, is 15.1 percent. (ii) Temporary limitation on maximum rebate amount In no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning (I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or (II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the average manufacturer price. (C) “Best price” defined For purposes of this section (i) In general The term “best price” means, with respect to a single source drug or innovator multiple source drug of a manufacturer, the lowest price available from the manufacturer during the rebate period to any wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity within the United States, excluding (I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department of Veterans Affairs, a State home receiving funds under section 1741 of title 38, the Department of Defense, the Public Health Service, or a covered entity described in subsection (a)(5)(B) of this section (including inpatient prices charged to hospitals described in section 340B(a)(4)(L) of the Public Health Service Act); (II) any prices charged under the Federal Supply Schedule of the General Services Administration; (III) any prices used under a State pharmaceutical assistance program; and (IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of the Federal Government; (V) the prices negotiated from drug manufacturers for covered discount card drugs under an endorsed discount card program under section 1860D-31; and (VI) any prices charged which are negotiated by a prescription drug plan under part D of title XVIII, by an MA-PD plan under part C of such title with respect to covered part D drugs or by a qualified retiree prescription drug plan (as defined in section 1860D22(a)(2)) with respect to such drugs on behalf of individuals entitled to benefits under part A or enrolled under part B of such title. (ii) Special rules The term “best price” (I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement, volume discounts, and rebates (other than rebates under this section); (II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form or product or package; and C-8

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(III) shall not take into account prices that are merely nominal in amount. (iii) Application of auditing and recordkeeping requirements With respect to a covered entity described in section 340B(a)(4)(L) of the Public Health Service Act, any drug purchased for inpatient use shall be subject to the auditing and recordkeeping requirements described in section 340B(a)(5)(C) of the Public Health Service Act. (2) Additional rebate for single source and innovator multiple source drugs (A) In general The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount equal to the product of (i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State Plan for the rebate period; and (ii) the amount (if any) by which (I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds (II) the average manufacturer price for such dosage form and strength for the calendar quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an entity, including a division or subsidiary of the manufacturer, after the first day of such quarter), increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index for September 1990. . (B) Treatment of subsequently approved drugs In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter after the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and “the month prior to the first month of the first full calendar quarter after the day on which the drug was first marketed” for “September 1990.” (3) Rebate for other drugs (A) In general The amount of the rebate paid to a State for a rebate period with respect to each dosage form and strength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs) shall be equal to the product of (i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the dosage form and strength for the rebate period, and (ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State Plan for the rebate period. (B) “Applicable percentage” defined For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning (i) before January 1, 1994, is 10 percent, and (ii) after December 31, 1993, is 11 percent. (d) Limitations on coverage of drugs (1) Permissible restrictions

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(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of paragraph (5). (B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if (i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this section); (ii) the drug is contained in the list referred to in paragraph (2); (iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection (a)(4) of this section; or (iv) the State has excluded coverage of the drug from its formulary established in accordance with paragraph (4). (2) List of drugs subject to restriction The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted: (A) Agents when used for anorexia, weight loss, or weight gain. (B) Agents when used to promote fertility. (C) Agents when used for cosmetic purposes or hair growth. (D) Agents when used for the symptomatic relief of cough and colds. (E) Agents when used to promote smoking cessation. (F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. (G) Nonprescription drugs. (H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. (I) Barbiturates. (J) Benzodiazepines. (3) Update of drug listings The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by surveillance and utilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriate use. (4) Requirements for formularies A State may establish a formulary if the formulary meets the following requirements: (A) The formulary is developed by a committee consisting of physicians, pharmacists, and other appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s drug use review board established under subsection (g)(3) of this section). (B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any manufacturer which has entered into and complies with an agreement under subsection (a) of this section (other than any drug excluded from coverage or otherwise restricted under paragraph (2)). (C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate compendia described in subsection (k)(6) of this section), C-10

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the excluded drug does not have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such treatment for such population over other drugs included in the formulary and there is a written explanation (available to the public) of the basis for the exclusion. (D) The State Plan permits coverage of a drug excluded from the formulary (other than any drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that is consistent with paragraph (5). (E) The formulary meets such other requirements as the Secretary may impose in order to achieve program savings consistent with protecting the health of program beneficiaries. A prior authorization program established by a State under paragraph (5) is not a formulary subject to the requirements of this paragraph. (5) Requirements of prior authorization programs A State Plan under this subchapter may require, as a condition of coverage or payment for a covered outpatient drug for which Federal financial participation is available in accordance with this section, with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the system providing for such approval – (A) provides response by telephone or other telecommunication device within 24 hours of a request for prior authorization; and (B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by the Secretary). (6) Other permissible restrictions A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or maximum quantities per prescription or on the number of refills, if such limitations are necessary to discourage waste, and may address instances of fraud or abuse by individuals in any manner authorized under this chapter. (e) Treatment of pharmacy reimbursement limits (1) In general During the period beginning on January 1, 1991, and ending on December 31, 1994 – (A) a State may not reduce the payment limits established by regulation under this subchapter or any limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1, 1991, and (B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph (A). (2) Special rule If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not apply to such State until such State is in compliance with such regulations.

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(3) Effect on State maximum allowable cost limitations This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31, 1994, relating to any maximum allowable cost limitation established by a State for payment by the State for covered outpatient drugs, and rebates shall be made under this section without regard to whether or not payment by the State for such drugs is subject to such a limitation or the amount of such a limitation. (4) Establishment of upper payment limits The Secretary shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA has rated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all such additional formulations are rated as such and shall use only such formulations when determining any such upper limit. (f) Repealed and redesignated (g) Drug use review (1) In general (A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by not later than January 1, 1993, for a drug use review program described in paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical results. The program shall be designed to educate physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients, or associated with specific drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs including education on therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. (B) The program shall assess data on drug use against predetermined standards, consistent with the following: (i) compendia which shall consist of the following: (I) American Hospital Formulary Service Drug Information; (II) United States Pharmacopeia-Drug Information; and (III) the DRUGDex information System. (ii) the peer-reviewed medical literature. (C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each State an amount equal to 75 per centum of so much of the sums expended by the State Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug use review program which conforms to the requirements of this subsection. (D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to residents of nursing facilities which are in compliance with the drug regimen review procedures prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations. (2) Description of program Each drug use review program shall meet the following requirements for covered outpatient drugs:

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(A) Prospective drug review (i) The State plan shall provide for a review of drug therapy before each prescription is filled or delivered to an individual receiving benefits under this subchapter, typically at the point-of-sale or point of distribution. The review shall include screening for potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literature referred to in paragraph (1)(B) as its source of standards for such review. (ii) As part of the State’s prospective drug use review program under this subparagraph applicable State law shall establish standards for counseling of individuals receiving benefits under this subchapter by pharmacists which includes at least the following: (I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapter or caregiver of such individual (in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which in the exercise of the pharmacist’s professional judgment (consistent with State law respecting the provision of such information), the pharmacist deems significant including the following: (aa) The name and description of the medication. (bb) The route, dosage form, dosage, route of administration, and duration of drug therapy. (cc) Special directions and precautions for preparation, administration and use by the patient. (dd) Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur. (ee) Techniques for self-monitoring drug therapy. (ff) Proper storage. (gg) Prescription refill information. (hh) Action to be taken in the event of a missed dose. (II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the following information regarding individuals receiving benefits under this subchapter: (aa) Name, address, telephone number, date of birth (or age) and gender. (bb) Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices. (cc) Pharmacist comments relevant to the individual’s drug therapy. Nothing in this clause shall be construed as requiring a pharmacist to provide consultation when an individual receiving benefits under this subchapter or caregiver of such individual refuses such consultation. (B) Retrospective drug use review The program shall provide, through its mechanized drug claims processing and information retrieval systems (approved by the Secretary under section 1396b(r) of this title) or otherwise, for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving benefits under this subchapter, or associated with specific drugs or groups of drugs. (C) Application of standards The program shall, on an ongoing basis, assess data on drug use against explicit predetermined standards (using the compendia and literature referred to in paragraph (1)(B) as the source of standards for such assessment) including but not limited to monitoring for therapeutic C-13

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appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical abuse/misuse and, as necessary, introduce remedial strategies, in order to improve the quality of care and to conserve program funds or personal expenditures. (D) Educational program The program shall, through its State drug use review board established under paragraph (3), either directly or through contracts with accredited health care educational institutions, State medical societies or State pharmacists associations/societies or other organizations as specified by the State, and using data provided by the State drug use review board on common drug therapy problems, provide for active and ongoing educational outreach programs (including the activities described in paragraph (3)(C)(iii) of this subsection) to educate practitioners on common drug therapy problems with the aim of improving prescribing or dispensing practices.

(3) State drug use review board (A) Establishment Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the “DUR Board”) either directly or through a contract with a private organization. (B) Membership The membership of the DUR Board shall include health care professionals who have recognized knowledge and expertise in one or more of the following: (i) The clinically appropriate prescribing of covered outpatient drugs. (ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs. (iii) Drug use review, evaluation, and intervention. (iv) Medical quality assurance. The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed and actively practicing physicians and at least 1/3 licensed and actively practicing pharmacists. (C) Activities The activities of the DUR Board shall include but not be limited to the following: (i) Retrospective DUR as defined in section. (ii) Application of standards as defined in paragraph (2)(C). (iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems or individuals identified in the course of retrospective drug use reviews performed under this subsection. Intervention programs shall include, in appropriate instances, at least: (I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists in the State of information concerning its duties, powers, and basis for its standards; (II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both) information and suggested changes in prescribing or dispensing practices, communicated in a manner designed to ensure the privacy of patient-related information; (III) use of face-to-face discussions between health care professionals who are experts in rational drug therapy and selected prescribers and pharmacists who have been targeted for educational intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up face-to-face discussions; and (IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluate interventions after an appropriate period of time to determine if the C-14

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intervention improved the quality of drug therapy, to evaluate the success of the interventions and make modifications as necessary. (D) Annual report Each State shall require the DUR Board to prepare a report on an annual basis. The State shall submit a report on an annual basis to the Secretary which shall include a description of the activities of the Board, including the nature and scope of the prospective and retrospective drug use review programs, a summary of the interventions used, an assessment of the impact of these educational interventions on quality of care, and an estimate of the cost savings generated as a result of such program. The Secretary shall utilize such report in evaluating the effectiveness of each State’s drug use review program. (h) Electronic claims management (1) In general In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the Secretary shall encourage each State agency to establish, as its principal means of processing claims for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management system, for the purpose of performing on-line, real time eligibility verifications, claims data capture, adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and receiving payment. (2) Encouragement In order to carry out paragraph (1) (A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State Plan attributable to development of a system described in paragraph (1) shall receive Federal financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90 percent) if the State acquires, through applicable competitive procurement process in the State, the most cost-effective telecommunications network and automatic data processing services and equipment; and (B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in competitive procurement for advance planning and implementation documents otherwise required. (i) Annual report (1) In general Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives a report on the operation of this section in the preceding fiscal year. (2) Details Each report shall include information on – (A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and nonprescription covered outpatient drugs; (B) the total value of rebates received and number of manufacturers providing such rebates;

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(C) how the size of such rebates compare with the size of rebates offered to other purchasers of covered outpatient drugs; (D) the effect of inflation on the value of rebates required under this section; (E) trends in prices paid under this subchapter for covered outpatient drugs; and (F) Federal and State administrative costs associated with compliance with the provisions of this subchapter. (j) Exemption of organized health care settings (1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid managed care organizations that contract under section 1396b(m) of this title, are not subject to the requirements of this section. (2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not be subject to the requirements of this section. (3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid by the institutions described in this subsection should not be taken into account for purposes of determining the best price as described in subsection (c) of this section. (k) Definitions In this section (1) Average manufacturer price The term “average manufacturer price” means, with respect to a covered outpatient drug of a manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United States by wholesalers for drugs distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts. (2) Covered outpatient drug Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means (A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title, a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and (i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) of such Act (21 U.S.C. 355(j)); (ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the subject of a final determination by the Secretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or 304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21 U.S.C. 352(f), 355(a)); or (iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of C-16

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the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to withdraw approval of an application for such drug under such section because the Secretary has determined that the drug is less than effective for some or all conditions of use prescribed, recommended, or suggested in its labeling; and (B) a biological product, other than a vaccine which (i) may only be dispensed upon prescription, (ii) is licensed under section 262 of this title, and (iii) is produced at an establishment licensed under such section to produce such product; and (C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356). (3) Limiting definition The term “covered outpatient drug” does not include any drug, biological product, or insulin provided as part of, or as incident to and in the same setting as, any of the following (and for which payment may be made under this subchapter as part of payment for the following and not as direct reimbursement for the drug): (A) Inpatient hospital services. (B) Hospice services. (C) Dental services, except that drugs for which the State Plan authorizes direct reimbursement to the dispensing dentist are covered outpatient drugs. (D) Physicians’ services. (E) Outpatient hospital services. (F) Nursing facility services and services provided by an intermediate care facility for the mentally retarded. (G) Other laboratory and x-ray services. (H) Renal dialysis. Such term also does not include any such drug or product for which a National Drug Code number is not required by the Food and Drug Administration or a drug or biological used for a medical indication which is not a medically accepted indication. Any drug, biological product, or insulin excluded from the definition of such term as a result of this paragraph shall be treated as a covered outpatient drug for purposes of determining the best price (as defined in subsection (C)(1)(C) of this section) for such drug, biological product, or insulin. (4) Nonprescription drugs If a State Plan for medical assistance under this subchapter includes coverage of prescribed drugs as described in section 1396d(a)(12) of this title and permits coverage of drugs which may be sold without a prescription (commonly referred to as “over-the-counter” drugs), if they are prescribed by a physician (or other person authorized to prescribe under State law), such a drug shall be regarded as a covered outpatient drug. (5) Manufacturer C-17

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The term “manufacturer” means any entity which is engaged in (A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis, or (B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law. (6) Medically accepted indication The term “medically accepted indication” means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i) of this section. (7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug (A) Defined (i) Multiple source drug The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or more drug products which (I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”), (II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and (III) are sold or marketed in the State during the period. (ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source drug that was originally marketed under an original new drug application approved by the Food and Drug Administration. (iii) Noninnovator multiple source drug The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator multiple source drug. (iv) Single source drug The term “single source drug” means a covered outpatient drug which is produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application. (B) Exception Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C). (C) Definitions For purposes of this paragraph -

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(i) drug products are pharmaceutically equivalent if the products contain identical amounts of the same active drug ingredient in the same dosage form and meet compendial or other applicable standards of strength, quality, purity, and identity; So in original. Probably should be “pharmaceutically”. (ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if they do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and (iii) a drug product is considered to be sold or marketed in a State if it appears in a published national listing of average wholesale prices selected by the Secretary, provided that the listed product is generally available to the public through retail pharmacies in that State. (8) Rebate period The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a calendar quarter or other period specified by the Secretary with respect to the payment of rebates under such agreement. (9) State agency The term “State agency” means the agency designated under section 1396a(a)(5) of this title to administer or supervise the administration of the State Plan for medical assistance.

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Appendix D: Federal Upper Limits for Multiple Source Products

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The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of the Social Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL) listing has been accomplished by computer. Payments for multiple source drugs identified and listed in the accompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drug entity a reasonable dispensing fee (established by the State and specified in the State Plan), plus an amount based on the limit per unit which CMS has determined to be equal to a 150 percent applied to the lowest price listed (in package sizes of 100 units, unless otherwise noted) in any of the published compendia of cost information of drugs. Issued by CMS on November 20, 2001 the initial listing was based on data current as of April 2001 from the First Data Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional changes (i.e., additions, deletions, pricing changes) through January 14, 2005. The list does not reference the commonly known brand names. However, the brand names are included in the FUL listing provided to the State agencies in electronic media format. The FUL price list is in Microsoft Word format at http://www.cms.hhs.gov/Medicaid/drugs/drug10.asp. In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL listing for which the Food and Drug Administration (FDA) has issued a notice of an opportunity for a hearing as a result of the Drug Efficacy Study and Implementation (DESI) program and which has been found to be less than effective or is identical, related, or similar (IRS) to the DESI drug. The DESI drug is identified by the FDA or reported by the drug manufacturer for purposes of the Medicaid drug rebate program. The November 20, 2001 list has been amended with all changes to be implemented no later than February 14, 2005. Generic Name

Upper Limit per Unit (Source)

Acebutolol Hydrochloride Eq 200 mg base, Capsule, Oral 100 Eq 400 mg base, Capsule, Oral 100

$0.4612 B 0.6713 B

Acetaminophen; Butalbital; Caffeine 500 mg; 50mg; 40 mg, Tablet, Oral 100

0.6870 B

Acetaminophen; Codeine Phosphate 300 mg; 15 mg, Tablet, Oral 100 300 mg; 30 mg, Tablet, Oral 100 300 mg; 60 mg, Tablet, Oral 100

0.1500 R 0.2137 B 0.3833 B

Acetaminophen; Hydrocodone Bitartrate 500 mg; 5 mg, Capsule, Oral 100 500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral 473 ml 500 mg, 2.5 mg, Tablet, Oral 100 500 mg; 5 mg, Tablet, Oral 100 500 mg; 7.5 mg, Tablet, Oral 100 500 mg; 10 mg, Tablet, Oral 100 650 mg; 7.5 mg, Tablet, Oral 100 650 mg; 10 mg, Tablet, Oral 100 660 mg; 10 mg, Tablet, Oral 100 750 mg; 7.5 mg, Tablet, Oral 100

0.1943 B 0.1014 R 0.2190 B 0.0833 B 0.1913 B 0.4603 B 0.1550 B 0.1852 R 0.5284 B 0.1750 R

Generic Name

Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-3

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Acetaminophen; Oxycodone Hydrochloride 500 mg; 5 mg, Capsule, Oral 100 325 mg; 5 mg, Tablet, Oral 100

0.2248 B 0.1192 B

Acetaminophen; Propoxyphene Hydrochloride 650 mg; 65 mg, Tablet, Oral 100

0.1688 B

Acetaminophen; Propoxyphene Napsylate 650 mg; 100 mg, Tablet, Oral 100

0.1800 R

Acetazolamide 250 mg, Tablet, Oral 100

0.2454 R

Acyclovir 200 mg, Capsule, Oral 100 400 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.1478 B 0.4425 B 0.8700 B

Albuterol 0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm

0.8823 B

Albuterol Sulfate Eq 0.083% base, Solution, Inhalation 3ml Eq 0.5% base, Solution, Inhalation 20 ml 4 mg, Tablet, Oral 100

0.1450 B 0.3360 B 0.1425 B

Allopurinol 100 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100

0.0784 B 0.1671 B

Alprazolam 0.25 mg, Tablet, Oral 100 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.0614 R 0.0698 B 0.0885 B 0.1745 R

Amantadine Hydrochloride 50 mg/5 ml, Syrup, Oral 480 ml

0.0656 M

Amiloride Hydrochloride; Hydrochlorothiazide Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100

0.0675 B

Amiodarone Hydrochloride 200 mg, Tablet, Oral 60

1.6875 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-4

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Generic Name

Upper Limit per Unit (Source)

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

0.0608 B 0.0653 B 0.0666 B 0.1425 B 0.1500 R 0.2430 B

Amitriptyline Hydrochloride; Perphenazine 10 mg; 2 mg, Tablet, Oral 100 25 mg; 2 mg, Tablet, Oral 100

0.0704 B 0.0869 B

Amoxapine 50 mg, Tablet, Oral 100

0.5425 R

Amoxicillin 250 mg, Capsule, Oral 100 500 mg, Capsule, Oral 100 125 mg/5 ml, Powder for Reconstitution, Oral 150 250 mg/5 ml, Powder for Reconstitution, Oral 100

0.0675 B 0.1302 R 0.0201 B 0.0281 B

Ampicillin/Ampicillin Trihydrate 250 mg, Capsule, Oral 100 500 mg, Capsule, Oral 100

0.1736 B 0.2991 B

Aspirin; Butalbital; Caffeine 325 mg; 50 mg; 40 mg, Tablet, Oral 100

0.2400 R

Aspirin; Carisoprodol 325 mg; 200 mg, Tablet, Oral 100

0.3522 B

Atenolol 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.0975 B 0.1058 B 0.1943 B

Atenolol; Chlorthalidone 50 mg; 25 mg, Tablet, Oral 100 100 mg; 25 mg, Tablet, Oral 100

0.1762 B 0.2549 B

Atropine Sulfate; Diphenoxylate Hydrochloride 0.025 mg; 2.5 mg, Tablet, Oral 100

0.1088 B

Baclofen 10 mg, Tablet, Oral, 100 20 mg, Tablet, Oral, 100

0.4492 B 0.8438 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-5

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Generic Name

Upper Limit per Unit (Source)

Benazepril Hydrochloride 5 mg, Tablet, Oral, 100 10 mg, Tablet, Oral, 100 20 mg, Tablet, Oral, 100 40 mg, Tablet, Oral, 100

0.4905 R 0.4905 R 0.4905 R 0.4905 R

Benazepril Hydrochloride; Hydrochlorothiazide 5 mg; 6.25 mg, Tablet, Oral, 100 10 mg; 12.5 mg, Tablet, Oral, 100 20 mg; 12.5 mg, Tablet, Oral, 100 20 mg; 25 mg, Tablet, Oral, 100

0.4958 B 0.4958 B 0.4958 B 0.4958 B

Benzonatate 100 mg, Capsule, Oral 100

0.4387 B

Benztropine Mesylate 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.1227 B 0.1502 B 0.1930 B

Betamethasone Dipropionate Eq 0.05% base, Cream, Topical 15 gm Eq 0.05% base, Lotion, Topical 60 ml

0.2330 B 0.1500 B

Betamethasone Valerate Eq 0.1% base, Cream, Topical 45 gm

0.1197 B

Bisoprolol Fumarate; Hydrochlorothiazide 2.5 mg; 6.25 mg, Tablet, Oral 100 5 mg; 6.25 mg, Tablet, Oral 100 10 mg; 6.25 mg, Tablet, Oral 100

1.0260 B 1.0260 B 0.8250 B

Brompheniramine Maleate/Dextromethorphan Hydrobromide/ Pseudoephedrine Hydrochloride 2 mg/10 mg/30 mg per 5 ml, Syrup, Oral, 480 ml

0.0387 B

Bumetanide 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.1743 B 0.2814 B 0.4708 B

Buspirone Hydrochloride 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100 15 mg, Tablet, Oral 60

0.2964 B 0.3942 B 0.4470 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-6

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Generic Name

Upper Limit per Unit (Source)

Captopril 12.5 mg, Tablet, Oral 100 50 mg, Tablet, Oral, 100 100 mg, Tablet, Oral 100

0.0232 B 0.0390 B 0.1080 B

Captopril; Hydrochlorothiazide 25 mg; 15 mg, Tablet, Oral 100 50 mg; 25 mg, Tablet, Oral 100

0.2360 B 0.3702 B

Carbamazepine 200 mg, Tablet, Oral 100

0.1388 R

Carbidopa; Levodopa 10 mg; 100 mg, Tablet, Oral 100 25 mg; 100 mg, Tablet, Oral 100 25 mg; 250 mg, Tablet, Oral 100

0.3644 B 0.4455 B 0.5145 B

Carisoprodol 350 mg, Tablet, Oral 100

0.3743 B

Carteolol Hydrochloride 1%, Solution/Drops, Ophthalmic 10 ml

3.6775 R

Cefaclor Eq 250 mg base, Capsule, Oral 100 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

0.6600 B 1.2900 B 0.0980 B 0.1470 B 0.2995 B 0.4492 B

Cefadroxil/Cefadroxil Hemihydrate Eq 500 mg base, Capsule, Oral 50

2.4837 B

Cephalexin Eq 250 mg base, Capsule, Oral 100 Eq 500 mg base, Capsule, Oral 100

0.1835 R 0.3641 R

Chlordiazepoxide Hydrochloride 5 mg, Capsule, Oral 100 10 mg, Capsule, Oral 100

0.1140 B 0.0877 B

Chlorhexidine Gluconate 0.12%, Solution, Dental 480 ml

0.0109 B

Generic Name

Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-7

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Chlorpropamide 100 mg, Tablet, Oral 100 250 mg, Tablet, Oral 100

0.1837 B 0.3885 B

Chlorzoxazone 500 mg, Tablet, Oral 100

0.0757 B

Cholestyramine Eq 4 gm Resin/Packet, Powder, Oral 60

1.2767 B

Cimetidine 200 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100 400 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.1313 B 0.1313 B 0.1071 R 0.2775 B

Cimetidine Hydrochloride Eq 300 mg base/ 5 ml Solution, Oral , 240 ml

0.1139 B

Ciprofloxacin Hydrochloride 0.3%, Solution/Drops, Ophthalmic, 5ml 250 mg, Tablet, Oral, 100 500 mg, Tablet, Oral, 100 750 mg, Tablet, Oral, 100

7.5690 B 0.3750 B 0.4500 B 0.4800 B

Clindamycin Hydrochloride Eq 150 mg base, Capsule, Oral 100

0.9180 R

Clindamycin Phosphate Eq 1% base, Solution, Topical 60 ml

0.2060 R

Clobetasol Propionate 0.05%, Cream, Topical 30 gm

0.8315 B

Clomipramine Hydrochloride 25 mg, Capsule, Oral 100 50 mg, Capsule, Oral 100 75 mg, Capsule, Oral 100

0.3322 R 0.5138 B 0.6623 B

Clonazepam 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.2455 B 0.2852 B 0.3903 B

Clonidine Hydrochloride 0.1 mg, Tablet, Oral 100 0.2 mg, Tablet, Oral 100 0.3 mg, Tablet, Oral 100

0.0968 B 0.1350 B 0.1830 B

Generic Name

Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-8

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Clorazepate Dipotassium 3.75 mg, Tablet, Oral 100 7.5 mg, Tablet, Oral 100 15 mg, Tablet, Oral 100

0.8350 B 1.0388 B 1.4094 B

Cromolyn Sodium 4%, Solution/ Drops, Ophthalmic 10 ml

3.3750 B

Cyclobenzaprine Hydrochloride 10 mg, Tablet, Oral 100

0.2728 B

Desonide 0.05%, Ointment, Topical 60 gm 0.05%, Cream, Topical 100

0.4077 B 0.2337 B

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate 0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm

1.0713 B

Dextroamphetamine Sulfate 10 mg, Tablet, Oral, 100

0.3435 B

Diazepam 2 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.0423 B 0.0718 B 0.0573 B

Diclofenac Potassiuim 50 mg, Tablet, Oral 100

0.8625 B

Diclofenac Sodium 50 mg, Tablet, Delayed Release, Oral 100 75 mg, Tablet, Delayed Release, Oral 100

0.4748 R 0.5850 R

Dicyclomine Hydrochloride 10 mg, Capsule, Oral 100 20 mg, Tablet, Oral 100

0.1222 B 0.1185 B

Diltiazem Hydrochloride 30 mg, Tablet, Oral 100 60 mg, Tablet, Oral 100 90 mg, Tablet, Oral 100 120 mg, Tablet, Oral 100

0.1019 B 0.1114 B 0.2312 B 0.2331 B

Diphenhydramine Hydrochloride 12.5 mg/5 ml, Elixir, Oral 120 ml

0.0137 B

Dipivefrin Hydrochloride 0.1%, Solution/Drops, Ophthalmic 5 ml

0.8700 B

Generic Name

Upper Limit per Unit (Source)

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-9

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Doxazosin Mesylate 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100 4 mg, Tablet, Oral 100 8 mg, Tablet, Oral 100

0.5918 B 0.5918 B 0.6210 B 0.6518 B

Doxepin 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 Eq 100 mg base, Capsule, Oral 100 Eq 10 mg base/ml, Concentrate, Oral 120 ml

0.0891 R 0.1822 B 0.1447 R 0.2052 R 0.4174 B 0.1145 R

Doxycycline Hyclate Eq 50 mg base, Capsule, Oral 50 Eq 100 mg base, Capsule, Oral 50 Eq 100 mg base, Tablet, Oral 50

0.1317 B 0.1491 B 0.1287 B

Doxycycline Hydrochloride Eq 50 mg base, Capsule, Oral 50 Eq 100 mg base, Capsule, Oral 50

0.0945 R 0.1215 R

Enalapril Maleate 2.5 mg, Tablet, Oral, 100 5 mg, Tablet, Oral, 100 10 mg, Tablet, Oral, 100 20 mg, Tablet, Oral, 100

0.4334 B 0.5490 B 0.6863 B 0.9150 B

Erythromycin 2%, Solution, Topical 60 ml 2%, Gel, Topical, 30 gm 0.5%, Ointment, Ophthalmic, 3 gm

0.0687 B 0.6250 B 1.0714 B

Estazolam 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.5925 R 0.6449 R

Estradiol 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.1791 B 0.2175 B 0.3060 B

Estropipate 0.75 mg, Tablet, Oral 100 1.5 mg, Tablet, Oral 100 3 mg, Tablet, Oral 100

0.2754 B 0.3450 B 0.8622 B

Generic Name

Upper Limit per Unit (Source)

Etodolac SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-10

National Pharmaceutical Council

Pharmaceutical Benefits 2004

200 mg, Capsule, Oral 100 400 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.4800 B 0.3600 R 1.0032 R

Famotidine 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100

0.1500 B 0.3000 B

Fenoprofen Calcium Eq 600 mg base, Tablet, Oral 100

0.2400 R

Flecainide Acetate 50 mg, Tablet, Oral, 100 100 mg, Tablet, Oral, 100 150 mg, Tablet, Oral, 100

0.8610 B 1.4070 B 1.9328 B

Fluocinonide 0.05%, Cream, Topical 60 gm 0.05%, Gel, Topical 60 gm 0.05%, Solution, Topical 60 ml

0.0790 R 0.4965 R 0.2483 R

Fluocinonide Emulsified Base (Fluocinonide-E) 0.05%, Cream, Topical, 60 gm

0.2453 R

Fluorometholone 0.1%, Suspension/Drops, Ophthalmic 5 ml

1.6590 B

Fluoxetine Hydrochloride 10 mg, Capsule, Oral 100 20 mg, Capsule, Oral 100 40 mg Capsule, Oral 30 20 mg/5ml, Solution, Oral 120 ml 10 mg, Tablets, Oral 30

0.5850 B 0.2520 B 4.0125 B 0.7500 R 0.6000 B

Fluphenazine Hydrochloride 1 mg, Tablet, Oral 100 2.5 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.2273 B 0.2775 B 0.3546 B 0.5099 R

Flurazepam Hydrochloride 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.0975 B 0.1148 B

Flurbiprofen 100 mg, Tablet, Oral 100

0.2438 B

Generic Name

Upper Limit per Unit (Source)

Flurbiprofen Sodium 0.03%, Solution/Drops, Ophthalmic 2ml SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-11

4.0679 B

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Furosemide 10 mg/ml, Solution, Oral 60 ml 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100

0.1300 B 0.0563 B 0.0599 B 0.1043 B

Gemfibrozil 600 mg, Tablet, Oral 500

0.3800 B

Gentamicin Sulfate Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml

0.5700 B

Glipizide 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.0699 B 0.1192 B

Glyburide 1.5 mg, Tablet, Oral 100 3 mg, Tablet, Oral 100

0.2549 R 0.3202 R

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate 0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml Solution/Drops, Ophthalmic 10 ml

2.0250 B

Guanfacine Hydrochloride Eq 1 mg base, Tablet, Oral 100 Eq 2 mg base, Tablet, Oral 100

0.5250 B 0.7200 B

Haloperidol Lactate Eq 2 mg base/ml, Concentrate, Oral 120 ml

0.1369 B

Hydrochlorothiazide 25 mg, Tablet, Oral, 1000 50 mg, Tablet, Oral, 1000

0.0577 R 0.1019 R

Hydrochlorothiazide; Propranolol Hydrochloride 25 mg; 40 mg, Tablet, Oral 100 25 mg; 80 mg, Tablet, Oral 100

0.0877 B 0.1320 B

Hydrochlorothiazide; Spironolactone 25 mg; 25 mg, Tablet, Oral 100

0.3463 B

Hydrochlorothiazide; Triamterene 25 mg; 37.5 mg, Capsule, Oral 100 25 mg; 37.5 mg, Tablet, Oral 100 50 mg; 75 mg, Tablet, Oral 100 Generic Name

0.3177 B 0.1683 R 0.0488 B Upper Limit per Unit (Source)

Hydrocortisone 0.5%, Cream, Topical, 30 gm 1%, Cream, Topical 30 gm 2.5%, Cream, Topical 30 gm

0.0510 M 0.0572 B 0.1820 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-12

National Pharmaceutical Council

Pharmaceutical Benefits 2004

1%, Lotion, Topical 120 ml 2.5%, Lotion, Topical 59 ml

0.0572 B 0.6814 B

Hydroxychloroquine Sulfate 200 mg, Tablet, Oral 100

0.8535 B

Hydroxyzine Hydrochloride 10 mg/5 ml, Syrup, Oral 480 ml 25 mg, Tablet, Oral 100

0.0367 B 0.7134 B

Hydroxyzine Pamoate Eq 25 mg HCL, Capsule, Oral 100 Eq 50 mg HCL, Capsule, Oral 100

0.0892 B 0.1013 B

Ibuprofen 400 mg, Tablet, Oral 100 600 mg, Tablet, Oral 100 800 mg, Tablet, Oral 100

0.0493 B 0.0573 B 0.1065 B

Imipramine Hydrochloride 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.2643 B 0.3551 B 0.4604 B

Indapamide 1.25 mg, Tablet, Oral 100 2.5 mg, Tablet, Oral 100

0.1035 B 0.1125 B

Ipratropium Bromide 0.02%, Solution for Inhalation, 2.500 ml, 25s

0.1080 R

Isoniazid 300 mg, Tablet, Oral 100

0.0890 B

Isosorbide Dinitrate 5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100

0.0217 R 0.0228R 0.0558B

Isosorbide Mononitrate 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100 60 mg, Tablet, Extended Release, Oral 100

0.6110 R 0.4950 B 0.7492 B

Generic Name

Upper Limit per Unit (Source)

Ketoconazole 200 mg, Tablet, Oral 100

2.2500 R

Ketorolac Tromethamine 10 mg, Tablet, Oral 100

0.6773 M

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-13

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Labetalol Hydrochloride 100 mg, Tablet, Oral 100 200 mg, Tablet, Oral 100 300 mg, Tablet, Oral 100

0.2157 B 0.3582 B 0.5363 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 10 ml

1.2749 B 1.4925 B

Lidocaine Hydrochloride 2%, Solution, Oral 100 ml

0.0315 R

Lisinopril 2.5 mg, Tablet, Oral, 100 5 mg, Tablet, Oral, 100 10 mg, Tablet, Oral, 100 20 mg, Tablet, Oral, 100 30 mg, Tablet, Oral, 100 40 mg, Tablet, Oral, 100

0.3855 B 0.5783 B 0.5970 B 0.6390 B 0.9038 B 0.9345 B

Lisinopril ; Hydrochlorothiazide 10 mg ; 12.5 mg, Tablet, Oral, 100 20 mg ; 12.5 mg, Tablet, Oral, 100 20 mg ; 25 mg, Tablet, Oral, 100

0.6450 B 0.6983 B 0.7065 B

Lithium Carbonate 300 mg, Capsule, Oral, 1000

0.1350 B

Lorazepam 0.5 mg, Tablet, Oral 100 1 mg, Tablet, Oral 100 2 mg, Tablet, Oral 100

0.4350 B 0.5718 B 0.5698 B

Lovastatin 10 mg, Tablet, Oral 60 20 mg, Tablet, Oral 60 40 mg, Tablet, Oral 60

0.7487 B 1.2488 B 3.2012 B

Generic Name

Upper Limit per Unit (Source)

Meclizine Hydrochloride 12.5 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100

0.0599 B 0.0420 B

Medroxyprogesterone Acetate 2.5 mg, Tablet, Oral 100

0.2025 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-14

National Pharmaceutical Council

Pharmaceutical Benefits 2004

5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.3061 B 0.3787 B

Megestrol Acetate 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100

0.3489 B 0.6755 B

Meperidine Hydrochloride 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.5370 B 1.0347 B

Metformin Hydrochloride 500 mg, Tablet, Oral 100 850 mg, Tablet, Oral 100 1000 mg, Tablet, Oral, 100

0.3557 B 0.3863 B 0.4597 B

Methazolamide 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100

0.3150 R 0.4650 R

Methenamine Mandelate 1 gm, Tablet, Oral 100

0.2923 B

Methocarbamol 500 mg, Tablet, Oral 100 750 mg. Tablet, Oral 100

0.1463 B 0.1792 B

Methotrexate Sodium Eq 2.5 mg base, Tablet, Oral 100

1.2637 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

0.2849 B

Metoclopramide 10 mg, Tablet, Oral 100

0.1095 B

Generic Name

Upper Limit per Unit (Source)

Metoclopramide Hydrochloride Eq 5 mg base/5 ml, Solution, Oral 480 ml Eq 5 mg base, Tablet, Oral 100 Eq 10 mg base, Tablet, Oral 100

0.0155 B 0.1842 B 0.1089 B

Metoprolol Tartrate 50 mg, Tablet, Oral 100

0.0500 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-15

National Pharmaceutical Council

Pharmaceutical Benefits 2004

100 mg, Tablet, Oral 100

0.0690 B

Metronidazole 250 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.0849 B 0.2184 B

Mexiletine Hydrochloride 200 mg, Capsule, Oral 100

0.9712 R

Minocycline Hydrochloride Eq 50 mg base, Capsule, Oral 100 Eq 100 mg base, Capsule, Oral 50

0.9000 B 1.8000 B

Minoxidil 2.5 mg, Tablet, Oral 100 10 mg, Tablet, Oral 100

0.3170 B 0.6965 B

Mirtazapine 15 mg, Tablet, Oral, 30 30 mg, Tablet, Oral, 30 45 mg, Tablet, Oral, 30

1.6300 B 1.6775 B 1.7100 B

Nadolol 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100

0.4650 B 0.4289 B 0.8025 B

Naltrexone Sodium 50 mg, Tablet, Oral 100

4.0400 B

Naphazoline Hydrochloride 0.1%, Solution/Drops, Ophthalmic 15 ml

0.3140 R

Naproxen 250 mg, Tablet, Oral 100 375 mg, Tablet, Oral 100 500 mg, Tablet, Oral 100

0.1044 R 0.1383 R 0.1805 B

Niacin 500 mg, Tablet, Oral 100

0.0390 B

Generic Name

Upper Limit per Unit (Source)

Nicardipine Hydrochloride 20 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.3375 B 0.4050 B

Nizatidine 150 mg, Capsule, Oral, 60 300 mg, Capsule, Oral, 30

1.8307 B 3.6615 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-16

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Nortriptyline Hydrochloride Eq 10 mg base, Capsule, Oral 100 Eq 25 mg base, Capsule, Oral 100 Eq 50 mg base, Capsule, Oral 100 Eq 75 mg base, Capsule, Oral 100

0.1019 B 0.1406 B 0.1722 B 0.2203 B

Nystatin 100,000 units/gm, Cream, Topical 30 gm 100,000 units/gm, Ointment, Topical 15 gm

0.0755 B 0.1019 B

Nystatin; Triamcinolone Acetonide 100,000 units/gm; 0.1%, Cream, Topical 30 gm

0.0975 B

Oxaprozin 600 mg, Tablet, Oral 100

0.6758 B

Oxazepam 10 mg, Capsule, Oral 100 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.5363 B 0.5709 B 1.2337 R

Oxybutynin Chloride 5 mg, Tablet, Oral 100

0.1260 R

Oxycodone Hydrochloride 5 mg, Capsule, Oral, 100 20 mg/ml, Concentrate, Oral, 30 ml 5 mg, Tablet, Oral, 100 15 mg, Tablet, Oral, 100 30 mg, Tablet, Oral, 100

0.2138 B 0.9500 B 0.2399 B 0.6695 M 1.3094 M

Paroxetine Hydrochloride 10 mg, Tablet, Oral, 30 20 mg, Tablet, Oral, 30 30 mg, Tablet, Oral, 30 40 mg, Tablet, Oral, 30

2.4300 R 2.5200 R 2.6100 R 2.7000 R

Pentoxifylline 400 mg, Tablet, Extended Release, Oral 100

0.3147 B

Generic Name

Upper Limit per Unit (Source)

Perphenazine 2 mg, Tablet, Oral 100 16 mg, Tablet, Oral 100

0.3473 R 1.3833 B

Piroxicam 10 mg, Capsule, Oral 100 20 mg, Capsule, Oral 100

0.0891 B 0.1131 B

Polymyxin B Sulfate; Trimethoprim Sulfate SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-17

National Pharmaceutical Council

Pharmaceutical Benefits 2004

10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Ophthalmic 10 ml

1.2360 B

Potassium Chloride 8 MEQ, Tablet, Extended Release, Oral 100

0.0893 B

Prednisolone 15 mg/5 ml, Syrup, Oral 480 ml

0.2081 B

Prednisolone Acetate 1%, Suspension/Drops, Ophthalmic 10 ml

1.6950 B

Primidone 250 mg, Tablet, Oral 100

0.6956 R

Probenecid 500 mg, Tablet, Oral 100

0.7059 B

Prochlorperazine Maleate Eq 5 mg base, Tablet, Oral 100 Eq 10 mg base, Tablet, Oral 100

0.3986 B 0.5766 B

Propafenone Hydrochloride 150 mg, Tablet, Oral 100 225 mg, Tablet, Oral 100

1.1049 B 1.5624 B

Propranolol Hydrochloride 10 mg, Tablet, Oral 100 20 mg, Tablet, Oral 100 40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100

0.0585 B 0.0705 B 0.0848 B 0.1140 B

Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride 60 mg; 2.5 mg, Tablet, Oral 100

0.0336 B

Ranitidine Hydrochloride Eq 150 mg base, Tablet, Oral, 100 Eq 300 mg base, Tablet, Oral 100

0.3411 R 0.3180 B

Rimantadine Hydrochloride 100 mg, Tablet, Oral, 100 Generic Name

1.5120 B Upper Limit per Unit (Source)

Selegiline Hydrochloride 5 mg, Tablet, Oral 60

0.7658 R

Selenium Sulfide 2.5%, Lotion/Shampoo, Topical 120 ml

0.0750 B

Sotalol Hydrochloride (Does Not Apply to the “AF” Versions) 80 mg, Tablet, Oral, 100 120 mg, Tablet, Oral, 100 160 mg, Tablet, Oral, 100

1.7850 B 2.3550 B 2.9250 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-18

National Pharmaceutical Council

Pharmaceutical Benefits 2004

240 mg, Tablet, Oral, 100

3.9750 B

Spironolactone 25 mg, Tablet, Oral 100

0.3000 B

Sucralfate 1 gm, Tablet, Oral 100

0.3690 B

Sulfacetamide Sodium 10%, Solution/Drops, Opthalmic 15 ml

0.1530 B

Sulfamethoxazole; Trimethoprim 400 mg; 80 mg, Tablet, Oral 100 800 mg; 160 mg, Tablet, Oral 100

0.1325 B 0.1454 R

Sulfasalazine 500 mg, Tablet, Oral 100

0.1565 B

Sulindac 150 mg, Tablet, Oral 100 200 mg, Tablet, Oral 100

0.3317 B 0.4289 B

Tamoxifen Citrate 10 mg, Tablet, Oral, 60 20 mg, Tablet, Oral, 30

0.9713 B 1.9425 B

Temazepam 15 mg, Capsule, Oral 100 30 mg, Capsule, Oral 100

0.1365 B 0.1748 B

Terazosin Hydrochloride Eq 1 mg base, Capsule, Oral 100 Eq 2 mg base, Capsule, Oral 100 Eq 5 mg base, Capsule, Oral 100 Eq 10 mg base, Capsule, Oral 100

1.5413 B 1.5413 B 1.5413 B 1.5413 B

Tetracycline Hydrochloride 500 mg, Capsule, Oral 100

0.0975 B

Generic Name

Upper Limit per Unit (Source)

Thioridazine Hydrochloride 10 mg, Tablet, Oral 100 25 mg, Tablet, Oral 100 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100

0.2190 B 0.3030 B 0.3885 R 0.4941 B

Thiothixene 1 mg, Capsule, Oral 100 2 mg, Capsule, Oral 100 5 mg, Capsule, Oral 100 10 mg, Capsule, Oral 100

0.1388 B 0.1860 B 0.2963 B 0.4065 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-19

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Ticlopidine Hydrochloride 250 mg, Tablet, Oral 60

0.2732 B

Timolol Maleate Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml

0.6975 B 0.9000 B

Tizanidine Hydrochloride 2 mg, Tablet, Oral, 150 4 mg, Tablet, Oral, 150

0.6499 B 0.7899 B

Tobramycin 0.3%, Solution/Drops, Ophthalmic 5 ml

0.6720 B

Tolazamide 250 mg, Tablet, Oral 100

0.4005 B

Tramadol Hydrochloride 50 mg, Tablet, Oral, 100

0.3068 B

Trazodone Hydrochloride 50 mg, Tablet, Oral 100 100 mg, Tablet, Oral 100 150 mg, Tablet, Oral 100

0.0742 R 0.1140 B 0.3113 B

Triamcinolone Acetonide 0.1%, Cream, Topical 80 gm 0.5%, Cream, Topical 15 gm 0.1%, Ointment, Topical 80 gm

0.0469 B 0.2370 B 0.0502 B

Triazolam 0.125 mg, Tablet, Oral 100

0.4041 B

Trihexyphenidyl Hydrochloride 2 mg, Tablet, Oral 100 5 mg, Tablet, Oral 100

0.1275 B 0.2295 B

Generic Name

Upper Limit per Unit (Source)

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

0.5250 B 0.0594 M

Verapamil Hydrochloride 120 mg, Capsule, Extended Release, Oral 100 180 mg, Capsule, Extended Release, Oral 100 240 mg, Capsule, Extended Release, Oral 100

0.8250 B 0.8700 B 0.4350 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-20

National Pharmaceutical Council

Pharmaceutical Benefits 2004

40 mg, Tablet, Oral 100 80 mg, Tablet, Oral 100 120 mg, Tablet, Oral 100 180 mg, Tablet, Extended Release, Oral 100 240 mg, Tablet, Extended Release, Oral 100

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book D-21

0.1509 B 0.0735 B 0.1110 B 0.4838 B 0.4350 B

National Pharmaceutical Council

Pharmaceutical Benefits 2004

D-22

National Pharmaceutical Council

Pharmaceutical Benefits 2004

Appendix E: Glossary

E-1

National Pharmaceutical Council

Pharmaceutical Benefits 2004

E-2

National Pharmaceutical Council

Pharmaceutical Benefits 2004

GLOSSARY OF MEDICAL, MEDICAID, AND MANAGED CARE TERMS Term

Definition

Access

A patient’s ability to obtain medical care. The ease of access is determined by components such as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and affordability of care.

Actual Acquisition Cost (AAC)

The pharmacist’s net payment made to purchase a drug product, after taking into account such items as purchasing allowances, discounts, and rebates.

Actual Charge

The amount a physician or other provider actually bills a patient for a particular medical service, procedure or supply in a specific instance. The actual charge may differ from the usual, customary, prevailing, and/or reasonable charge.

Acute Care

Medical treatment rendered to individuals whose illnesses or health problems are of a short-term or episodic nature. Acute care facilities are those hospitals that mainly serve persons with short-term health problems.

Additional Drug Benefit List

A list of pharmaceutical products approved by a health plan and employer for dispensing in larger quantities than the standards covered under a benefit package in order to facilitate long-term patient use. The list is subject to periodic review and modification by the health plan. Also called “drug maintenance list.”

Adjudication

Processing a claim through a series of edits in order to determine proper payment.

Administrative Costs

The costs incurred by a carrier, such as an insurance company or HMO, for services such as claims processing, billing and enrollment, and overhead costs. Administrative costs can be expressed as a percentage of premiums or on a per member per month basis. Additional costs that are often expressed as administrative include those related to utilization review, insurance marketing, medical underwriting, agents’ commissions, premium collection, claims processing, insurer profit, quality assurance activities, medical libraries and risk management.

Administrative Services Only (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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Pharmaceutical Benefits 2004

Term

Definition

Aged

For purposes of Medicare enrollment, persons 65 years of age or over are considered to be aged. Medicaid eligibility is determined on the basis of financial need for people who meet Supplemental Security Income (SSI) eligibility criteria (aged, blind, or disabled individuals) and Temporary Assistance for Needy Families (TANF) criteria (adults and children). Eligibility determinations are made for an entire economic unit or “case” (sometimes a family) based on whether or not one member of a case meets the criteria. For example, an “aged” case could consist of a 66 year old male and his 63 year old wife. In contrast, a disabled enrollee could be over 65 years of age. May also be defined as “Elderly.”

Agency for Healthcare Research and Quality (AHRQ)

A Federal agency under Health and Human Services (HHS) whose purpose is to enhance the quality and effectiveness of health care by funding healthcare services research, conducting health technology assessments and outcomes studies, and developing and disseminating clinical practice guidelines.

Aid to Families with Dependent 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 for Needy Families (TANF).

Allied Health Personnel

Specially trained and licensed (when necessary) health workers other than physicians, dentists, optometrists, chiropractors, podiatrists and nurses. The term is sometimes used synonymously with paramedical personnel, all health workers who perform tasks that must otherwise be performed by a physician, or health workers who do not usually engage in independent practice.

Allowable Charge

The maximum fee that a third party will reimburse a provider for a given service. An allowable charge may not be the same amount as either a reasonable or customary charge.

Allowable Costs

Charges for services rendered or supplies furnished by a health provider, which qualify for an insurance reimbursement.

Ambulatory Care

All types of health services that are provided on an outpatient basis, in contrast to services provided in the home or to persons who are inpatients. While many inpatients may be ambulatory, the term ambulatory care usually implies that the patient must travel to a location to receive services which do not require an overnight stay.

Ambulatory Surgery

Any minor surgical procedures that can be performed at any type of medical facility on an outpatient basis, i.e., not requiring an overnight stay.

American National Standards 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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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Term

Definition

Ancillary Services

Hospital services other than room, board, and professional services. They may include X-rays, lab tests, or anesthesia.

Antitrust

A legal term encompassing a variety of efforts on the part of government to assure that sellers do not conspire to restrain trade or fix prices for their goods or services in the market.

Any Willing Provider

A requirement that a health insurance plan or a health maintenance organization (HMO) must sign a contract for the delivery of health care services with any provider in the area that would like to provide such services to the plan’s or HMO’s enrollees, and can meet the terms of a contract.

Assignee

The person to whom the rights to a health insurance policy are assigned, either in part or in whole, by the original policyholder.

Assignment of Benefits

A method under which a claimant requests that his/her benefits under a claim be paid to some designated person or institution, usually a physician or hospital.

At-Risk

Accepting prepayment as full coverage for a predetermined health care benefit and assuming financial liability for any loss that occurs when premiums paid are less than the cost of services provided.

Authorization

As it applies to managed care, authorization is the approval of care, such as hospitalization.

Average Cost Per Claim

The average dollar amount of administrative and/or medical services rendered for the unit of measure within each expenditure category. The calculation is $amount / #of units.

Average Manufacturer Price (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.

Benefit Package

Services an insurer, government agency, or health plan offers to a group or individual under the terms of a contract.

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Pharmaceutical Benefits 2004

Term

Definition

Best Price

For purposes of Medicaid rebate calculations, lowest price paid for a product by any purchaser other than Federal agencies and State pharmaceutical assistance programs.

Biological Equivalents

Those chemical equivalents which, when administered in the same amounts, will provide the same biological or physiological availability, as measured by blood levels, urine levels, etc.

Blue Book (MDBT)

The generic name for a widely used pricing guide entitled the American Druggist First Databank Annual Directory of Pharmaceuticals. Brand name and generic drugs are listed by product, manufacturer, National Drug or Universal Price Codes, direct price and average wholesale price (AWP). Other pricing guides are the Red Book and Medispan’s Pricing Guide.

Brand Name

Name identifying a drug as the product of a specific pharmaceutical company. Also known as proprietary trademark name.

Cafeteria Plan

An employee benefit plan under which all participants are permitted to choose among two or more benefit options according to their needs and/or ability to pay. Also called a flexible benefit plan of “flex plan.”

Capitation

A method of payment in which a health plan, such as an HMO or a specific health care provider, receives a fixed amount for each person eligible to receive services ($ per member per month), which is made whether or not the covered person becomes an active patient and without regard to the number and mix of services used by that patient.

Capitation Fund

A fund based on the number of members multiplied by the budgeted or capitated amount each member pays. Some HMOs, in lieu of reimbursing physicians on a direct capitation basis, may establish such a fund. Physicians are then reimbursed on a fee-for-service basis from the capitation fund. The HMO monitors patient visits for over-utilization; patients exceeding the norm are notified.

Card Programs

The use of a drug benefit identification card which, when presented to a participating pharmacy by employees or their dependents, usually entitles them to receive the medication for a copay.

Care Coordinator

A primary health care practitioner: (1) who provides primary care services to an enrollee, (2) who is generally responsible for coordinating the enrollee’s health care, and (3) with whom, other than in an emergency, a patient must consult to obtain a referral to a specialist provider in order to obtain the highest level of benefits available under a health plan. Care coordinators are sometimes called “gatekeepers.”

Carve Out

A decision to purchase separately a service that is typically a part of an indemnity or HMO plan. Example: an HMO may “carve out” the behavioral health benefits and select a specialized vendor to supply these services on a stand-alone basis.

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Term

Definition

Case Management

(1) A process whereby covered persons with specific health care needs are identified and a plan designed to efficiently utilize health care resources is formulated and implemented to achieve the optimum patient outcome in the most cost-effective manner. (2) A utilization management program that assists the patient in determining the most appropriate and cost-effective treatment plan. It is used for patients who have prolonged expensive or chronic conditions, helps determine the treatment location (hospital, or other institution, or home), and authorizes payment for such care if it is not covered under the patient’s benefit agreement.

Case Manager

An experienced professional (e.g., nurse, doctor or social worker) who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Categorically Needy

Under Medicaid, categorically needy are aged, blind, or disabled individuals or families and children who meet financial eligibility requirements for TANF, Supplemental Security Income, or an optional State supplement.

Center for Medicaid and State Operations (CMSO)

The agency within the Centers for Medicare and Medicaid Services (CMS) with responsibility for administering the Medicaid and The Children’s Health Insurance Program (SCHIP).

Centers for Medicare and Medicaid Services (CMS)

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. Formerly known as the Health Care Financing Administration (HCFA).

Certificate of Need (CON)

A certificate issued by a government body, where required, to an individual or organization proposing to construct or modify a health facility, acquire major new medical equipment, or offer a new or different health service. Such issuance recognizes that a facility or services, when available, will meet the needs of those for whom it is intended.

Chain Pharmacy

One of a group of pharmacies, usually three or more, under the same management or ownership.

Charity Care Pools

The assets of several funds combined to cover health care costs to the poor and uninsured. The pools are established by organizations such as hospitals and insurance companies to offset a portion of the cost for providing health care to the indigent.

Chemical Equivalents

Those multiple-source drug products containing identical amounts of the same active ingredients, in equivalent dosage forms, and meeting existing physical/chemical standards.

Chronic Care

Care and treatment rendered to individuals whose health problems are of a long-term and continuing nature. Rehabilitation facilities, nursing homes, and mental hospitals may be considered chronic care facilities.

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Pharmaceutical Benefits 2004

Term

Definition

Claim

Information on medical services provided that is submitted by a provider or a covered person from which processing for payment to the provider or covered person is made. The term generally refers to the liability for health care services received by covered persons.

Claims Administration

A carrier function involving the review of health insurance claims submitted for payment, by individual claim or in the aggregate. Claims administration, as it relates to professional review programs, is an identification procedure, screening treatment or charge pattern, for subsequent peer review and adjudication.

Claims Clearinghouse System

A system which allows electronic claims submission through a single source.

Claims Review

The method by which an enrollee’s health care service claims are reviewed before reimbursement is made. The purpose of this monitoring system is to validate the medical appropriateness of the provided services and to be sure the cost of the service is not excessive.

Clearinghouse Capability

A company capable of submitting electronic and/or paper claims to several third-party payers.

Clinical Indicator

A tool or marker used to monitor and evaluate care to assure desirable outcomes and to explain or prevent undesirable outcomes.

Clinical Outcome

The status of the patient’s health, especially after receipt of medical care services. Assessment of outcomes may be dependent upon targeted goals, clinical markers, and the ability to provide objective measurements.

Clinical Practice Guidelines

Guidelines that specify the appropriate course(s) of treatment for specified health conditions.

Closed-Panel HMO

Generally offers the services of a relatively limited number of health care providers, e.g., physicians employed by the HMO. Staff- and group-model HMOs are usually referred to as being in this category.

CMS MSIS Report

The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic source of State-reported eligibility and claims data on the Medicaid population, their characteristics, utilization, and payments. Through FY 1998, the HCFA-2082 was an annual State submitted report designed to collect aggregate statistical data on Medicaid eligibles, recipients, services, and expenditures during each federal fiscal year. States summarized and reported the data processed through their own Medicaid claims processing and payment systems unless they opted to participate in the Medicaid Statistical Information System (MSIS) where the 2082 Report was produced by CMS. State-by-State national summary tables were developed based on the 2082 Reports. As a result of legislation enacted by The Balanced Budget Act of 1997, States, beginning in FY 1999, are required to submit all of their eligibility and claims data on a quarterly basis through MSIS. The State requirement for completing the HCFA-2082 Report has been eliminated.

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Pharmaceutical Benefits 2004

Term

Definition

CMS-64 Report

The CMS-64 Report is a product of the financial budget and grant system. It is a statement of expenditures for the Medicaid program that States submit to CMS 30 days after each quarter. The Report is an accounting statement of actual expenditures made by the States for which they are entitled to receive Federal reimbursement under Title XIX for that quarter. Along with The CMS MSIS Report, it is one of the primary sources for Medicaid statistical data.

Coinsurance

The portion of covered health care costs for which the covered person has a financial responsibility, usually according to a fixed percentage. Often coinsurance applies after first meeting a deductible requirement.

Commercial Managed Care Organization (Comp-MCO)

A health maintenance organization with a contract §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.

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. Department 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.

Continuum of Care

A range of clinical services provided to an individual or group, which may reflect treatment rendered during a single inpatient hospitalization, or care for multiple conditions over a lifetime. The continuum provides a basis for analyzing quality, cost and utilization over the long term.

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Pharmaceutical Benefits 2004

Term

Definition

Contract Pharmacy System

Pharmaceutical benefit delivery arrangement in which an HMO contracts with community pharmacies (chain or selected independents) to provide medications to members. Reimbursement may be by fee-for-service, capitation, or some other arrangement.

Contributory Program

A method of payment for group coverage in which part of the premium is paid by the employee and part is paid by the employer or union.

Copay/Copayment

A cost-sharing arrangement in which a covered person pays a specified charge for a specified service, such as $10 for an office visit. The covered person is usually responsible for payment at the time the care is rendered. Typical copayments are fixed or variable flat amounts for physician office visits, prescriptions or hospital services. Some copayments are referred to as coinsurance, with the distinguishing characteristics that copayments are flat or variable dollar amounts and coinsurance is a defined percentage of the charges for services rendered.

Cosmetic Procedures

Those procedures which involve physical appearance, but which do not correct or materially improve a physiological function and are not deemed medically necessary.

Cost Sharing

Any provision of a health insurance policy that requires the insured to pay some portion of medical expenses. The general term includes deductibles, copayments, and coinsurance.

Cost Shifting

The redistribution of payment sources. Typically, cost shifting occurs when one payer obtains a discount on provider services, and the providers increase costs to another payer to make up the difference.

Cost-Based Reimbursement

Payment by third-party insurers in which the amount is based on the cost to the provider of delivering services.

Cost-Effectiveness

Usually considered as a ratio, the cost-effectiveness of a drug or procedure, for example, relates the cost of that drug or procedure to the health benefits resulting from it. In health terms, it is often expressed as the cost per year per life saved.

Counter Detailing

A process of re-educating or influencing prescribers in a closed or controlled HMO plan. Usually done in order to gain more compliance with a formulary. In a counter-detailing program, techniques used by pharmaceutical sales representatives are adapted to a “counter” objective, i.e., to provide doctors with basic pharmacological information designed to influence their prescribing habits.

Coverage

Entire range of protection provided under an insurance contract.

Covered Expenses

Medical and related costs, experienced by those covered under the policy, that qualify for reimbursement under terms of the insurance contract.

Covered Services

The specific services and supplies for which Medicaid will provide reimbursement. Covered services under Medicaid consist of a combination of mandatory and optional services within each State.

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Pharmaceutical Benefits 2004

Term

Definition

Credentialing

A process of review to approve a provider who applies to participate in a health plan. Specific criteria and prerequisites are applied in determining initial and ongoing participation in the health plan.

Customary Charge

The charge a physician or supplier usually bills his patients for furnishing a particular service or supply is called the customary charge.

Customary, Prevailing, and 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.

Diagnosis Center

Freestanding or hospital-based facility that specializes in diagnosing illnesses and injuries.

Diagnosis 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.

Disease Management

An effort to improve patient outcomes and lower costs by organizing managed care initiatives around patients with a particular disease or condition.

Dismemberment

Loss of body parts stemming from accidental physical injury.

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Term

Definition

Dispense As Written (DAW)

A prescribing directive issued by physicians to indicate that the pharmacy should not in any way alter a prescription. Such alterations are usually done in order to substitute a generic drug for the brand name drug ordered.

Dispensing, Fill or Professional Fee

The amount paid to a pharmacy for each prescription, in addition to the negotiated formula for reimbursing ingredient cost.

Dispensing or Prescribing Limits

Limitations on the number of prescriptions per month, or the amount of medication that may be prescribed in a given time frame.

Disproportionate Share Hospital (DSH)

A disproportionate share hospital (DSH) is a hospital that serves a disproportionate number of low-income patients with special needs and receives a payment adjustment for providing such services. In addition to certain requirements for the provision of obstetrical services to individuals entitled to medical assistance, a hospital is deemed to be a disproportionate share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at least one standard deviation above the mean Medicaid inpatient utilization rate for hospitals receiving Medicaid payments in the State, or 2) the hospital’s low-income utilization rate exceeds 25 percent.

Drug Detailing

Presenting information about a brand name drug product to prescribers to educate them about its activity, uses, side effects, proper dosage and administration, etc.

Drug Formulary

A listing of prescription medications which are preferred for use by a health plan and which may be dispensed through participating pharmacies to covered persons. This list is subject to periodic review and modification by the health plan. A plan that has adopted an “open or voluntary” formulary allows coverage for both formulary and non-formulary medications. A plan that has adopted a “closed, select or mandatory” formulary limits coverage to those drugs in the formulary.

Drug Use Evaluation (DUE)

Evaluations of prescribing patterns of prescribers to specifically determine the appropriateness of drug therapy. There are three forms of DUE: prospective (before or at the time of prescription dispensing), concurrent (during the course of drug therapy), and retrospective (after the therapy has been completed). Same as “Drug Utilization Review.”

Drug Utilization

The prescribing, dispensing, administering and ingestion or use of pharmaceutical products.

Drug Utilization Review (DUR)

A quantitative evaluation of prescription drug use, physician prescribing patterns or patient drug utilization to determine the appropriateness of drug therapy. Most often focuses on over-utilization.

Dual Eligibles

The term describes a population of low-income elderly and individuals with disabilities who qualify for both Medicare and Medicaid coverage. While Medicare covers basic health services, including physician and hospital care, dual eligibles rely on Medicaid to pay Medicare premiums and cost-sharing and to cover critical benefits Medicare does not cover, such as long-term care and prescription drugs. However starting in 2006, coverage of prescription drugs for dual eligibles will shift from Medicaid to Medicare.

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Pharmaceutical Benefits 2004

Term

Definition

Early and Periodic Screening, Diagnostic, 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.

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 health care 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 health care professionals in the U.S. as effective in treating the condition, illness or diagnosis for which their use is proposed; or not proven by scientific evidence to be effective in treating the condition, illness or diagnosis for which their use is proposed.

Extended Care

Long-term care, ranging from routine assistance for daily activities to sophisticated medical and nursing care for those needing it. The care, covered under certain insurance policies, can be provided in homes, daycare centers or other facilities.

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Term

Definition

Family Planning Services

Any medically approved means, including diagnosis, treatment, drugs, supplies and devices, and related counseling which are furnished or prescribed by or under the supervision of a physician for individuals of childbearing age for purposes of enabling such individuals freely to determine the number or spacing of their children.

Favorable Selection

A tendency for utilization of health services in a population group to be lower than expected or estimated.

Federal Financial Participation

The technical term for Federal Medicaid matching funds paid to States for allowable expenditures for Medicaid services or administrative costs.

Federal Medical Assistance Percentage (FMAP)

The Federal Medical Assistance Percentage (FMAP) determines that Federal government’s share of medical assistance expenditures under each State’s Medicaid program. Each year, the FMAP is established by a formula that compares the State's average per capita income level with the national income average. States with a higher per capita income level are reimbursed a smaller share of their costs. By law, the FMAP cannot be lower than 50 percent or higher than 83 percent. The FMAP is defined in Section 1933(d) of the Social Security Act.

Federal Poverty Level (FPL)

The Federal government’s working definition of poverty is used as the reference point for the income standard for Medicaid eligibility for certain categories of beneficiaries. The Federal Poverty Level is the administrative version of the poverty measure and is issued by the Department of Health and Human Services (HHS). It is a simplification of the poverty thresholds and is used in determining financial eligibility for certain Federal programs. The FPL is also referred to as the Federal poverty guidelines.

Federal Upper Limits (FUL)

The upper limit amount that Medicaid can reimburse for a drug product if there are three or more generic versions of the product rated therapeutically equivalent and at least three suppliers listed in the current editions of published national compendia. These limits are intended to assure that the Federal government acts as a prudent buyer of drugs. The upper limits program seeks to achieve savings by taking advantage of current market prices.

Federally Qualified Health Center (FQHC)

Federally Qualified Health Centers 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 Medicaid providers of services if: 1) The facility receives a grant under sections 329, 330, or 340 of The Public Health Services Act; 2) HRSA recommends, and the HHS Secretary determines, that the facility meets the requirements of the grant; or 3) The Secretary determines that a facility may qualify through waivers of the requirements (such a waiver cannot exceed two years).

Federally Qualified HMOs

HMOs that meet certain Federally stipulated provisions aimed at protecting consumers: e.g., providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care. HMOs must apply to the Federal government for qualification. The Office of Prepaid Health Care of CMS administers the process.

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Pharmaceutical Benefits 2004

Term

Definition

Fee Maximum

The maximum amount a participating provider may be paid for a specific health care service provided to a covered person under a specific contract. Sometimes called “fee max.”

Fee Schedule

A listing of codes and related services with pre-established payment amounts that could be percentages of billed charges, flat rates or maximum allowable amounts.

Fee-for-Service Reimbursement

The traditional health care 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 or noninnovator multiple source drug.

Generic Equivalent

See “Generic Drug.”

Generic Substitution

Dispensing a generic drug in place of a brand name medication.

Global Target

A financing method identical to a global budget except that no enforcement mechanism is used to keep providers and hospitals within budget (i.e., providers and hospitals will receive additional funding if their costs exceed their budgeted payments).

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Pharmaceutical Benefits 2004

Term

Definition

HCFA 1500

A universal form developed by the government agency previously known as the Health Care Financing Administration (HCFA, now CMS), for providers of services to bill professional fees to health carriers.

HCFA Common Procedural 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 CMS in order to supplement CPT codes. They include physician services not included in CPT as well as nonphysician 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)

See “Centers for Medicare and Medicaid Services.”

Health Care Prepayment Plan (HCPP)

A cost contract with the CMS 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 Insurance Flexibility and Accountability (HIFA) Waiver

A Medicaid and State Children’s Health Insurance Program (SCHIP) demonstration waiver, using Section 1115 waiver authority, that offers States greater flexibility in setting benefits and cost-sharing for some groups of Medicaid beneficiaries. States can use the waiver to cut benefits and /or increase cost-sharing for certain Medicaid beneficiaries and invest resulting savings into expanding coverage of uninsured individuals through Medicaid and SCHIP.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Public Law 104-191, a law which requires each State’s Medicaid Management Information System (MMIS) to have the capacity to exchange data with the Medicare program and contains “administrative simplification” provisions that require State Medicaid Programs to use standard codes for electronic transactions relating to the processing of health claims.

Health Insuring Organization (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.

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Pharmaceutical Benefits 2004

Term

Definition

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 health care or otherwise assuring health care delivery in a geographic area, (b) An agreed upon set of basic and supplemental health maintenance and treatment services, and (c) A voluntary enrolled group of people.

Health Plan

An organization that provides a defined set of benefits; this term usually refers to an HMO-like entity, as opposed to an indemnity insurer.

Health Plan Employer Data and Information Set (HEDIS)

A core set of performance measures to assist employers and other health purchasers in understanding the value of health care purchases and evaluating health plan performance. HEDIS 2005 is currently used and distributed by NCQA (National Committee for Quality Assurance).

HMO - Group Model

A health care model involving contracts with physicians organized as a partnership, professional corporation, or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients.

HMO - Individual Practice Association (IPA)

A health care model that contracts with physicians and other community health care providers, to provide services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service basis.

HMO - Network Model

An HMO type in which the HMO contracts with more than one physician group, and may contract with single- and multi-specialty groups. The physician works out of his/her own office. The physician may share in utilization savings, but does not necessarily provide care exclusively for HMO members.

HMO - Staff Model

A health care model that employs physicians to provide health care to its members. All premiums and other revenues accrue to the HMO, which compensates physicians by salary and incentive programs.

Home and Community-Based Waivers

See “Section 1915(c) Waivers.”

Home Health Agency (HHA)

A facility or program licensed, certified or otherwise authorized pursuant to State and Federal laws to provide health care services in the home.

Home Health Services

Services and items furnished to an individual who is under the care of a physician by a home health agency or by others under arrangements made by such agency. Services are furnished under a plan established and periodically reviewed by a physician. They are provided on a visiting basis in an individual’s home and include: nursing, physical therapy, dietary, counseling, and social services; part-time or intermittent skilled nursing care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances (other than drugs and biologicals); home health aide services; and services of interns and residents.

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Pharmaceutical Benefits 2004

Term

Definition

Hospice

A program that provides palliative and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or another community agency. Originally a medieval name for a way station for crusaders where they could be replenished, refreshed, and cared for, hospice is used here for an organized program of care for people going through life's "last station." The whole family is considered the unit of care, and care extends through their period of mourning.

Indemnity Insurance

An insurance program in which the insured person is reimbursed or the provider is paid for covered expenses after services are rendered.

Innovator Multiple-Source Drug

An innovator multiple-source drug is a multiple source drug that was originally marketed under an original new drug application approved by the FDA.

Inpatient Hospital Services

Items and services furnished to a resident patient of a hospital by the hospital. May include such items as: bed and board; nursing and related services; diagnostic and therapeutic services; and medical or surgical services.

Integrated Behavioral Health

A carve-out benefit plan that combines independent managed care services into what is designed as a seamless delivery system for behavioral health concerns. Components could include employee assistance services, a telephone counseling triage, utilization management, behavioral health treatment networks, claims payment, and data management.

Integrated Delivery System

A generic term referring to a joint effort of physician/hospital integration for a variety of purposes. Some models of integration include physicianhospital organization, group practice without walls, integrated provider organization and medical foundation.

Intensive Care

Skilled nursing services, usually in a hospital, prescribed by a physician for individuals with serious medical conditions and delivered with the guidance of a registered nurse.

Intergovernmental Transfer (IGT)

The transfer of non-Federal public funds from a local government (or locally owned hospital or nursing facility) to the State Medicaid agency, or from another State agency (or State-owned hospital) to the State Medicaid agency, usually for the purpose of providing the State share of a Medicaid expenditure in order to draw down Federal matching funds.

Intermediate Care Facility for the Mentally Retarded (ICF/MR)

The ICF/MR benefit is an optional Medicaid benefit for States. Section 1905(d) of the Social Security Act created this benefit to fund "institutions" (4 or more beds) for people with mental retardation, and specifies that these institutions must provide health and/or rehabilitative services.

International Classification of 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.

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National Pharmaceutical Council

Pharmaceutical Benefits 2004

Term

Definition

Investigational Treatments

Medical treatments, including drugs waiting for FDA approval, that are considered experimental and, therefore, may not be covered by insurance plans. The definition of experimental currently varies from plan to plan.

Laboratory and Radiological 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 health care for an individual stated by an insurer. This amount serves as a cap on contractual liability and can be exceeded only in rare and unusual circumstances.

Long-Term Care

A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.

Magnetic Resonance Imaging

State-of-the-art machine used as a diagnostic tool, using magnetic fields to produce comprehensive pictures of the anatomy.

Managed Care

(1) A system of health care delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to high quality, cost-effective health care; (2) A systemized approach which seeks to ensure the provision of the right health care at the right time, place and cost.

Managed Care Organization (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 ProviderSponsored 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 fixed maximum cost 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.

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Term

Definition

Means Testing

The policy of basing eligibility for benefits upon an individual’s lack of means, as measured by his or her income or resources. Means testing, by definition, requires the disclosure of personal financial information by an applicant as a condition of eligibility. Medicaid and SCHIP are means tested programs.

Medicaid

A Federally aided State-operated and administered program that provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad Federal guidelines, States determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program. Also referred to as State Medical Assistance Programs.

Medicaid Buy-In

A provision in certain health reform proposals whereby the uninsured would be allowed to purchase Medicaid coverage by paying premiums on a sliding scale based on income.

Medicaid Management 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.

Medicaid-only Managed Care Organization (Mcaid-MCO)

An MCO that provides comprehensive services to Medicaid beneficiaries but not commercial or Medicare enrollees.

Medicaid Statistical Information System (MSIS)

The information system developed by CMS to collect detailed data on eligibility, utilization, and payments for services covered by State Medicaid programs.

Medical Assistance

The term used in the Federal Medicaid statute (Title XIX of the Social Security Act) to refer to payment for items and services covered under a State’s Medicaid program.

Medical Care Advisory Committee (MCAC)

A committee, consisting of physicians, other health professionals, Medicaid beneficiaries, and the director of the public health or welfare agency, appointed by the Medicaid agency director to participate in policy development and administration of a State’s Medicaid program.

Medical Necessity The evaluation of health care services to determine if they are: medically appropriate and required to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost-effective manner; and consistent with national medical practice guidelines regarding type, frequency and duration of treatment. Medical Savings Account (MSA)

A non-taxable savings account used to cover medical expenses. Based loosely on the idea of individual retirement accounts.

Medically Needy

Under Medicaid, medically needy cases are aged, blind, or disabled individuals or families and children who are not otherwise eligible for Medicaid, and whose income resources are above the limits for eligibility as categorically needy (TANF or SSI) but are within limits set under the Medicaid State Plan.

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Term

Definition

Medicare

A U.S. health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured. It consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B). Recent legislation has expanded the Medicare program to include an HMO option (Part C) and a prescription drug benefit (Part D). See “Medicare Prescription Drug, Improvement and Modernization Act of 2003.”

Medicare Beneficiary

A person designated by the Social Security Administration as entitled to receive Medicare benefits.

Medicare Payment Advisory 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 Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)

The Medicare Prescription Drug, Improvement, and Modernization Act (Public Law 108-173), also known as the Medicare Modernization Act (MMA) was enacted December 8, 2003. It enacted the Prescription Drug Program (Medicare Part D) effective January 2006, under which Medicare will assume responsibility for the prescription drug needs of beneficiaries eligible for both Medicare and Medicaid. It also enacted the temporary Medicare Prescription Drug Discount Card Program, effective June 2004December 2005. Many other amendments to the Medicare and Medicaid programs were also enacted, including coverage of an initial preventive physical examination, cardiovascular screening blood tests, and diabetes screening tests. Health Savings Accounts were also authorized. Medicare payment limits were established for certain hospital outpatient departments.

Medicare Supplemental Insurance

A policy guaranteeing that a health plan will pay a policyholder’s coinsurance, deductible and copayments and will provide additional health plan or non-Medicare coverage for services up to a predefined benefit limit. In essence, the product pays for the portion of the cost of services not covered by Medicare. Also called “Medigap” or “Medicare wrap.”

Medigap (Medicare 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.

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Term

Definition

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 health care contracts.

Multiple-Source Drug

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

National Committee for Quality 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.”

Nurse-Midwife Services

Nurse-midwife services are those concerned with the management of care of mothers and newborns throughout the maternity cycle. OBRA 1980 required that payment be made for providing nurse-midwife services to categorically needy recipients to the extent that the nurse-midwife is authorized to practice under State law or regulation. States are also required to offer direct reimbursement to nurse-midwives as one of the payment options. Nurse-midwives must be registered nurses who are either certified by an organization recognized by the Secretary of HHS or who have completed a program of study and clinical experience that has been approved by the Secretary.

Nursing Facility (NF)

A facility in either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital.

Nursing Facility Services

All services furnished to inpatients of, and billed for by, a formally certified nursing facility that meets standards set by Secretary of DHHS.

Other Practitioners’ Services

Health care services of licensed practitioners other than physicians and dentists.

Out-of-Pocket Costs/Expenses (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 nonprecertification, etc.) are not eligible for out-of-pocket limits.

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Term

Definition

Outcome Measures

Assessments which gauge the effect or results of treatment for a particular disease or condition. Outcome measures include such parameters as: the patient’s perception of restoration of function, quality of life and functional status, as well as objective measures of mortality, morbidity and health status.

Outcomes Management

Systematically improving health care results, typically by modifying practices in response to data gleaned through outcomes measurement, then remeasuring and remodifying - often in a formal program of continuous quality improvement.

Outcomes Research

Studies aimed at measuring the effect of a given product, procedure, or medical technology on health or costs.

Outlier

An observation in a distribution that is outside a certain range, often defined as two or three standard deviations from the mean or exceeding a specific percentile. Frequently refers to a case or hospital stay that is unusually long or expensive for its type, or to a physician practice that uses an abnormally high or low volume of resources.

Outpatient Services

Outpatient services are medical and other services provided on a nonresident basis (patients are not admitted to the facility) by a hospital or other qualified facility, such as a mental health clinic, rural health clinic, mobile X-ray unit, or freestanding dialysis unit. Such services include outpatient physical therapy services, diagnostic X-ray and laboratory tests, and X-ray and other radiation therapy.

Over-the-Counter (OTC)

A drug product that does not require a prescription under Federal or State law.

Participating Provider

A provider who has contracted with the health plan to provide medical services to covered persons. The provider may be a hospital, pharmacy, other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan.

Patient Health Status Survey

Questionnaire used to solicit patient perceptions regarding the state of their health. Questions may be general and address overall health status with regard to a specific condition (e.g., an arthritic patient’s ability to make a fist or an asthmatic patient’s ability to climb a flight of stairs).

Patient Satisfaction Survey

Questionnaire used to solicit the perceptions the plan enrollees or patients have regarding how a health plan meets their medical needs and how the delivery of care is handled, (e.g., waiting time, access to treatments).

Payer

A general term indicating the responsible party for the payment of medical care service expenses. Payers may be patients, insurance companies, government agencies, or a combination of these.

Pediatric Nurse Practitioner and Family Nurse Practitioner Services

Services furnished as authorized under State law by a registered professional nurse who meets a State’s advanced educational and clinical practice requirements, whether or not the practitioner is under the supervision of or associated with a physician or other health care provider.

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Term

Definition

Peer Review

The evaluation of quality of total health care 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.”

Personal Support Services

Personal support services consist of a variety of services including personal care, targeted case management, home and community-based care for functionally disabled elderly, rehabilitative services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing services.

Pharmacy And Therapeutics (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 comprises the official organizational line of communication between the medical and pharmacy components of the health plan. A major function of such a committee is to develop, manage and administer a drug formulary.

Pharmaceutical Benefits Manager (PBM)

An entity that is responsible for managing prescription benefits.

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 nonparticipating benefits through a supplemental major medical policy; a PPO may be used to provide both participating and non-participating levels of coverage and access; or various combinations of the above may be used.

Portability

Requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans.

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Term

Definition

Practice Guideline

Systematically developed statements on medical practice that assist a practitioner and a patient in making decisions about appropriate health care for specific medical conditions. Managed care organizations frequently use these guidelines to evaluate appropriateness and medical necessity of care. Terms used synonymously include practice parameters, standard treatment protocols and clinical practice guidelines.

Practice Parameters

See “Practice Guidelines.”

Practice Variation

An assessment of the patterns of a practitioner’s practice to determine if the provider’s care is significantly different from others with similar practices. If there is a significant difference, the practitioner’s practice is analyzed to determine the reasons for the variation and whether that practitioner’s practice patterns should be modified.

Pre-Certification Review

See “Utilization Review.”

Pre-Existing Condition (PEC)

Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person’s effective date of coverage under the master group contract.

Preferred Provider 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.

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Term

Definition

Primary Care

Basic or general health care traditionally provided by family practice, pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case 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.

Primary Care Physician (PCP)

The primary care practitioner (e.g., internist, family/general practitioner, pediatrician, and in some cases, OB/Gyn) in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non-routine services. See Care Coordinator.

Prior Authorization

The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Prospective Financing

Financing for health care services based on prices or budgets determined prior to the delivery of service. Payments can be per unit of service, per member, or per time period. In all its forms prospective financing differs from cost-based reimbursement, under which a provider is paid for costs incurred.

Protocol

See “Practice Guidelines.”

Provider Network

See “Network Plan.”

Providers

A physician, hospital, group practice, nurse, nursing home, pharmacy or any individual or group of individuals that provides a health care service.

Qualified Medicare Beneficiary (QMB)

An individual who qualifies for Medicare Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to payments of their Medicare cost-sharing charges, such as Medicare premiums, coinsurance, and copayment amounts.

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.

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Term

Definition

Reasonable Charge

In processing claims for Supplementary Medical Insurance benefits, carriers use CMS guidelines to establish the reasonable charge for services rendered. The reasonable charge is the lowest of: the actual charge billed by the physician or supplier; the charge the physician or supplier customarily bills his patients for the same services, and the prevailing charge which most physicians or suppliers in that locality bill for the same service. Increases in the physicians’ prevailing charge levels are recognized only to the extent justified by an index reflecting changes in the costs of practice and in general earnings.

Reasonable Cost

In processing claims for health insurance benefits, intermediaries use CMS guidelines to determine the reasonable cost incurred by the individual providers in furnishing covered services to enrollees. The reasonable cost is based on the actual cost of providing such services, including direct and indirect costs of providers, excluding any costs that are unnecessary in the efficient delivery of services covered by the insurance program.

Rebate

A monetary amount that is returned to a payer from a prescription drug manufacturer based upon utilization by a covered person or purchases by a provider.

Recipient

A recipient of Medicaid is an individual who has been determined to be eligible for Medicaid and who has used medical services covered under Medicaid.

Referral

The process of sending a patient from one practitioner to another for health care services. Health plans may require that designated primary care providers authorize a referral for coverage of specialty services.

Restrictive Formulary

A term often used synonymously with closed formulary. See “Drug Formulary.”

Retrospective Review

Determination of medical necessity and/or appropriate billing practice for services already rendered.

Risk

Responsibility for paying for or otherwise providing a level of health care services based on an unpredictable need for these services.

Risk Contract

(1) An agreement between a State Medicaid program and an HMO or competitive medical plan requiring the HMO to furnish at a minimum all Medicaid covered services to Medicaid eligible enrollees for an annually determined, fixed monthly payment rate from the State government. The HMO is then liable for services regardless of their extent, expense or degree. (2) An agreement between a provider and payer, or intermediary, on behalf of a payer, that requires the provider to furnish all specified services for a specified enrollee for a set fee, usually prepaid, and for a set period of time (usually one year). The provider is then liable for services regardless of their extent, expense or degree. Such stated limitations for such liability are stated in advance and may be subject to reinsurance.

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Term

Definition

Rural Health Clinic

A rural health clinic is an outpatient facility which is primarily engaged in furnishing physician and other medical and health services, which meets certain other requirements designed to ensure the health and safety of the individuals served by the clinic. The clinic must be located in an area that is not urbanized as defined by the Census Bureau and that is designated by the Secretary of DHHS either as an area with a shortage of personal health services, or as a health manpower shortage area, and has filed an agreement with the Secretary not to charge any individual or other person for items or services for which such individual is entitled to have payment made by Medicare, except for the amount of any deductible or coinsurance amount applicable.

Secondary Care

Services provided by medical specialists, such as cardiologists, urologists and dermatologists, who generally do not have first contact with patients. See also “Primary Care.”

Section 1115 Waivers

Section 1115 of the Social Security Act grants the Secretary of Health and Human Services broad authority to waive certain laws relating to Medicaid for the purpose of conducting pilot, experimental or demonstration projects. Section 1115 demonstration waivers allow States to change provisions of their Medicaid programs, including: eligibility requirements, the scope of services available, the freedom to choose a provider, a provider’s choice to participate in a plan, the method of reimbursing providers, and the statewide application of the program. Projects typically run three to five years.

Section 1915(b) Waivers

Section 1915(b) of the Social Security Act authorizes the Secretary of Health and Human Services to waive compliance with certain portions of the Medicaid statute that prevent a State from mandating Medicaid beneficiaries obtain their care from a single provider or health plan. Section 1915(b) waivers allow States to operate mandatory managed care programs in all or portions of the State while continuing to receive Federal Medicaid matching funds. Waivers must be approved by the Centers for Medicare & Medicaid Services (CMS).

Section 1915(c) Waivers

Section 1915(c) of the Social Security Act authorizes the Secretary of Health and Human Services to allow State Medicaid programs to offer special services to beneficiaries at risk of institutionalization in a nursing facility or facility for the mentally retarded. These services, which would otherwise not qualify for Federal matching funds, include case management, homemaker/home health aide services, rehabilitation services, and respite care. They also include, in the case of individuals, with chronic mental illness, day treatment and partial hospitalization, psychosocial rehabilitation, and clinic services. Also know as home and community-based (HCBS) waivers.

Self-Referral Restrictions

Restrictions on or prohibitions against providers referring patients to a designated health service (e.g., pharmacies, clinical laboratories, and outpatient surgery) in which the provider or the provider’s immediate family member has a financial interest.

Sin Taxes

Taxes imposed on items considered harmful to public health interests, such as tobacco and alcohol.

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Term

Definition

Single-Source Drug

A single-source drug is a covered outpatient drug which is produced or distributed under an original new drug application approved by the FDA, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application.

Single State Agency

The agency within State government designated as responsible for administration of the State Medicaid Plan. The Single State Agency is not required to administer the entire Medicaid program. It may delegate certain functions or supervise other State agencies, private contractors, or both.

Skilled Nursing Facility (SNF)

See “Nursing Facility.”

Specified Low-Income Medicare Beneficiary (SLMB) Program

These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid as a dual eligible. Medicaid pays their Medicare Part B premiums only, but they are not eligible for Medicaid payment for their Medicare cost-sharing obligations.

Spend-Down

Under Medicaid, “spend-down” refers to a method by which an individual establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income (after medical expenses) meets Medicaid financial requirements.

State Buy-In

The term given to the process by which a State may provide Supplementary Medical Insurance coverage for its needy eligible persons through an agreement with the Federal government under which the State pays the premiums for them.

State Children’s Health Insurance Program (SCHIP)

As part of the Balanced Budget Act of 1997, Congress created SCHIP as a Federal/State partnership with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance. SCHIP is designed to provide coverage to "targeted low-income children." A "targeted lowincome child" is one who resides in a family with income below 200% of the Federal Poverty Level (FPL) or whose family has an income 50% higher than the State's Medicaid eligibility threshold. Unlike Medicaid, SCHIP is a block grant awarded to the States each year. Children who are eligible for Medicaid are not eligible for SCHIP.

State Mandated Benefits Laws

State laws requiring insurance contracts to provide coverage for certain health services (e.g., in vitro fertilization) or services provided by certain health care providers (e.g., audiologists). Self-insureds are exempt from these requirements.

State Medical Assistance Programs

See “ Medicaid.”

State Pharmacy Assistant Programs

State authorized programs to provide pharmaceutical coverage or assistance to low-income and/or persons with disabilities who do not qualify for Medicaid. Also known as Expanded Drug Benefit Programs.

State Plan

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Term

Definition

State Plan Amendment

A State that wishes to change its Medicaid eligibility criteria or its covered benefits or its provider reimbursement rates must amend its State Medicaid Plan to reflect the proposed change. The State must submit the State Plan Amendment to CMS for approval.

Stop Loss

That point at which a third party has reinsurance to protect against the overly large single claim or the excessively high aggregate claim during a given period of time. Large employers, who are self-insured, may also purchase “reinsurance” for stop-loss purposes.

Supplemental Security Income (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.

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 CMS 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.”

Title XIX

See “ Medicaid.”

Universal Access

The availability of affordable public or private insurance coverage for every United States citizen or legal resident. There is no guarantee, however, that all individuals will actually choose to purchase or have the funds to purchase coverage. See “Universal Coverage.”

Universal Coverage

The guaranteed provision of at least basic health care services to every United States citizen or legal resident. See “Universal Access.”

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Term

Definition

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 health care services and treatment plans on a prospective, concurrent or retrospective basis.

Vaccines for Children Program (VCF)

A program under which the Federal government, through the Centers for Disease Control and Prevention, purchases and distributes pediatric vaccines to States at no charge and the State, in turn, arranges for the immunization of Medicaid-eligible and uninsured children through public and private physicians or other authorized providers.

Vendor

A medical vendor is an institution, agency, organization, or individual practitioner that provides health or medical products and/or services either to a medical provider, who in turn interfaces with patients, or directly to the public.

Vendor Payments

In welfare programs, direct payments are made by the State to providers such as physicians, pharmacists and health care institutions rather than to the welfare recipient himself.

Waiver

A rider or clause in a health insurance contract excluding an insurer’s liability for some sort of pre-existing illness or injury. Also refers to a plan amendment, such as a CMS waiver or State Plan modification.

Withhold

“At-risk” portion of a claim deducted and withheld by the health plan before payment is made to a participating physician as an incentive for appropriate utilization and quality of care. This amount – for example, 20% of the claim – remains within the plan and is credited to the doctor’s account. Can be used where the plan needs additional funds to pay for claims. The withhold may be returned to the physician in varying levels which are determined based on analysis of his/her performance or productivity compared against his/her peers. Also called “physician contingency reserve (PCR).”

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ACRONYMS AABD

Aid to Aged, Blind, and Disabled

AAC

Actual Acquisition Cost

AHRQ

Agency for Health Research and Quality

AIDS

Acquired Immune Deficiency Syndrome

AMP

Average Manufacturer Price

ANSI

American National Standards Institute

ARF

Area Resource File

ASO

Administrative Services Only

AWP

Any Willing Provider or Average Wholesale Price

BBA

Balanced Budget Act of 1997

BIPA

Benefits Improvement and Protection Act

BLS

Bureau of Labor Statistics

CHIP

See SCHIP

CFR

Code of Federal Regulations

CMP

Competitive Medical Plan

CMS

Centers for Medicare and Medicaid Services (formerly HCFA)

CMSO

CMS’ Center for Medicaid and State Operations

CNAB

Categorically Needy Aid to the Blind

CNAFDC

Categorically Needy Aid to Families with Dependent Children

CNAPTD

Categorically Needy Aid to the Permanently and Totally Disabled

CNOAA

Categorically Needy Old Age Assistance

COBRA

Consolidated Omnibus Reconciliation Act of 1985

COM-MCO

Commercial Managed Care Organization

CON

Certificate of Need

CPI

Consumer Price Index

CPR

Customary Prevailing, and Reasonable (charges)

CPT

Current Procedural Terminology

CQI

Continuous Quality Improvement

DAW

Dispense As Written

DBA

Doing Business As

DEFRA

Deficit Reduction Act of 1984

DESI

Drug Efficacy Study and Implementation

DHHS

Department of Health and Human Services

DRGs

Diagnostic Related Groupings

DSH

Disproportionate Share Hospital

DUE

Drug Use Evaluation

DUR

Drug Utilization Review

EAC

Estimated Acquisition Cost

EDI

Electronic Data Interchange

E-32

National Pharmaceutical Council

Pharmaceutical Benefits 2004

EPSDT

Early and Periodic Screening, Diagnostic and Treatment

ERISA

Employee Retirement Income Security Act

ESRD

End Stage Renal Disease

FDA

Food and Drug Administration

FFP

Federal Financial Participation

FFS

Fee-for-Service

FMAP

Federal Medical Assistance Percentage

FOC

Freedom of Choice

FPL

Federal Poverty Level

FQHC

Federally Qualified Health Center

FUL

Federal Upper Limits

FY

Fiscal Year

HCFA

Health Care Financing Administration (see CMS)

HCPCS

HCFA Common Procedural Coding System

HCPP

Health Care Prepayment Plan

HEDIS

Health Plan Employer Data and Information Set

HH

Home Health

HIFA

Health Insurance Flexibility and Accountability

HIO

Health Insuring Organizations

HIPAA

Health Insurance Portability and Accountability Act

HMO

Health Maintenance Organization

HRSA

Health Resources and Services Administration

ICF-MR

Intermediate Care Facility for the Mentally Retarded

IGT

Intergovernmental Transfer

IPA

Individual Practice Association

MAC

Maximum Allowable Cost

MAIC

Maximum Allowable Ingredient Cost

MCAC

Medical Care Advisory Committee

MCAID-MCO

Medicaid-only Managed Care Organization

MCO

Managed Care Organization

MMA

Medicare Prescription Drug, Improvement and Modernization Act of 2003

MMIS

Medicaid Management Information System

MNAB

Medically Needy Aid to the Blind

MNAFDC

Medically Needy Aid to Families with Dependent Children

MNAPTD

Medically Needy Aid to the Permanently and Totally Disabled

MNOAA

Medically Needy Old Age Assistance

MQC

Medicaid Quality Control

MSA

Medical Savings Account

MSIS

Medicaid Statistical Information System

NDC

National Drug Code

NF

Nursing Facility

E-33

National Pharmaceutical Council

Pharmaceutical Benefits 2004

NP

Nurse Practitioner

OACT

Office of the Actuary

OASDI

Old Age, Survivors, and Disability Insurance

OBRA

Omnibus Budget Reconciliation Act

OHS

Outpatient Hospital Services

OMB

Office of Management and Budget

ORD

Office of Research and Demonstrations

OT

Occupational Therapy

OTC

Over-the-Counter (drugs)

P&T

Pharmacy and Therapeutics Committee

PA

Physician’s Assistant or Prior Authorization

PBM

Pharmaceutical Benefits Manager

PCCM

Primary Care Case Management

PCF

Program Characteristics File

PCP

Primary Care Physician

PHP

Prepaid Health Plan

PMPM

Per Member Per Month

PHO

Physician-Hospital Organization

POS

Point-of-Service

PPO

Preferred Provider Organization

PRO

Peer Review Organization

ProPAC

Prospective Payment Assessment Commission

PT

Physical Therapy

QA/QI

Quality Assurance/Quality Improvement

QMB

Qualified Medicare Beneficiary

RHC

Rural Health Clinic

RPH

Registered Pharmacist

Rx

Pharmaceutical

SCHIP

State Children’s Health Insurance Program

SFO

State Funds Only

SLMB

Specified Low-Income Medicare Beneficiary

SSA

Social Security Administration

SSI

Supplemental Security Income

SSP

State Supplemental Payments

TANF

Temporary Assistance for Needy Families

TDOC

Total Days of Care

TEFRA

Tax Equity & Fiscal Responsibility Act

Title XIX

Title XIX of The Social Security Act (See Medicaid)

TPA

Third-Party Administrator

TQM

Total Quality Management

UCR

Usual, Customary and Reasonable

UM

Utilization Management

E-34

National Pharmaceutical Council

Pharmaceutical Benefits 2004

UR

Utilization Review

VCF

Vaccines for Children Program

WAC

Weighted Average Cost or Wholesale Acquisition Cost

E-35