Pharmaceutical Benefits Under State Medical Assistance Programs, 2002

Pharmaceutical Benefits Under State Medical Assistance Programs

2002

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

©2003 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 Compensation Solutions, LLC 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, Steven Heath, M.P.A., Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A., Errica Philpott, Liz Segall, and Tiffany Crawford of Muse & Associates. Paul Gavejian and Philip Farber of Compensation Solutions prepared and conducted the 2001 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 Dietrich of the National Pharmaceutical Council provided valuable input and support, including the conceptualization of the methodology used in Section 1.

Pharmaceutical Benefits 2002

National Pharmaceutical Council v

INTRODUCTION

The year 2002 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 37th year that the National Pharmaceutical Council (NPC) has published this unique source of information on pharmacy programs within the State Medical Assistance Programs (Title XIX). Over the years, this “Medicaid Compilation” of statistics has become a standard reference in government offices, research libraries, consultancies, the pharmaceutical industry, and numerous businesses.

The data used to create each edition of the Compilation are assembled from many sources. The “Medicaid 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 other organizations. Each year, finding and compiling current, relevant information for inclusion in the Compilation presents a challenge. Updating the data for the 2002 Compilation was no exception.

For example, in previous versions of the Compilation, a main data source was the HCFA-2082, an annual report providing State-reported data on Medicaid population characteristics, service utilization, and expenditures during a Federal fiscal year. Historically, States summarized and reported data processed through their Medicaid claims processing and payment operations unless they opted to participate in the Medicaid Statistical Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary program where States participating in the MSIS project provided data tapes from their claims processing systems to CMS in lieu of the HCFA-2082 tables. In accordance with the Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, had to be submitted electronically in the MSIS format and the HCFA-2082 ceased to be a Federal reporting requirement.

This new requirement resulted in major difficulties in the submission of data to CMS by some States and in the preparation of summary tables for FY 1999 and later by CMS. At press time, CMS has released MSIS data for 2000, which are included in this year’s Compilation. However, CMS has only released MSIS data for 2001 for a subset of states, and partial data are included in Appendix B as appropriate.

The U.S. Bureau of the Census has also lagged behind its normal schedule for release of annual population and demographic data due to data processing problems. Although a few tables showing total population counts by State for 2001 are available, the bulk of the more detailed data for 2001 have yet to be released. Discussions with Census Bureau staff indicate that the additional 2001 data will not become available until sometime during 2003, at the same time that data for 2002 are scheduled for release.

Data availability and the challenges of compiling relevant information have led us to examine all available data sources and to select, from among the alternatives, those data that, in our opinion, best represent the current snapshot of


vi National Pharmaceutical Council

State characteristics, especially their Medicaid programs. For example, on occasion, we have substituted more recent data from the CMS-64 Report for older MSIS data. However, the payment information presented in the MSIS and CMS-64 Reports differ slightly due to differences in the data captured. The primary differences result from the fact that disproportionate share hospital (DSH) payments and Medicare premium payments are reported in the CMS-64 Reports but do not appear in the MSIS data. Thus, differences in national aggregate and individual State data will occur between the two sources. However, this has resulted in some mixing and matching of data from differens sources and/or years. To assist users of the Compilation, the data sources used in each table have been carefully footnoted.

In order to structure the material in a more logical manner, the reader will note there has been some reorganization of the sequence of topics from previous versions of the Compilation. For example, in order to provide a more complete introduction of the Medicaid program to the reader, the overview of the Medicaid program has been moved from Section 4 to Section 2. Also, since the expanded drug programs are in addition to the standard Medicaid benefit provided by each state, this information now appears as Section 6, located after the profiles.

In order to give a better understanding of the content of the “Medicaid Compilation,” the information contained in this version of the book is summarized below by section:

• Section 1: Reports on a methodology for identification of Medicaid chronic illness propulations for case and disease management programs.

• 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 2001. 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 2002 NPC annual survey of State pharmacy program administrators. In addition, this section provides Medicaid eligibility statistics from CMS for fiscal year 2000 and program expenditure data for fiscal years 2000 and 2001. 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.


National Pharmaceutical Council vii

• 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 1999 and FY 2000 and data on total number of drug recipients for each State and the nation as a whole for the period 1996-2000. 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.

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 an 82 percent response rate to the 2002 Survey. Unfortunately, not all States were able to submit revised/updated information. In such instances, we have incorporated the most recently available data from other sources. However, for these States, much of the information may reflect data that have been presented in previous versions of the Compilation.

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

Gary Persinger Vice President, Health Care Systems National Pharmaceutical Council


viii National Pharmaceutical Council


National Pharmaceutical Council 1-1

SECTION 1: IDENTIFYING MEDICAID CHRONIC ILLNESS POPULATIONS FOR CASE AND DISEASE MANAGEMENT PROGRAMS


1-2 National Pharmaceutical Council



BACKGROUND AND PURPOSE

Medicaid is the largest single health insurance program in the U.S. Total Medicaid spending was $202.4 billion in Federal Fiscal Year (FFY) 2000, which accounted for more than 15% of national health care expenditures.1 Medicaid covered 44.3 million low-income children, their families, elderly people and individuals with disabilities – approximately 15% of the U.S. population. The Medicaid program is currently a major contributor to the fiscal crisis that many states are experiencing. It is second only to education as a percentage of state budgets. Managing these very large programs and their budgets requires an understanding of the forces that influence trends in Medicaid program spending. The purpose of this section is to illustrate ways in which policy makers can identify high impact Medicaid groups as the focus for case and disease management cost containment programs. High impact groups are groups that are likely to show program savings when placed in case or disease management programs. We believe that this method represents a significant tool for policy makers in their attempt to reduce program costs without adversely affecting the Medicaid population’s access to quality care.

The analysis begins at the most aggregate level by an examination of overall Medicaid trends with emphasis on the role of chronic illness in the growth of the program. This section builds on Section 1 from last year’s compendium in which Medicaid expenditures and the importance of chronic illness was examined. We use the most recent data (2000) available from the Centers for Medicare and Medicaid Services (CMS) for both expenditures and beneficiaries. We focus on one “typical” state, which allows us to conduct the necessary in depth analysis.

SPENDING TRENDS

Overall, Medicaid expenditures have almost doubled in the last decade, from $108.2 billion in 1992 to $202.4 billion in 2000; however, the spending growth rate has been affected by program changes during this time period.2 As seen in Figure 1-1, the rate of growth dropped throughout most of the decade but then started to rise in 1998. During the early to mid 1990’s, welfare reform, moderate growth of the aged and disabled population, and an improved economy led to a reduction in spending growth; indeed, all these led to changes in population size and mix effects. Also, increased use of managed care affected utilization incentives and the supply of providers. More recently, just as in the private sector, Medicaid expenditures have risen more rapidly. Among the most important factors explaining spending increases is the increasing cost of providing care to elderly and disabled individuals.



Figure 1-1: Total Medicaid Expenditures and Growth Rates 3

$122$134

$144 $152 $160$171

$186$202

$108

16.0%

5.6%4.8%

8.6% 8.8%7.4%12.4%7.7%10.0%

$0

$50

$100

$150

$200

$250

1992 1993 1994 1995 1996 1997 1998 1999 2000

Billi

ons

0

0.05

0.1

0.15

0.2

0.25

0.3

Gro

wth

Rat

e %

POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE

Medicaid is the largest financier of health care in the United States in terms of number of beneficiaries. In 2000, there were 44.3 million Medicaid beneficiaries.4 This represents an increase of about 66 percent in the number of Medicaid recipients since 1991, when there were 28.3 million recipients.5 In the past, it was automatically assumed that a person who was on welfare would qualify for the Medicaid program. Besides the working poor and those on assistance, Medicaid coverage can be extended to low income people who are elderly, blind, or disabled. In 2000, the majority of Medicaid funds, 69.7 percent of expenditures, were spent on aged, blind, and disabled beneficiaries (who constitute only 24.8 percent of persons served).6 In contrast, children made up 46.1 percent of the total beneficiaries in 2000, yet only 15.9 percent of all Medicaid expenditures went toward children.7 Figure 1-2 below shows the disproportionate share of spending by the aged and disabled.



Figure 1-2: Population vs. Expenditures* 8

* Figure 1-2 shows the 44.3 million Medicaid patients who received assistance, and the $168.3 billion in expenditures, reflects the total Medicaid program costs when the expenses for items such as administration and disproportionate share hospitals (DSH) are removed.

Because of the increasing burden of care for the elderly and disabled, long-term care services represent the largest portion of Medicaid expenditures (Figure 1-3). These services include nursing facility services, mental retardation facilities, and mental health institutions. Nursing facility services, the largest component of the long-term care category, grew approximately 5.6 between FFY 1999 and FFY 2000.9 Spending for hospital and physician services rose only slightly and larger increases in spending occurred for prescription drugs.

0%10%20%30%40%50%60%70%80%90%

100%

Beneficiaries Payments

Women, Children and Others Aged or Disabled

32.5 Million

$51.1 Billion

11.8Million $117.2

Billion

44.3 $168.3



Figure 1-3: Distribution of Medicaid Spending* by Type of Service10

42.3

23.1 22.1

12.0

44.2

21.5 19.5

13.5

44.3

22.2 21.316.6

45.6

24.3 23.420.0

$0

$10

$20

$30

$40

$50

$60

Long Term Care^ Hospital -Inpatient‡

Physician† Prescription Drugs

Bill

ions

1997199819992000

* Excludes managed care payments; only major categories of spending are included ^ LTC (long-term care) = nursing facilities, mental health, and mental retardation facilities ‡ Direct payments for services † Physician, dental, other practitioner, lab, clinic, EPSDT, outpatient hospital

PRESCRIPTION DRUG USE IN THE MEDICAID POPULATION

Table 1-1 shows the total expenditures for prescription drugs for all Medicaid recipients in State X, broken down by eligibility group. Again, it is the blind, disabled, and aged that consume the vast majority of dollars in this category; 84.8 percent of the total when added together.

TABLE 1-1: Prescription Drug Therapy

State X – 2000-2001 Prescription Drug Expenditures

Fee-for-Service in Millions of Dollars

Group Dollars Percent Aged $ 291 34.1%

Blind/Disabled $ 434 50.7% Children $ 92 10.7%

Other Adults $ 38 4.5% Total $ 855



As Figure 1-4 demonstrates, the use of specific types of prescription drugs varies greatly among the specific groups of beneficiaries. In Figure 1-4 “Antinfectives” include antibiotics, “Antinfectives/Miscellaneous” include anti-parasitics, anti-virals (HIV/AIDS), fungicides, antiseptics, etc.

Figure 1-4: Share of Rx Expenditures, by Eligibility Basis

The next part of this section provides an analysis of chronic conditions that play a large role in contributing to these increases in expenditures.

CHRONIC DISEASES IN THE MEDICAID FEE-FOR-SERVICE POPULATION

The purpose of this section is to focus on Medicaid Statistical Information System (MSIS) fee-for-service data from one “typical” State and examine the importance of chronic diseases in Medicaid spending. The diseases that were used for analysis were asthma, diabetes, hypertension, and depression (ICD-9 codes were used to define the three medical conditions. Asthma = 490 - 496, diabetes = 250, hypertension = 401- 405, and depression =296, 298.0, 300.4, 301.12, and 311). These diseases were selected based on their incidence in the Medicaid population and their amenability to case and disease management programs. The focus of our analysis is total Medicaid program costs for recipients with these medical conditions.

0%

5%

10%

15%

20%

25%

30%

PSYCHOTHER

APEUTI

C DRUGS

GASTROINTE

STINAL

CNS DRUGS

CARDIOVASCULA

R

ANALGES

ICS

BLOOD

ANTIIN

FECTI

VES

ANTIIN

FECTI

VES/MIS

CELLA

NEOUS

CARDIAC D

RUGS

HYPOGLYCEM

ICS

aged blind/disabled adult child



DATA AND METHODOLOGY

The analysis utilizes MSIS data from one State we believe is a “typical” Medicaid State. The data cover FFY 2000 & FFY 2001. MSIS data consists of four claims files and an eligibility file. The claims files are inpatient, long-term care, prescription drug, and the “other” file. These files contain all claims paid during each fiscal quarter. Obtaining the data required that a strict confidentiality agreement be signed with the State. Hence, we will refer to “State X” as we show the results of the data analysis. A copy of the data dictionary and a detailed overview of the MSIS files can be found at http://cms.hhs.gov/medicaid/datasources.asp.

The Selection of State X We selected State X based on a comparison of the percentage of eligibles and expenditures, the Medicaid population age distribution, and the percentage of money spent on types of service for the State compared to national data. Table 1-2 shows how similar the numbers for State X are to the National numbers.

Table 1-2: State X Compared to National Program

Comparison of National and State X Medicaid Programs National State X Percentage of Eligibles Disabled/Blind/Aged 26.6% 26.8% Children/Adults/Other 72.4% 75.8% Percentage of Expenditures Disabled/Blind/Aged 69.4% 76.8% Children/Adults Other 30.3% 23.2% Inpatient Hospital 14.4% 13.8% Nursing Facilities 20.5% 39.5% Physicians 4.0% 4.5% Prescription Drugs 11.9% 15.7%

Based on the similarity of the State X and national distributions, we believe that State X is a reasonably good proxy for what could be considered a “typical” Medicaid State. Although we cannot quantify the analysis, we also looked at the eligibility, coverage and reimbursement policies of State X, including their use of waivers. This analysis revealed no particularly unusual policies.

Analytic File Development All primary diagnosis fields in the inpatient, long-term care, and “other” files were queried for the most frequent diagnoses. The prescription drug file was not searched because prescription drug claims do not contain diagnosis codes. All claims with any one of the three diagnoses were extracted and placed in a temporary file. Beneficiary identification numbers, which are unique to each individual, were extracted from each record and unduplicated. This produced a list of all beneficiaries with one or more of the diagnoses. The final step was to extract all claims for this unduplicated list of recipients from the four claims files and the eligibility file. This resulted in a record that contained all Medicaid expenditures for those beneficiaries with one or more of the selected diagnoses.



Limitations of the Data

There are three major limitations to the MSIS data sets. First, with few exceptions, Medicaid reimbursement does not depend on the accuracy of ICD-9 coding. Hence, the accuracy of the diagnosis data can be questioned, just as many researchers have questioned the accuracy of similar Medicare data. Second, the MSIS system theoretically requires States to submit “encounter” records for recipients enrolled in managed care. The States have had difficulty complying with this relatively recent requirement. We found few encounter records for the managed care population. As a result, this study is limited to an analysis of the fee-for-service population. The final data limitation is that a significant percentage of primary diagnosis codes were missing in the long term care and “other” claims files.

ANALYSIS

In an earlier section, we looked at some of the major trends in the Medicaid program. This section outlines a methodology for examining the prevalence of chronic disease in the Medicaid fee-for-service population and their total Medicaid program expenditures. To help assess the importance of chronic illness in Medicaid growth and its potential for case and disease management programs, we asked the following questions:

1. How many recipients had the chronic medical conditions of interest in State X?

2. What are the groups with these chronic diseases that appear to be most amenable to case and disease management?

3. Can we identify particular groups that have high total and/or per capita expenditures where case and disease management might have a high impact on expenditures?

The third part of the analysis involves our making particular judgments regarding who might be good candidates for such programs. The methodology we propose makes these judgments based on our own analytic experience and a considerable number of conversations with experts in the programmatic and research areas. However, there may be many other methods – we propose just one method that identifies recipients that suggest a closer look.

A METHODOLOGY FOR IDENTIFING HIGH IMPACT MEDICAID RECIPIENT GROUPS POTENTIALLY AMENABLE TO CASE AND DISEASE MANAGEMENT PROGRAMS

We start with the entire Medicaid population in State X and sequentially apply a series of screens that remove Medicaid patients that may be less amenable to case and disease management than others. Once we have limited the population due to those we feel are high impact recipients, we examine the potential for one policy initiative in this final group. The process is summarized in Figure 1-5.



Figure 1-5: Flow Chart Depicting One Method of Identifying Beneficiaries with a Potential for Disease Management in State X

We started with the total Medicaid Population in State X, and sequentially eliminate populations. Each of the steps is outlined below:

Step 1: Removed all Medicaid recipients enrolled in managed care. Rationale: The care of Medicaid managed care patients is provided under a contract between the State and the managed care organization. The risk and responsibility for their care by and large rests with the managed care organization. Enrolling managed care Medicaid recipients into State run case and disease management programs confuses responsibility for their care and makes little policy sense.

Step 2: Removed Medicaid recipients with less than a full year of Medicaid eligibility. Rationale: Most policy options, in particular case and disease management programs, require that a person be enrolled in them for at least six months, if not a full year. Enrolling persons with records

MCO enrollees88,712$229 M

Cost/patient/yr: $1,611 < 1 year eligibility 203,901 $590 M

Cost/patient/yr: $4,268

Total Medicaid Population

767,668 $5.7 B

Cost/patient/year: $5,113

FFS enrollees678,956$5.5 B


Not amenable to C & DM: 75+,LTC, MR 7,887, $525 M

Amenable to C&DM efforts: < 75 years, not in LTC, not mentally retarded

378,366, $1.8 B, Cost/patient/yr: $2,730

> 1 year eligibility457,055$4.9 B


Medicaid only386,253 $2.3 B


Dual eligibles 81,860 $2.6 B


Medicare w/o full Medicaid 6,942 $10 M

Cost/patient/yr: $475

Amenable to C&DM efforts (w/ waiver): < 75 years, not in LTC, not mentally retarded

36,403, $500 M, Cost/patient/yr: $7,187

Not amenable to C & DM:75+,LTC, MR45,457, $2.1 B

Patients with Selected Chronic Diseases

95,794 See Table 1-3

Patients with 9+ Rx in 180 Days 42,632,Cost/patient/yr: $9,956

See Table 1-4

Patients with 20+ Rx in 180 Days 8,914, Cost/patient/yr: $20,093

See Table 1-5



that show they migrate on and off the program would not be optimal for achieving the desired effects and savings.

Step 3: We split the populations into those dually enrolled in Medicare and Medicaid and those with Medicaid-only eligibility.

Rationale: Dual eligibles have high per capita spending. Although both populations have significant expenditures, dual eligibles represent one of the most important potential high impact groups. The MSIS data do not capture all claims for dual eligibles since Medicare is responsible for paying many of their costs. Disease or case management efforts undertaken by Medicaid for this population would likely benefit Medicare and cost Medicaid, so a waiver would need to be implemented to make the undertaking mutually beneficial.

Step 4: Removal of patients over 75 years old, those in long term care facilities, and facilities for the mentally retarded.

Rationale: Aged patients are more likely to become sick simply because of their advancing age. Similarly, persons in institutions are very ill by definition and are covered by elaborate plan of care requirements based on the Medicaid statute. In theory, the plan of care for each Medicaid recipient would include a case or disease management program if that were deemed appropriate.

Step 5: The application of the screens resulted in 49.3 percent of total patient count being identified as potential pool of patients for high impact cost savings. These patients had an average cost per patient per year in Medicaid expenditures of $2,730. Table 1-3 shows the characteristics of the resultant group. Another potential high impact groups that overlaps with this pool is the dually eligible recipients. The method outlines here can also be used to identify this pool of patients.

The results in Table 1-3 show the high cost of chronic illness when four of the most prevalent diseases in the Medicaid population in State X are examined through the filters shown in Figure 1-5.

Table 1-3: FFY 2000-2001 Summary of Primary Diagnosis Data for Selected Conditions in the Medicaid Population of State X, and the Average Amount Spent on Each Patient Per Year

Disease (Patients may have more than one disease)

Number of Patients Medicaid $/patient/Year*

Asthma/COPD 61,439 $ 5,506

Depression 33,589 $ 8,159

Hypertension 17,896 $ 12,033

Diabetes 10,623 $ 12,698

Unduplicated Total 95,794 $ 6,063 *Costs represent total for patients who have these diseases, not disease-specific costs



Table 1-4 shows the characteristics of recipients with chronic diseases who had nine or more unique prescription drugs in 180 days and their costs. Unique prescriptions are defined as prescriptions for unique compounds excluding refills, changes in strength, and generic equivalents.

Table 1-4: Patients with Nine or More Prescription Drugs in 180 Days

Of the beneficiaries who received nine or more prescriptions in 180 days, 39 percent were blind or disabled, 40 percent were children, 20 percent were adults, and 1 percent aged with an average per patient/per year cost of $8,742.

Table 1-5 repeats the analysis for Medicaid recipients who, in this case, received twenty or more unique prescription drugs in 180 days. This group has much higher costs per patient per year than the population with less prescription drug use.

Table 1-5: Patients with Twenty or More Prescription Drugs in 180 Days

Of the beneficiaries who received twenty or more prescriptions in 180 days, 76 percent were blind or disabled, 6 percent were children, 15 percent were adults, and 3 percent were aged with an average per patient / per year cost of $20,093.

States, such as Florida, which have focused on this population, have documented that case management of these individuals identifies unnecessary utilization and that costs can be reduced.11



Asthma/COPD 27,170 $ 9,737

Depression 16,921 $ 11,759


Diabetes 8,639 $ 14,449

Total 42,632 $ 9,956 *Costs represent total for patients who have these diseases, not disease-specific costs



Asthma/COPD 5,985 $ 20,909

Depression 4,714 $ 19,437


Diabetes 3,688 $ 21,443

Total 8,914 $ 20,093 *Costs represent total for patients who have these diseases, not disease-specific costs



CONCLUSION Against the backdrop of significant Medicaid growth over the last decade, this analysis indicates that a large proportion of Medicaid expenditures are made for a small group of recipients who are chronically ill, many of whom are amenable to case and disease management. We have demonstrated one way to identify this high impact population. Clearly, other approaches exist. We believe that one way for States to reduce potential overutilization and the resulting unnecessary expenditures in such groups is to identify them using the methodology we have demonstrated and then explore different policy options oriented toward case and disease management.



REFERENCES 1 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Historical

National Health Expenditures Tables, by Type of Service and Source of Funds: Calendar Years 1960-2001. available from http://www.cms.hhs.gov/statistics/nhe/historical/nhe01.zip; Internet.

2 Ibid.

3 Ibid.

4 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Table 4. Medicaid Beneficiaries, 2000. available from http://cms.hhs.gov/medicaid/msis/00total.pdf; Internet.

5 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Table 1. Program Statistics, 1991, available from http://cms.hhs.gov/medicaid/msis/mstats.asp; Internet.

6 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Tables 3 and 4. Medicaid Expenditures, and Medicaid Beneficiaries, 2000. http://cms.hhs.gov/medicaid/msis/00total.pdf.

7 op. cit.: 1

8 Ibid.

9 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Table 5. Medicaid Expenditures by Type of Service for Maintenance Assistance Status and Basis of Eligibility All States, 1999 & 2000. available from http://cms.hhs.gov/medicaid/msis/99total.pdf and http://cms.hhs.gov/medicaid/msis/00total.pdf; Internet.

10 Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Table 3. Medicaid Expenditures by Type of Service, 1999 and 2000 available from http://cms.hhs.gov/medicaid/msis/99total.pdf and http://cms.hhs.gov/medicaid/msis/00total.pdf; and Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid Statistics, Table 10, Medicaid Medical Vendor Payments by Type of Service,1997 and 1998. available from http://www.cms.gov/medicaid/msis/MCD97T10.pdf and http://www.cms.gov/medicaid/msis/MCD98T10.pdf; Internet.

11 Medicaid Prescription Drug Spending Control Program Annual Report, State of Florida, Agency for Health Care Administration, Jan. 2002, p. 23.



Section 2: The Medicaid Program





MEDICAID PROGRAM OVERVIEW

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

MEDICAID ELIGIBILITY

Medicaid Eligibility: Medicaid is a “means tested program for low income individuals.” To qualify, a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits prescribed in the law and regulations.

Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition, the State has the option of providing Medicaid benefits to certain additional categories of persons. These are the “optional” categorically needy. An additional category of Medicaid recipients that a State may choose to include in its program is the “medically needy.”

Mandatory Categorically Needy: There are numerous and detailed categories under which the “categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory categorically needy are:

• Low-income families with children;

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

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

• Qualified pregnant women;

• Newborn children of Medicaid-eligible women;

• Various categories of low-income children; and

• Certain low-income Medicare beneficiaries.

Optional Categorically Needy: These are groups of individuals who meet the characteristics of the mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in determining their incomes and resources, they are allowed to exclude certain kinds of income. The “optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives, and pregnant women who meet the SSI income and resources requirements but are not receiving SSI cash payments.



Medically Needy: The “medically needy” are those individuals who meet the definitional requirements described above, except that their income or resources exceed the limitations applicable to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct their medical bills from their income and resources until they meet the applicable income and resources requirements. Their Medicaid benefits can then begin.

Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special categories of individuals. In general, these are individuals whose income and resources would otherwise be too high to qualify for full Medicaid benefits under the regular provisions.

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 Federally poverty level, and whose resources do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and co-payment amounts.

Non-Eligibles: A State can include in its Medicaid program individuals who do not meet the statutory eligibility criteria. However, the State must pay the full costs for these individuals. There are no Federal matching payments.

MEDICAID SERVICES

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

• Inpatient and outpatient hospital services;

• Physician services;

• Medical and surgical dental services;

• Laboratory and X-ray services;

• Nursing facility services (for persons 21 years of age or older);

• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children under age 21;

• Family planning services and supplies;

• Home health services for persons eligible for nursing facility services;

• Rural health clinic services and any other ambulatory services offered by a rural health clinic that are otherwise covered under the State Plan;

• Nurse-midwife services (to the extent authorized under State law);

• Pediatric and family nurse practitioners services; and

• Federally-qualified health center services and any other ambulatory services offered by a Federally-qualified health center that are otherwise covered under the State plan.



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

• Prenatal care and delivery services for pregnant women;

• Ambulatory services to individuals under age 18 and individuals entitled to institutional services;

• Home health services to individuals entitled to nursing facility services; and

• If the State Plan includes services either in institutions for mental diseases or in intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically needy groups certain specified services provided to the categorically needy.

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

• Clinic services;

• Services of ICFs/MR;

• Nursing facility services (children under 21 years old);

• Prescribed drugs;

• Optometrist services and eyeglasses;

• 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 an 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 HHS 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, Diagnosis and Treatment

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

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

• 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 nor 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 HHS 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.

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 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 HHS or who have completed a program of study and clinical experience that has been approved by the Secretary.

Pediatric Nurse Practitioner and Family Nurse Practitioner Services

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

CPNP and CFNP certification requirements include a current license to practice as a registered nurse in the State, meet the applicable state requirements for qualification of pediatric nurse practitioners or family nurse practitioners, and be currently certified by the American Nurses’ Association as a pediatric nurse practitioner or a family nurse practitioner.

Federally Qualified Health Center and other Ambulatory Services

Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other ambulatory services offered by an FQHC under the provisions of the Omnibus Budget Reconciliation Act of 1989. The definition of FQHC services is the same as that of the services provided by rural health clinics (RHC). FQHC services include physician services, services provided by physician assistants, nurse practitioners, clinical psychologists, clinical social workers, and services and supplies incident to services normally covered if furnished by a physician or if incident to a physician’s services.

FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant Health Centers, and Health Care for the Homeless. These centers may qualify as providers of service under Medicaid, under the following conditions:

• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service Act;

• The Health Resources and Services Administration recommends, and the HHS Secretary determines, that the facility meets the requirements of the grant; or

• The Secretary determines that a facility may qualify through waivers of the requirements. Such a waiver cannot exceed two years.



AMOUNT AND DURATION OF SERVICES

Within broad Federal guidelines and certain limitations, States may determine the amount and duration of services offered under their Medicaid programs. Federal regulations require that the amount and/or duration of each type of medical and remedial care and services furnished under a State’s program must be specified in the State Plan, and that these types of care and services must be sufficient in amount, duration, and scope to “reasonably achieve” their purpose. States are required to provide Medicaid coverage for comparable amounts, duration, and scope of service to all “categorically needy” and categorically-related eligible 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 76.62%, depending on the State’s per capita income (see the Federal Medical Assistance Percentage (FMAP) table, page 2-17).

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 76.62%.

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 2000, the Medicaid program enrolled 44.3 million eligible individuals with vendor payments for medical care services totaling $168.3 billion. The vendor payments reported in the 2000 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 2000 of $195.2 billion. When administrative costs are added to total net expenditures, total Medicaid program expenditures in 2000 were $205.7 billion.





Total Medicaid Eligibles by Basis of Eligibility, 20001, 2

State Total Eligibles

Age 65And Older

Blind/Disabled Children Adults

Foster Care/Children

BOEUnknown

National Total 44,297,288 4,294,963 7,474,797 20,996,425 10,669,787 859,992 1,324 Alabama 665,767 86,218 177,114 346,609 50,401 5,425 -Alaska 109,457 6,186 10,681 65,496 25,532 1,562 -Arizona 683,224 33,097 94,815 383,101 164,311 7,900 -Arkansas 504,297 54,050 100,939 233,833 109,878 5,584 13 California 8,063,644 592,107 925,316 3,042,220 3,358,935 145,061 5 Colorado 377,670 45,866 65,460 180,978 68,175 17,111 80 Connecticut 417,682 55,492 56,931 225,166 70,835 9,258 -Delaware 124,327 9,098 15,899 56,116 41,199 2,015 -District of Columbia 150,802 9,993 30,501 71,351 34,595 4,327 35 Florida 2,237,610 226,094 460,214 1,071,794 440,410 39,084 14 Georgia 1,238,794 110,369 224,319 679,595 205,832 18,674 5 Hawaii* 202,912 18,824 21,616 85,074 73,338 4,060 -Idaho 150,817 11,583 23,873 90,382 22,989 1,990 -Illinois 1,736,185 118,108 290,194 880,812 363,330 83,740 1 Indiana 756,195 76,488 106,594 439,316 122,596 11,201 -Iowa 316,425 41,030 55,488 147,659 62,984 9,264 -Kansas 267,812 32,794 51,079 135,869 37,028 11,042 -Kentucky 724,478 71,436 199,503 347,296 97,873 8,370 -Louisiana 827,413 99,146 172,986 444,597 100,787 9,897 -Maine 214,093 24,532 48,780 93,499 43,976 3,306 -Maryland 721,762 54,898 114,793 382,719 153,321 16,031 -Massachusetts 1,103,724 111,412 226,612 452,178 312,804 718 -Michigan 1,360,726 100,013 282,072 697,249 240,198 41,081 113 Minnesota 596,726 64,047 83,529 298,386 141,413 9,351 -Mississippi 595,824 69,571 152,132 306,810 63,944 3,356 11 Missouri 991,428 100,617 136,500 519,167 213,518 21,626 -Montana 97,136 9,922 17,340 46,546 19,348 3,978 2 Nebraska 238,054 23,051 29,019 131,100 44,695 9,468 721 Nevada 158,526 17,122 28,598 77,203 30,445 5,158 -New Hampshire 110,155 12,985 13,836 64,644 16,074 2,616 -New Jersey 855,745 107,341 163,608 430,674 135,381 18,741 -New Mexico 398,498 22,148 49,028 252,392 71,518 3,412 -New York 3,401,448 386,897 673,989 1,416,361 839,958 84,243 -North Carolina 1,228,105 176,471 219,068 608,976 208,630 14,960 -North Dakota 62,235 9,740 9,291 29,389 12,114 1,701 -Ohio 1,420,386 146,410 262,415 730,648 241,620 39,137 156 Oklahoma 584,620 63,136 73,801 354,566 85,532 7,585 -Oregon 560,734 41,711 61,569 224,236 219,202 13,981 35 Pennsylvania 1,767,817 204,871 391,401 739,868 386,071 45,606 -Rhode Island 182,149 18,650 34,028 78,806 45,412 5,253 -South Carolina 775,428 78,018 117,345 391,606 181,293 7,134 32 South Dakota 98,740 10,047 15,793 55,826 15,350 1,724 -Tennessee 1,535,121 89,078 318,868 653,469 460,933 12,733 40 Texas 2,706,974 360,971 346,479 1,520,123 450,755 28,646 -Utah 203,751 11,653 25,260 113,620 46,742 6,476 -Vermont 147,817 18,604 18,223 63,494 45,178 2,260 58 Virginia 681,292 95,398 131,535 348,706 91,992 13,660 1 Washington 916,838 69,054 121,662 520,323 191,871 13,927 1 West Virginia 354,326 31,872 84,511 171,119 60,629 6,195 -Wisconsin 619,129 61,834 131,980 267,639 138,847 18,828 1 Wyoming 52,470 4,910 8,210 27,819 9,995 1,536 -

1. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. 2. FY 2001 data have not been released for all states. Partial data are available in Appendix B. *Hawaii did not report for FY 2000. Their FY 1999 data are used in this table. Source: CMS, MSIS Report, FY 2000.



Total Medicaid Eligibles Per 1000 Population, 20001

State

Total StatePopulation

Total Eligibles*

Eligibles per1000 Populations

National Total 281,421,906 44,297,288 157.4Alabama 4,447,100 665,767 149.7Alaska 626,932 109,457 174.6Arizona 5,130,632 683,224 133.2Arkansas 2,673,400 504,297 188.6California 33,871,648 8,063,644 238.1Colorado 4,301,261 377,670 87.8Connecticut 3,405,565 417,682 122.6Delaware 783,600 124,327 158.7District of Columbia 572,059 150,802 263.6Florida 15,982,378 2,237,610 140.0Georgia 8,186,453 1,238,794 151.3Hawaii 1,211,537 202,912 167.5Idaho 1,293,953 150,817 116.6Illinois 12,419,293 1,736,185 139.8Indiana 6,080,485 756,195 124.4Iowa 2,926,324 316,425 108.1Kansas 2,688,418 267,812 99.6Kentucky 4,041,769 724,478 179.2Louisiana 4,468,976 827,413 185.1Maine 1,274,923 214,093 167.9Maryland 5,296,486 721,762 136.3Massachusetts 6,349,097 1,103,724 173.8Michigan 9,938,444 1,360,726 136.9Minnesota 4,919,479 596,726 121.3Mississippi 2,844,658 595,824 209.5Missouri 5,595,211 991,428 177.2Montana 902,195 97,136 107.7Nebraska 1,711,263 238,054 139.1Nevada 1,998,257 158,526 79.3New Hampshire 1,235,786 110,155 89.1New Jersey 8,414,350 855,745 101.7New Mexico 1,819,046 398,498 219.1New York 18,976,457 3,401,448 179.2North Carolina 8,049,313 1,228,105 152.6North Dakota 642,200 62,235 96.9Ohio 11,353,140 1,420,386 125.1Oklahoma 3,450,654 584,620 169.4Oregon 3,421,399 560,734 163.9Pennsylvania 12,281,054 1,767,817 143.9Rhode Island 1,048,319 182,149 173.8South Carolina 4,012,012 775,428 193.3South Dakota 754,844 98,740 130.8Tennessee 5,689,283 1,535,121 269.8Texas 20,851,820 2,706,974 129.8Utah 2,233,169 203,751 91.2Vermont 608,827 147,817 242.8Virginia 7,078,515 681,292 96.2Washington 5,894,121 916,838 155.6West Virginia 1,808,344 354,326 195.9Wisconsin 5,363,675 619,129 115.4Wyoming 493,782 52,470 106.3

1. FY 2001 data have not been released for all states. Partial data are available in Appendix B. *Hawaii did not report Medicaid eligibles for FY 2000. Their FY 1999 Medicaid eligibility data are used in this table. Source: U.S. Department of Commerce, Bureau of the Census, Census 2000; CMS, MSIS, FY 2000.



Total Net U.S. Medical Assistance Expenditures by Type of Service

Service FY 2001 Percent of Total FY 2000

Percent of Total

Percent Change

Nursing Facility $43,317,811,704 20.1% $39,607,169,035 20.3% +9.4%Inpatient Acute Care Hospital $39,586,413,122 18.3% $36,650,532,554 18.8% +8.0%Pharmaceuticals $24,656,812,921 11.4% $20,551,215,451 10.5% +20.0%HCBS Waivers $14,864,788,473 6.9% $12,628,550,113 6.5% +17.7%ICF-Mentally Retarded $10,686,809,919 5.0% $10,184,590,576 5.2% +4.9%Hospital Outpatient $7,709,540,429 3.6% $7,055,207,899 3.6% +9.3%Inpatient Mental Health Hospital $6,862,423,184 3.2% $7,331,896,067 3.8% -6.4%Clinic* $6,689,968,278 3.1% $5,863,580,557 3.0% +14.1%Physicians $6,670,379,109 3.1% $5,892,807,109 3.0% +13.2%Personal Care Services $5,251,140,806 2.4% $4,566,864,434 2.3% +15.0%Home Health Care $2,613,356,673 1.2% $2,311,780,853 1.2% +13.0%Dental $2,193,475,415 1.0% $1,795,228,321 0.9% +22.2%Other Practitioners $1,141,272,064 0.5% $1,030,135,204 0.5% +10.8%EPSDT $935,836,328 0.4% $829,205,382 0.4% +12.9%Lab/X-ray $660,398,684 0.3% $612,378,794 0.3% +7.8%Other** $41,969,472,522 19.4% $38,245,755,438 19.6% +9.7%Total Expenditures $215,809,899,631 100.0%‡ $195,156,897,787 100%‡ +10.6%

‡ 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, HCFA-64 Report, FY 2001 and FY 2000



Federal Medical Assistance Percentage (FMAP), FY 2002 and FY 2003

State 2002 FMAP 2003 FMAP 2003 FMAP (Q3&Q4)* 2003 Enhanced FMAP**Alabama 70.45% 70.60% 73.55% 79.42%Alaska 57.38% 58.27% 61.22% 70.79%Arizona 64.98% 67.25% 70.20% 77.08%Arkansas 72.64% 74.28% 77.23% 82.00%California 51.40% 50.00% 54.35% 65.00%Colorado 50.00% 50.00% 52.95% 65.00%Connecticut 50.00% 50.00% 52.95% 65.00%Delaware 50.00% 50.00% 52.95% 65.00%District of Columbia** 70.00% 70.00% 72.95% 79.00%Florida 56.43% 58.83% 61.78% 71.18%Georgia 59.00% 59.60% 62.55% 71.72%Hawaii 56.34% 58.77% 61.72% 71.14%Idaho 71.02% 70.96% 73.97% 79.67%Illinois 50.00% 50.00% 52.95% 65.00%Indiana 62.04% 61.97% 64.99% 73.38%Iowa 62.86% 63.50% 66.45% 74.45%Kansas 60.20% 60.15% 63.15% 72.11%Kentucky 69.94% 69.89% 72.89% 78.92%Louisiana 70.30% 71.28% 74.23% 79.90%Maine 66.58% 66.22% 69.53% 76.35%Maryland 50.00% 50.00% 52.95% 65.00%Massachusetts 50.00% 50.00% 52.95% 65.00%Michigan 56.36% 55.42% 59.31% 68.79%Minnesota 50.00% 50.00% 52.95% 65.00%Mississippi 76.09% 76.62% 79.57% 83.63%Missouri 61.06% 61.23% 64.18% 72.86%Montana 72.83% 72.96% 75.91% 81.07%Nebraska 59.55% 59.52% 62.50% 71.66%Nevada 50.00% 52.39% 55.34% 66.67%New Hampshire 50.00% 50.00% 52.95% 65.00%New Jersey 50.00% 50.00% 52.95% 65.00%New Mexico 73.04% 74.56% 77.51% 82.19%New York 50.00% 50.00% 52.95% 65.00%North Carolina 61.46% 62.56% 65.51% 73.79%North Dakota 69.87% 68.36% 72.82% 77.85%Ohio 58.78% 58.83% 61.78% 71.18%Oklahoma 70.43% 70.56% 73.51% 79.39%Oregon 59.20% 60.16% 63.11% 72.11%Pennsylvania 54.65% 54.69% 57.64% 68.28%Rhode Island 52.45% 55.40% 58.35% 68.78%South Carolina 69.34% 69.81% 72.76% 78.87%South Dakota 65.93% 65.29% 68.88% 75.70%Tennessee 63.64% 64.59% 67.54% 75.21%Texas 60.17% 59.99% 63.12% 71.99%Utah 70.00% 71.24% 74.19% 79.87%Vermont 63.06% 62.41% 66.01% 73.69%Virginia 51.45% 50.53% 54.40% 65.37%Washington 50.37% 50.00% 53.32% 65.00%West Virginia 75.27% 75.04% 78.22% 82.53%Wisconsin 58.57% 58.43% 61.52% 70.90%Wyoming 61.97% 61.32% 64.92% 72.92%

* The Tax Relief and Reconciliation Act of 2003 (May 28, 2003) provides for a temporary increase in the FMAP with regard to certain expenditures. This increase is only available for the last two quarters of FY 2003 and the first three quarters of FY 2004. More information is available at: http://cms.hhs.gov/states/letters/smd61303.pdf.

** 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 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 the District of Columbia is 50.00%.

Source: Federal Register, November 17, 2000, Vol. 65, No. 223, pages 69560-69561 and Federal Register, November 30, 2001, Vol. 66, No. 231, pages 59790-59793.



Medicaid Total Net Expenditures and Eligibles, 20001

State

Total Net MedicalAssistance Expenditures

Total Eligibles

AveragePer Eligible

National Total $195,156,897,787 44,297,288 $4,406Alabama $2,696,375,751 665,767 $4,050Alaska $481,281,298 109,457 $4,397Arizona $2,225,044,559 683,224 $3,257Arkansas $1,579,670,038 504,297 $3,132California $21,150,591,241 8,063,644 $2,623Colorado $1,944,315,136 377,670 $5,148Connecticut $3,141,982,373 417,682 $7,522Delaware $523,748,320 124,327 $4,213District of Columbia $827,804,186 150,802 $5,489Florida $7,525,260,503 2,237,610 $3,363Georgia $4,321,247,201 1,238,794 $3,488Hawaii $641,774,557 202,912 $3,163Idaho $577,303,622 150,817 $3,828Illinois $7,487,650,546 1,736,185 $4,313Indiana $3,469,954,218 756,195 $4,589Iowa $1,637,949,106 316,425 $5,176Kansas $1,410,784,891 267,812 $5,268Kentucky $3,034,651,254 724,478 $4,189Louisiana $3,443,268,554 827,413 $4,161Maine $1,184,602,684 214,093 $5,533Maryland $3,029,230,799 721,762 $4,197Massachusetts $6,345,106,895 1,103,724 $5,749Michigan $6,740,820,182 1,360,726 $4,954Minnesota $3,322,271,106 596,726 $5,567Mississippi $1,978,270,095 595,824 $3,320Missouri $3,939,465,005 991,428 $3,974Montana $450,228,083 97,136 $4,635Nebraska $1,046,569,334 238,054 $4,396Nevada $598,188,701 158,526 $3,773New Hampshire $791,841,232 110,155 $7,188New Jersey $6,069,845,736 855,745 $7,093New Mexico $1,222,368,395 398,498 $3,067New York $30,186,294,675 3,401,448 $8,875North Carolina $5,464,863,059 1,228,105 $4,450North Dakota $428,657,394 62,235 $6,888Ohio $7,479,847,366 1,420,386 $5,266Oklahoma $1,613,315,267 584,620 $2,760Oregon $2,110,836,095 560,734 $3,764Pennsylvania $10,387,923,145 1,767,817 $5,876Rhode Island $1,151,540,265 182,149 $6,322South Carolina $2,664,608,648 775,428 $3,436South Dakota $395,665,682 98,740 $4,007Tennessee $4,941,572,835 1,535,121 $3,219Texas $10,609,803,586 2,706,974 $3,919Utah $810,160,698 203,751 $3,976Vermont $516,874,481 147,817 $3,497Virginia $2,728,848,408 681,292 $4,005Washington $3,962,522,212 916,838 $4,322West Virginia $1,378,345,915 354,326 $3,890Wisconsin $3,266,901,080 619,129 $5,277Wyoming $218,851,375 52,470 $4,171

1. FY 2001 data have not been released for all states. Partial data are available in Appendix B. Source: CMS, CMS-64 Report, FY 2000 and CMS-MSIS Report, 2000.



Total Medicaid Program Expenditures, 2001

State


Administrative Expenditures

Total ProgramExpenditures

National Total $215,809,899,631 $11,818,203,540 $227,628,103,171Alabama $2,875,372,953 $112,293,202 $2,987,666,155Alaska $576,586,201 $47,263,457 $623,849,658Arizona $2,665,261,328 $158,520,658 $2,823,781,986Arkansas $1,852,176,546 $95,198,228 $1,947,374,774California $23,870,521,004 $1,912,661,153 $25,783,182,157Colorado $2,142,029,851 $104,816,374 $2,246,846,225Connecticut $3,213,848,086 $165,604,760 $3,379,452,846Delaware $591,974,246 $42,653,471 $634,627,717District of Columbia $979,941,105 $39,166,567 $1,019,107,672Florida $8,557,796,303 $488,243,434 $9,046,039,737Georgia $5,037,084,881 $277,430,878 $5,314,515,759Hawaii $634,781,970 $40,605,543 $675,387,513Idaho $693,205,598 $52,649,649 $745,855,247Illinois $7,764,611,352 $656,516,988 $8,421,128,340Indiana $4,008,812,857 $191,085,097 $4,199,897,954Iowa $1,666,923,701 $83,710,399 $1,750,634,100Kansas $1,686,410,544 $88,495,234 $1,774,905,778Kentucky $3,304,053,663 $94,086,870 $3,398,140,533Louisiana $4,201,982,590 $107,688,302 $4,309,670,892Maine $1,315,523,163 $71,766,795 $1,387,289,958Maryland $3,256,576,882 $237,787,627 $3,494,364,509Massachusetts $6,619,524,971 $315,960,095 $6,935,485,066Michigan $7,218,697,113 $672,727,945 $7,891,425,058Minnesota $3,835,870,579 $241,026,517 $4,076,897,096Mississippi $2,438,979,981 $77,574,664 $2,516,554,645Missouri $4,744,963,426 $218,348,725 $4,963,312,151Montana $482,357,404 $39,904,721 $522,262,125Nebraska $1,187,237,577 $65,002,223 $1,252,239,800Nevada $674,337,888 $41,319,522 $715,657,410New Hampshire $873,248,831 $49,011,939 $922,260,770New Jersey $7,123,653,988 $237,787,125 $7,361,441,113New Mexico $1,467,417,736 $77,150,962 $1,544,568,698New York $31,367,464,639 $1,100,100,703 $32,467,565,342North Carolina $6,150,681,587 $278,725,379 $6,429,406,966North Dakota $406,418,593 $23,266,231 $429,684,824Ohio $8,433,412,161 $423,705,111 $8,857,117,272Oklahoma $2,021,033,069 $149,559,238 $2,170,592,307Oregon $2,658,358,391 $219,388,229 $2,877,746,620Pennsylvania $10,908,343,146 $477,769,414 $11,386,112,560Rhode Island $1,187,880,819 $67,375,176 $1,255,255,995South Carolina $3,019,387,228 $100,847,623 $3,120,234,851South Dakota $464,455,469 $12,790,635 $477,246,104Tennessee $5,501,312,153 $164,842,053 $5,666,154,206Texas $11,583,679,558 $656,595,682 $12,240,275,240Utah $833,720,115 $71,485,808 $905,205,923Vermont $601,467,093 $46,209,258 $647,676,351Virginia $3,036,846,387 $164,701,821 $3,201,548,208Washington $4,305,724,247 $464,013,447 $4,769,737,694West Virginia $1,548,398,817 $69,489,949 $1,617,888,766Wisconsin $3,976,142,914 $202,500,424 $4,178,643,338Wyoming $243,408,927 $20,778,235 $264,187,162

Source: CMS, CMS-64 Report, 2001.



Total SCHIP Expenditures, 2001

State Medicaid SCHIP Expenditures

Non-Medicaid SCHIP Expenditures Total SCHIP Expenditures

National Total $1,085,406,288 $2,672,702,239 $3,758,108,527Alabama $11,028,787 $41,697,345 $52,726,132Alaska $30,027,779 $2,675,767 $32,703,546Arizona $0 $63,107,549 $63,107,549Arkansas $2,737,113 $304,124 $3,041,237California $21,573,132 $451,152,166 $472,725,298Colorado $0 $32,219,993 $32,219,993Connecticut $6,956,126 $13,320,314 $20,276,440Delaware $0 $3,522,910 $3,522,910District of Columbia $5,820,809 $858,195 $6,679,004Florida $51,638,344 $228,785,527 $280,423,871Georgia $0 $107,394,549 $107,394,549Hawaii $4,486,857 $7,517 $4,494,374Idaho $14,696,691 $1,632,965 $16,329,656Illinois $41,901,864 $18,270,672 $60,172,536Indiana $66,317,732 $15,344,243 $81,661,975Iowa $16,183,842 $17,447,153 $33,630,995Kansas $0 $34,226,716 $34,226,716Kentucky $60,436,382 $25,525,110 $85,961,492Louisiana $46,890,889 $3,127,086 $50,017,975Maine $11,719,012 $6,814,999 $18,534,011Maryland $132,783,049 $10,109,047 $142,892,096Massachusetts $59,140,780 $18,785,086 $77,925,866Michigan $29,599,152 $24,540,168 $54,139,320Minnesota $0 $1,050,703 $1,050,703Mississippi $11,272,829 $47,218,839 $58,491,668Missouri $70,016,456 $1,912,781 $71,929,237Montana $0 $17,078,586 $17,078,586Nebraska $11,522,522 $1,624,650 $13,147,172Nevada $0 $22,193,839 $22,193,839New Hampshire $159,278 $4,390,136 $4,549,414New Jersey $39,019,153 $159,261,877 $198,281,030New Mexico $9,650,244 $175,626 $9,825,870New York $7,936,900 $520,915,181 $528,852,081North Carolina $0 $96,119,888 $96,119,888North Dakota $108,421 $3,030,901 $3,139,322Ohio $138,236,701 $2,193,823 $140,430,524Oklahoma $30,734,515 $1,696,218 $32,430,733Oregon $0 $20,545,897 $20,545,897Pennsylvania $0 $134,241,636 $134,241,636Rhode Island $15,246,059 $11,869,131 $27,115,190South Carolina $55,068,762 $6,118,751 $61,187,513South Dakota $5,279,030 $1,441,298 $6,720,328Tennessee $18,061,561 $1,279,818 $19,341,379Texas $20,960,055 $343,705,290 $364,665,345Utah $0 $28,195,260 $28,195,260Vermont $0 $3,175,394 $3,175,394Virginia $0 $43,630,115 $43,630,115Washington $0 $8,447,279 $8,447,279West Virginia $218,084 $26,609,420 $26,827,504Wisconsin $37,977,378 $39,774,153 $77,751,531Wyoming $0 $3,936,548 $3,936,548

Source: CMS, CMS-21 (SCHIP) Report, 2001.





14.4% 23.2% 29.4%40.1% 47.8% 53.6% 55.6% 55.8% 56.8% 57.6%

85.6% 76.8% 70.6%59.9% 52.2% 46.4% 44.4% 44.2% 43.2% 42.4%

0%

20%

40%

60%

80%

100%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Managed Care Fee for Service

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. Over the past nine years, managed care enrollment as a percentage of total Medicaid enrollment has increased by 300 percent (i.e., from 14.4% to 57.6%). In 2001, more than half of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30, 2002, all but three States (Alaska, Mississippi, 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

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. 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): a MCO that provides comprehensive services to Medicaid beneficiaries, but not commercial or Medicare enrollees.

• Prepaid Health Plan (PHP): an entity that provides less than comprehensive services on an at-risk basis or one that provides any benefit package on a non-risk basis.

• Primary Care Case Management (PCCM): a provider (usually a physician, physician group practice, or an entity employing or having other arrangements with such physicians, but sometimes also including nurse practitioners, nurse-midwives, or physician assistants) who contracts to locate, coordinate, and monitor covered primary care (and sometimes additional services). This category includes those PHPs that act as PCCMs.

• “Other” Managed Care Arrangement: An entity where the plan is not considered a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.

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

Table 2-1: Medicaid Managed Care Plans

* Total number of enrollees includes 8,830,530 individuals enrolled in more than one managed care plan type. It also includes individuals enrolled in State healthcare reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.

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

Number of Plans Number of EnrolleesHealth Insuring Organization (HIO) 5 511,353

Commercial Managed Care Organization (COM-MCO) 188 9,734,395 Medicaid-only Managed Care Organization (Mcaid-MCO) 120 5,722,554

Primary Care Case Management (PCCM) 38 5,614,541 Prepaid Health Plan (PHP) 159 10,166,056

Other 25 199,299 Total 535 31,948,198*



Medicaid Managed Care Enrollment, As of June 30, 2002

State Medicaid

EnrollmentMedicaid Managed

Care Enrollment Percent in

Managed Care

Rank Based on Percent in

Managed CareNational Total 40,147,539 23,117,668 57.58% Alabama 730,619 405,090 55.44% 35Alaska 90,841 0 0.00% 50Arizona 738,556 697,171 94.40% 5Arkansas 507,969 336,111 66.17% 25California 6,074,019 3,191,168 52.54% 38Colorado 299,207 278,095 92.94% 6Connecticut 375,768 280,106 74.54% 16Delaware 113,480 87,465 77.08% 15District of Columbia 127,059 80,300 63.20% 33Florida 1,986,652 1,267,998 63.83% 32Georgia 1,447,398 1,043,154 72.07% 17Hawaii 168,616 132,787 78.75% 13Idaho 147,202 58,284 39.59% 41Illinois 1,475,137 130,988 8.88% 48Indiana 687,603 484,116 70.41% 20Iowa 261,923 227,495 86.86% 8Kansas 227,392 130,162 57.24% 34Kentucky 594,594 500,987 84.26% 10Louisiana 814,134 206,992 25.42% 45Maine 205,474 110,922 53.98% 37Maryland 655,940 451,307 68.80% 21Massachusetts 982,979 628,832 63.97% 31Michigan 1,208,803 1,208,803 100.00% 1Minnesota 536,722 368,186 68.60% 22Mississippi 709,260 0 0.00% 50Missouri 905,683 413,361 45.64% 40Montana 78,195 52,209 66.77% 24Nebraska 210,487 163,772 77.81% 14Nevada 156,585 60,823 38.84% 42New Hampshire 90,800 9,206 10.14% 47New Jersey 805,056 523,904 65.08% 28New Mexico 371,353 243,069 65.45% 26New York 3,129,731 1,099,900 35.14% 44North Carolina 1,023,601 722,089 70.54% 18North Dakota 47,788 30,808 64.47% 29Ohio 1,490,097 378,476 25.40% 46Oklahoma 480,373 338,819 70.53% 19Oregon 436,645 378,739 86.74% 9Pennsylvania 1,431,442 1,140,211 79.65% 12Puerto Rico 1,036,168 865,285 83.51% 11Rhode Island 171,673 117,024 68.17% 23South Carolina 744,808 64,272 8.63% 49South Dakota 90,040 85,868 95.37% 4Tennessee 1,430,966 1,430,966 100.00% 1Texas 2,209,031 839,798 38.02% 43Utah 154,784 154,784 100.00% 1Vermont 128,303 82,261 64.11% 30Virgin Islands 17,039 0 0.00% 50Virginia 496,555 323,863 65.22% 27Washington 919,487 829,625 90.23% 7West Virginia 286,123 144,911 50.65% 39Wisconsin 585,305 317,106 54.18% 36Wyoming 52,074 0 0.00% 50State 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, 2002. DHHS, CMS, Center for Medicaid & State Operations.



Pharmaceutical Benefits Under Managed Care Plans

State

Where do managed care recipients receive pharmacy benefits?

(State, Managed Care Plan, Both)

Special requirementsfor pharmacy benefits

in managed care?Alabama N/A N/AAlaska - -Arizona* - -Arkansas State NoneCalifornia Both Statutes, regulations, contractualColorado Managed Care Plan ContractualConnecticut Managed Care Plan Statutes, regulations, contractualDelaware State N/ADistrict of Columbia Both NoneFlorida Managed Care Plan ContractualGeorgia N/A N/AHawaii Both Guidelines Idaho N/A N/AIllinois Managed Care Plan ContractualIndiana Managed Care Plan NoneIowa State NoneKansas Managed Care Plan Guidelines, contractualKentucky Both ContractualLouisiana State N/AMaine State NoneMaryland Both RegulationsMassachusetts Managed Care Plan ContractualMichigan Both ContractualMinnesota Managed Care Plan ContractualMississippi - -Missouri Managed Care Plan ContractualMontana State NoneNebraska State NoneNevada Managed Care Plan NoneNew Hampshire State NoneNew Jersey Managed Care Plan GuidelinesNew Mexico Managed Care Plan Regulations, contractualNew York State Statutes, FFS programNorth Carolina State NoneNorth Dakota State NoneOhio Managed Care Plan StatutesOklahoma Both ContractualOregon Both ContractualPennsylvania Managed Care Plan ContractualRhode Island Managed Care Plan RegulationsSouth Carolina Managed Care Plan ContractualSouth Dakota N/A N/ATennessee* Managed Care Plan -Texas State N/AUtah State N/AVermont State NoneVirginia Managed Care Plan ContractualWashington Both ContractualWest Virginia State N/AWisconsin Both ContractualWyoming - - *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 2002 NPC Survey.



Medicaid Managed Care Enrollment Trends, 1998-2002

State 1998 1999 2000 2001 2002National Total 16,573,996 17,756,603 18,786,137 20,773,813 23,117,668Alabama 362,272 377,952 325,059 350,485 405,090Alaska 0 0 0 0 0Arizona 368,344 363,662 442,254 527,674 697,171Arkansas 186,215 232,123 222,261 257,662 336,111California 2,246,406 2,540,902 2,525,406 2,870,514 3,191,168Colorado 215,936 216,357 254,232 247,181 278,095Connecticut 220,803 230,217 229,995 239,829 280,106Delaware 62,010 68,869 75,535 83,422 87,465District of Columbia

51,022 75,499 78,864 79,673 80,300

Florida 915,554 912,045 1,016,641 1,184,506 1,267,998Georgia 673,528 638,082 806,009 878,140 1,043,154Hawaii 131,761 120,246 121,581 127,779 132,787Idaho 30,866 31,184 32,338 37,913 58,284Illinois 175,649 158,888 137,622 136,497 130,988Indiana 233,065 331,363 376,066 433,014 484,116Iowa 190,692 176,487 182,251 206,751 227,495Kansas 84,437 95,868 108,093 118,209 130,162Kentucky 325,233 324,447 464,191 489,711 500,987Louisiana 40,729 44,741 48,802 56,542 206,992Maine 16,295 23,720 57,151 96,051 110,922Maryland 306,474 347,937 385,687 421,355 451,307Massachusetts 532,971 575,186 583,324 616,241 628,832Michigan 752,568 1,130,608 1,063,557 1,023,264 1,208,803Minnesota 225,498 268,360 291,365 322,640 368,186Mississippi* 153,562 200,347 218,431 297,916 0Missouri 252,097 276,628 304,499 378,771 413,361Montana 66,331 69,738 42,312 46,995 52,209Nebraska 110,606 122,006 140,199 150,840 163,772Nevada 35,089 36,945 37,945 47,518 60,823New Hampshire 7,368 5,812 4,432 6,200 9,206New Jersey 376,839 356,956 371,641 459,087 523,904New Mexico 193,818 208,528 199,297 212,456 243,069New York 634,233 659,569 691,422 728,709 1,099,900North Carolina 559,035 689,104 598,852 674,133 722,089North Dakota 22,045 23,886 23,962 25,540 30,808Ohio 292,819 244,888 239,460 277,617 378,476Oklahoma 154,270 193,902 279,205 299,272 338,819Oregon 299,826 308,798 312,064 360,926 378,739Pennsylvania 904,701 1,004,601 975,211 1,037,374 1,140,211Puerto Rico 813,791 764,068 828,021 898,171 865,285Rhode Island 74,446 85,900 104,041 111,624 117,024South Carolina 15,823 23,149 32,149 41,716 64,272South Dakota 43,834 50,220 67,835 79,641 85,868Tennessee 1,268,769 1,312,969 1,323,319 1,426,622 1,430,966Texas 437,898 352,062 606,238 753,613 839,798Utah 112,803 118,601 119,200 128,898 154,784Vermont 52,153 65,692 55,605 78,181 82,261Virgin Islands 0 0 0 0 0Virginia 299,266 292,214 280,978 291,767 323,863Washington 718,023 706,202 800,481 766,366 829,625West Virginia 131,349 111,532 90,631 122,230 144,911Wisconsin 194,874 187,543 210,423 266,577 317,106Wyoming 0 0 0 0 0 State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. *As of 2002, HealthMacs no longer participates in the Medicaid program in Mississippi. Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1998; 1999; 2000; 2001 and 2002. DHHS, CMS, Center for Medicaid & State Operations.



Medicaid Managed Care Plan Type, As of June 30, 2002

State HIO Commercial

MCOMedicaid-only

MCO PCCM PHP OtherNational Total 5 189 120 39 159 25Alabama 0 0 0 2 1 0Alaska - - - - - -Arizona 0 2 26 0 1 0Arkansas 0 0 0 1 1 0California 5 24 0 2 14 5Colorado 0 5 1 1 7 0Connecticut 0 3 1 0 0 0Delaware 0 2 0 0 0 0District of Columbia 0 0 4 0 1 0Florida 0 12 2 1 2 1Georgia 0 0 0 1 2 0Hawaii 0 4 1 0 2 1Idaho 0 0 0 1 0 0Illinois 0 4 1 0 0 0Indiana 0 0 3 1 0 0Iowa 0 3 0 1 1 0Kansas 0 1 0 1 0 0Kentucky 0 0 1 1 1 0Louisiana 0 0 0 1 0 0Maine 0 0 0 1 0 0Maryland 0 0 6 0 0 0Massachusetts 0 2 2 1 1 0Michigan 0 10 11 0 48 0Minnesota 0 6 2 0 0 1Mississippi 0 0 0 0 0 0Missouri 0 4 4 0 0 0Montana 0 0 0 1 0 0Nebraska 0 1 0 1 0 1Nevada 0 2 0 0 0 0New Hampshire 0 1 0 0 0 0New Jersey 0 1 4 0 0 0New Mexico 0 3 0 0 0 0New York 0 13 15 6 1 16North Carolina 0 2 0 2 0 0North Dakota 0 1 0 1 0 0Ohio 0 5 2 0 0 0Oklahoma 0 1 3 1 0 0Oregon 0 5 9 1 18 0Pennsylvania 0 2 9 1 25 0Puerto Rico 0 4 0 0 3 0Rhode Island 0 3 0 0 0 0South Carolina 0 0 1 1 0 0South Dakota 0 0 0 1 1 0Tennessee 0 6 3 0 2 0Texas 0 11 2 2 1 0Utah 0 3 2 1 10 0Vermont 0 0 0 1 0 0Virgin Islands 0 0 0 0 0 0Virginia 0 6 1 1 0 0Washington 0 6 2 1 14 0West Virginia 0 2 0 1 0 0Wisconsin 0 29 2 0 2 0Wyoming - - - - - - HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only Managed Care Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.



Medicaid Managed Care Enrollment by Plan Type, As of June 30, 2002

State HIO Commercial

MCO Medicaid-only MCO PCCM PHP OtherNational Total 511,353 9,734,395 5,722,554 5,614,541 10,166,056 199,299Alabama - - - 387,947 392,196 -Alaska - - - - - -Arizona - 60,540 636,631 - 50,305 -Arkansas - - - 292,712 336,111 -California 511,353 2,640,578 - 26,775 296,189 3,509Colorado - 66,057 81,238 56,163 258,194 -Connecticut - 231,467 48,639 - - -Delaware - 87,465 - - - -District of Columbia - - 80,300 - 2,662 -Florida - 454,528 181,116 638,090 86,809 18,052Georgia - - - 1,043,154 998,269 -Hawaii - 113,019 28,996 - 1,113 1,672Idaho - - - 58,284 - -Illinois - 115,604 15,384 - - -Indiana - - 204,578 279,538 - -Iowa - 57,431 - 67,014 227,495 -Kansas - 61,167 - 68,995 - -Kentucky - - 122,972 293,560 500,987 -Louisiana - - - 206,992 - -Maine - - - 110,922 - -Maryland - - 451,307 - - -Massachusetts - 122,812 115,121 390,899 411,477 -Michigan - 465,549 318,867 - 1,208,803 -Minnesota - 356,975 15,288 - - 777Mississippi - - - - - -Missouri - 151,266 262,095 - - -Montana - - - 52,209 - -Nebraska - 32,426 - 37,379 - 163,772Nevada - 60,823 - - - -New Hampshire - 9,206 - - - -New Jersey - 40,790 483,114 - - -New Mexico - 243,069 - - - -New York - 585,915 475,082 20,156 7,230 11,517North Carolina - 20,738 - 701,351 - -North Dakota - 594 - 30,214 - -Ohio - 170,188 208,288 - - -Oklahoma - 22,640 160,863 155,316 - -Oregon - 71,207 194,626 13,812 728,352 -Pennsylvania - 227,305 775,544 129,901 930,249 -Puerto Rico - 865,285 0 0 865,285 -Rhode Island - 117,024 0 0 0 -South Carolina - 0 45,401 18,871 0 -South Dakota - 0 0 68,649 85,868 -Tennessee - 988,919 442,047 0 1,430,966 -Texas - 320,664 210,206 197,544 217,693 -Utah - 67,049 23,749 13,068 299,686 -Vermont - - - 82,261 - -Virgin Islands - - - - - -Virginia - 179,367 58,395 71,897 - -Washington - 363,024 81,608 4,146 829,625 -West Virginia - 48,189 - 96,722 - -Wisconsin - 315,515 1,099 - 492 -Wyoming - - - - - - * This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.



Medicaid Managed Care Enrollment by Payment Arrangement, As of June 30, 2002

State Fee-For-Service (FFS) Fully Capitated (FUL) Partially Capitated (PAR)National Total 5,595,064 26,127,344 211,970 Alabama 387,947 392,196 -Alaska - - -Arizona - 747,476 -Arkansas 292,712 336,111 -California 26,775 3,451,629 -Colorado 56,163 405,489 -Connecticut - 280,106 -Delaware - 87,465 -District of Columbia - 80,300 2,662 Florida 656,142 722,453 -Georgia 1,043,154 998,269 -Hawaii - 144,800 -Idaho 58,284 - -Illinois - 130,988 -Indiana 279,538 204,578 -Iowa 67,014 284,926 -Kansas 68,995 61,167 -Kentucky 293,560 623,959 -Louisiana 206,992 - -Maine 110,922 - -Maryland - 451,307 -Massachusetts 390,899 649,410 -Michigan - 1,993,219 -Minnesota 777 372,263 -Mississippi - - -Missouri - 413,361 -Montana 52,209 - -Nebraska 201,151 32,426 -Nevada - 60,823 -New Hampshire - 9,206 -New Jersey - 523,904 -New Mexico - 243,069 -New York 6,077 1,072,514 21,309 North Carolina 701,351 20,738 -North Dakota 30,214 594 -Ohio - 378,476 -Oklahoma - 183,503 155,316 Oregon - 994,185 13,812 Pennsylvania 129,901 1,933,098 -Puerto Rico - 1,730,570 -Rhode Island - 117,024 -South Carolina - 45,401 18,871 South Dakota 68,649 85,868 -Tennessee - 2,861,932 -Texas 197,544 748,563 -Utah 13,068 390,484 -Vermont 82,261 - -Virgin Islands - - -Virginia 71,897 237,762 -Washington 4,146 1,274,257 -West Virginia 96,722 48,189 -Wisconsin - 317,106 -Wyoming - - - Individual State totals will not sum to total managed care enrollment (page 2-5) because State totals include individuals enrolled in more than one plan type including dental, mental, and long-term care. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.



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 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 in two-year increments 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.

• Paragraph (b) (2) - Central Broker: Localities are allowed to act as a central broker in assisting Medicaid eligibles in selecting among competing health care plans, if such a restriction does not substantially impair access to medically necessary services of adequate quality.

• Paragraph (b) (3) - Shared Cost Saving: States are allowed to share (through provision of additional services) cost savings (resulting from use by the recipient of more cost-effective medical care) with recipients of medical assistance under the State Plan.

• Paragraph (b) (4) - Restrict Providers: States can limit the number of providers of certain services. These waivers are sometimes referred to as selective contracting waivers and are gaining in popularity. Recently approved 1915(b)(4) waivers included programs to restrict the number of providers of transportation services, organ transplants, and inpatient obstetrical care.

Refer to the table on page 2-13 for a listing of 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.

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 allowed States to waive freedom of choice, statewide access to care, and comparability requirements. However, a Section 1115 waiver also allow States to provide new and additional services, test new payment methods, offer benefits to new and expanded populations, and contract with managed care organizations that did not meet the necessary criteria of Section 1903 of the Social Security Act.

To receive approval of a Section 1115 waiver, States submit a proposal to 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) streamlined the process for States to submit requests for and receive extensions of Section 1115 demonstration waivers.

Currently, there are 17 Medicaid programs with Section 1115 waiver approvals: Arizona, Arkansas, California, Delaware, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, New York, Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin. Refer to the table on page 2-34 for a listing of implemented Section 1115 waivers.



Section 1915(b) Waivers, As of June 30, 2002

State Program(s) Approved 1915(b) Statutes

Utilized Implemented ExpirationAlabama Patient 1st 1, 3, 4 01/1/97 12/26/02Alaska None -- -- --Arizona None -- -- --

Non-Emergency Transportation 1, 4 3/1/98 8/22/03 Arkansas

Primary Care Physician 1 11/1/96 12/17/04

CALOPTIMA 1, 4 10/1/95 7/29/03Central Coast Alliance for Health 1, 4 1/1/96 6/2/03Health Plan of San Mateo 1, 4 11/30/87 8/26/04Hudman 4 4/24/92 7/15/03Managed Care Network 1, 2, 4 3/1/97 5/18/03Medi-Cal Mental Health Care Field Test 4 4/1/95 7/29/03Medi-Cal Specialty Mental Health Services Consolidation 4 3/15/95 11/19/02Partnership Health Plan of California 1, 4 5/1/94 2/10/03Primary Care Case Management Program 1, 4 8/1/84 2/4/04Sacramento Geographic Managed Care 1, 2, 4 4/1/94 11/10/02San Diego Geographic Managed Care 1, 2, 4 10/17/98 10/10/03Santa Barbara Health Initiative 1, 4 9/1/83 1/11/03Selective Provider Contracting Program 4 9/21/82 10/31/02

California

Two-Plan Model Program 1, 2, 4 1/23/96 11/8/03Managed Care Program 1, 2 5/1/83 4/14/03

Colorado Mental Health Capitation Program 1, 3, 4 7/1/95 4/9/03

Connecticut HUSKY A 1, 4 10/1/95 5/30/04Delaware None -- -- --District of Columbia DC Medicaid Managed Care Program 1, 2, 4 4/1/94 9/23/03

Managed Health Care 1, 2, 4 10/1/92 9/26/04Prepaid Mental Health Plan 1, 4 3/1/96 6/30/03Florida Statewide Inpatient Psychiatric Program 4 4/1/99 12/31/03Georgia Better Health Care 1 10/1/93 3/14/03Non-Emergency Transportation Broker Program 4 10/1/97 9/7/03Georgia Preadmission Screening and Annual Resident Review (PASARR) 1, 4 11/1/94 4/8/03

Hawaii None -- -- --Idaho Healthy Connections 1, 2 10/1/93 9/21/04Illinois None -- -- --Indiana Hoosier Healthwise 1 7/1/94 4/23/03Iowa Iowa Plan for Behavioral Health 1, 3, 4 1/1/99 2/28/03

KMMC: HealthConnect Kansas 1, 2, 4 1/1/84 10/4/02Kansas

KMMC: HealthWave 19 1, 2, 4 12/1/95 10/4/02

Kentucky Human Service Transportation 1, 4 6/1/98 3/7/03Louisiana Community Care 1 6/1/92 3/25/03Maine None -- -- --Maryland None -- -- --Massachusetts None -- -- --Michigan Comprehensive Health Care 1, 2, 4 7/1/97 9/24/04



State Program(s) Approved 1915(b) Statutes

Utilized Implemented Expiration Specialty Community Mental Health Services Programs 1, 4 10/1/98 3/13/03 Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 1/1/88 3/23/03Mississippi None -- -- --Missouri MC+ Managed Care/1915(b) 1, 2, 4 9/1/95 3/14/04Montana Passport to Health 1, 2 1/1/94 4/24/04Nebraska Nebraska Health Connection Combined Waiver Program 1, 2, 3, 4 7/1/95 10/31/02Nevada None -- -- --New Hampshire None -- -- --New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 9/30/02New Mexico SALUD! 1,4 7/1/97 10/21/02New York Non-Emergency Transportation 1, 4 7/1/96 11/14/02

ACCESS II /III1915(b) 1 7/1/98 11/08/02Carolina Access 1915(b) 1 4/1/91 11/08/02North Carolina Health Care Connection 1915(b) 1 7/1/96 11/08/02

North Dakota None -- -- --Ohio PremierCare 1, 2, 4 7/1/01 6/30/03Oklahoma None -- -- --Oregon Transportation Program 4 9/1/94 7/25/03

Family Care Network 1 2/1/94 6/16/04Pennsylvania HealthChoices 1, 2, 3, 4 2/1/97 6/16/04

Puerto Rico None -- -- --Rhode Island None -- -- --South Carolina None -- -- --South Dakota Prime 1 9/1/93 9/28/02Tennessee None -- -- --

Lonestar Select I 4 9/1/94 9/3/04

Lonestar Select II 4 3/10/95 3/4/04

NorthSTAR 1, 2, 4 11/1/99 11/5/03STAR 1, 2, 3, 4 8/1/93 8/31/03

Texas

STAR Plus 1, 2, 3, 4 1/1/98 8/31/04Choice of Health Care Delivery 1, 2, 4 7/1/82 7/23/03Non-Emergency Transportation 1, 4 7/1/01 9/18/04Utah Prepaid Mental Health Program 4 7/1/91 12/26/03

Vermont None -- -- --Medallion 1, 2 3/1/92 3/24/04

Virginia Medallion II 1, 4 1/1/96 12/26/02Healthy Options 1, 4 10/1/93 2/24/03

Washington The Integrated Mental Health Services 1, 4 7/1/93 11/4/04 Mountain Health Trust 1, 4 9/1/96 12/22/04

West Virginia Physician Assured Access System 1 6/1/92 4/27/04

Wisconsin None -- -- --Wyoming None -- -- --

Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002. Centers for Medicare and Medicaid Services, Center for Medicaid & State Operations.



Section 1115 Research and Demonstration Waivers As of June 30, 2002

State Program Implemented Expiration

Arizona Arizona Health Care Cost Containment System (AHCCCS) 10/1/82 9/30/06

Arkansas ARKids First 9/1/97 9/30/05

Altamed Health Senior Buencare 11/01/98 11/24/02

Center For Elders Independence 4/1/95 11/24/02

On Lok Senior Health Services 11/1/83 11/24/02

Senior Care Action Network 1/1/85 7/31/03

California

Sutter Senior Care 5/1/94 11/24/02

Delaware Diamond State Health Plan 1/1/96 3/15/04

Hawaii Hawaii QUEST 8/1/94 3/31/03

Kentucky Kentucky Health Care Partnership Program 11/1/97 11/1/02

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 6/30/05Minnesota

Prepaid Medical Assistance Program 7/1/85 6/30/05

Missouri MC+ Managed Care/1115 9/1/98 3/1/04

Partnership Plan – Family Health Plus 9/04/01 3/31/03New York

Partnership Plan Medicaid Managed Care Program 10/1/97 3/31/03

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

Vermont Vermont Health Access 1/1/96 12/31/03

BadgerCare (SCHIP) 7/01/99 3/31/04Wisconsin

Wisconsin Partnership Program 1/1/96 12/31/02

Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002. Centers for Medicare and Medicaid Services, Center for Medicare & State Operations.





Section 3: State Characteristics





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, income, employment, and insurance coverage 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 2001 Current Population Survey conducted by the U.S. Bureau of the Census. It is the only 2001 age breakout on a State-by-State basis that the Bureau had released while data collection for the 2002 Compilation was ongoing. Unfortunately, the approximately 5 million individuals residing in “group quarters” were not included. Hence, the total population figure (and the corresponding figures for each State) presented in this table is lower than the population total in the table showing insurance status. The data on insurance status was compiled from the March Supplement to the Current Population Survey, a collaborative effort by the Census Bureau and BLS. Hence, the estimates on the number of Medicare and Medicaid beneficiaries differ slightly from those published by CMS. HRSA’s Bureau of Health Professions, Division of Nursing is responsible for conducting the National Sample Survey of Registered Nurses. This survey is the Nation’s most extensive and comprehensive source of nursing statistics. The most recent survey, which is conducted every four years, is the 2000 version. Nothing more current is available from any other source that we examined. Hence, the nursing information included in 2002 Compilation is a repeat of the data presented in last year’s version.



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.



Age Demographics, 2001*

State Total Population Percent Ages19 and under

Percent Ages 20-44

Percent Ages 45-64

PercentAges 65+

National Total 277,017,622 28.5% 36.5% 23.0% 12.0%Alabama 4,349,601 28.4% 35.1% 23.8% 12.7%Alaska 615,531 34.0% 37.2% 23.4% 5.0%Arizona 5,197,474 30.9% 35.0% 21.0% 13.0%Arkansas 2,618,137 21.9% 34.4% 23.3% 13.5%California 33,681,509 31.3% 37.5% 20.8% 10.3%Colorado 4,314,724 29.0% 38.7% 23.0% 9.3%Connecticut 3,317,131 26.6% 35.4% 24.8% 13.2%Delaware 771,580 27.7% 36.5% 23.1% 12.7%District of Columbia 536,260 22.3% 42.6% 23.3% 11.8%Florida 16,007,098 26.1% 33.6% 23.2% 17.1%Georgia 8,150,008 30.1% 38.8% 21.9% 9.2%Hawaii 1,188,615 27.8% 35.1% 23.8% 13.3%Idaho 1,289,492 32.2% 34.4% 22.4% 11.0%Illinois 12,160,474 28.2% 37.4% 22.9% 11.5%Indiana 5,936,550 27.5% 37.0% 23.7% 11.8%Iowa 2,818,957 21.3% 34.4% 23.7% 14.1%Kansas 2,612,636 27.9% 36.6% 23.0% 12.6%Kentucky 3,950,704 27.6% 36.3% 24.0% 12.1%Louisiana 4,329,436 31.2% 35.3% 22.4% 11.2%Maine 1,251,745 24.2% 35.0% 26.9% 13.9%Maryland 5,241,087 28.8% 36.4% 23.7% 11.0%Massachusetts 6,159,307 25.0% 37.9% 24.1% 13.0%Michigan 9,740,127 27.6% 36.6% 23.9% 11.9%Minnesota 4,836,367 27.3% 37.8% 23.6% 11.3%Mississippi 2,762,576 40.6% 35.1% 22.4% 11.7%Missouri 5,467,596 28.4% 35.2% 23.6% 12.8%Montana 879,639 27.6% 33.6% 25.9% 12.9%Nebraska 1,662,378 29.0% 35.4% 22.8% 12.9%Nevada 2,072,391 29.3% 36.4% 23.2% 11.1%New Hampshire 1,223,636 26.1% 37.0% 25.6% 11.4%New Jersey 8,289,599 25.5% 37.5% 24.3% 12.7%New Mexico 1,792,823 30.9% 34.4% 23.2% 11.5%New York 18,433,370 27.1% 37.0% 23.5% 12.5%North Carolina 7,932,350 13.5% 37.2% 23.0% 11.7%North Dakota 610,793 25.5% 36.2% 24.3% 14.0%Ohio 11,074,368 27.0% 36.0% 24.2% 12.7%Oklahoma 3,347,660 28.9% 34.7% 23.5% 12.9%Oregon 3,395,357 27.7% 35.2% 24.6% 12.4%Pennsylvania 11,853,829 25.8% 34.7% 24.6% 15.0%Rhode Island 1,020,102 25.8% 36.7% 23.7% 13.8%South Carolina 3,927,982 28.3% 35.8% 24.0% 11.9%South Dakota 727,968 27.9% 35.1% 23.4% 13.6%Tennessee 5,592,019 27.5% 36.3% 24.2% 8.4%Texas 20,764,441 32.1% 37.3% 20.9% 9.6%Utah 2,229,295 35.6% 38.4% 17.6% 8.4%Vermont 592,321 25.0% 35.5% 27.1% 12.4%Virginia 6,956,276 28.0% 37.3% 23.7% 11.0%Washington 5,849,311 28.5% 36.9% 23.7% 10.9%

West Virginia 1,758,747 24.8% 33.8% 26.5% 14.9%Wisconsin 5,245,913 27.1% 36.6% 24.0% 12.4%Wyoming 480,332 28.5% 34.3% 25.8% 11.4%

This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters, which is less than 5 million people. 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. *Sum of percentages may not equal 100 percent due to rounding. Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey.



Race Demographics, 2001*

State

Total State Population

PercentWhite

PercentBlack

Percent Other**

PercentIndicated 2 or

More Races National Total 277,017,622 76.52% 11.97% 9.22% 2.29%Alabama 4,349,601 71.33% 25.80% 1.69% 1.18%Alaska 615,531 69.37% 3.36% 19.41% 7.86%Arizona 5,197,474 76.19% 2.97% 17.94% 2.90%Arkansas 2,618,137 80.78% 15.47% 2.14% 1.61%California 33,681,509 66.28% 6.21% 23.68% 3.83%Colorado 4,314,724 85.18% 3.65% 8.34% 2.83%Connecticut 3,317,131 83.17% 8.73% 6.28% 1.82%Delaware 771,580 75.82% 18.62% 4.16% 1.40%District of Columbia 536,260 29.29% 60.29% 7.55% 2.87%Florida 16,007,098 78.59% 14.77% 4.76% 1.88%Georgia 8,150,008 66.18% 27.99% 4.41% 1.43%Hawaii 1,188,615 24.67% 1.44% 50.22% 23.67%Idaho 1,289,492 92.11% 0.48% 5.59% 1.81%Illinois 12,160,474 74.68% 14.56% 8.98% 1.77%Indiana 5,936,550 87.86% 7.95% 2.67% 1.51%Iowa 2,818,957 93.89% 2.07% 2.83% 1.21%Kansas 2,612,636 86.49% 6.02% 5.01% 2.48%Kentucky 3,950,704 89.99% 6.90% 1.62% 1.48%Louisiana 4,329,436 63.98% 32.12% 2.60% 1.31%Maine 1,251,745 96.93% 0.40% 1.25% 1.42%Maryland 5,241,087 63.55% 26.85% 6.86% 2.74%Massachusetts 6,159,307 85.62% 5.51% 7.33% 1.54%Michigan 9,740,127 80.49% 13.73% 3.77% 2.01%Minnesota 4,836,367 89.45% 3.41% 5.62% 1.52%Mississippi 2,762,576 61.40% 36.37% 1.34% 0.89%Missouri 5,467,596 84.90% 11.13% 2.17% 1.80%Montana 879,639 90.34% 0.13% 7.61% 1.93%Nebraska 1,662,378 90.14% 3.98% 4.34% 1.54%Nevada 2,072,391 79.18% 6.50% 10.91% 3.40%New Hampshire 1,223,636 96.14% 0.72% 2.03% 1.11%New Jersey 8,289,599 74.12% 13.29% 10.83% 1.77%New Mexico 1,792,823 66.49% 1.73% 27.23% 4.55%New York 18,433,370 69.43% 15.46% 13.27% 1.84%North Carolina 7,932,350 72.48% 20.97% 4.95% 1.60%North Dakota 610,793 92.19% 0.47% 6.01% 1.34%Ohio 11,074,368 85.36% 11.17% 2.08% 1.38%Oklahoma 3,347,660 75.95% 6.54% 10.20% 7.31%Oregon 3,395,357 87.86% 1.62% 7.02% 3.50%Pennsylvania 11,853,829 85.71% 9.68% 3.34% 1.28%Rhode Island 1,020,102 85.67% 4.51% 8.20% 1.62%South Carolina 3,927,982 67.17% 29.61% 1.64% 1.58%South Dakota 727,968 93.08% 0.77% 4.22% 1.92%Tennessee 5,592,019 80.55% 16.08% 2.16% 1.21%Texas 20,764,441 71.96% 10.96% 14.96% 2.13%Utah 2,229,295 90.86% 0.44% 5.65% 3.06%Vermont 592,321 96.95% 0.38% 1.33% 1.34%Virginia 6,956,276 73.02% 19.39% 5.80% 1.79%Washington 5,849,311 81.35% 3.02% 11.15% 4.48%West Virginia 1,758,747 95.46% 2.74% 0.76% 1.03%Wisconsin 5,245,913 89.04% 5.50% 3.90% 1.56%Wyoming 480,332 92.69% 0.76% 4.26% 2.30%

This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters, which is less than 5 million people. 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. *Sum of percentages may not equal 100 percent due to rounding. ** Percent other includes American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and other. Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile.



Hispanic Demographics, 2001

State

Total StatePopulation Hispanic Population

Percent Hispanic

National Total 277,017,622 36,200,781 13.07%Alabama 4,349,601 70,025 1.61%Alaska 615,531 25,870 4.20%Arizona 5,197,474 1,363,226 26.23%Arkansas 2,618,137 87,579 3.35%California 33,681,509 11,334,407 33.65%Colorado 4,314,724 760,078 17.62%Connecticut 3,317,131 319,796 9.64%Delaware 771,580 38,207 4.95%District of Columbia 536,260 47,397 8.84%Florida 16,007,098 2,815,847 17.59%Georgia 8,150,008 440,915 5.41%Hawaii 1,188,615 84,236 7.09%Idaho 1,289,492 105,802 8.20%Illinois 12,160,474 1,573,733 12.94%Indiana 5,936,550 213,412 3.59%Iowa 2,818,957 81,958 2.91%Kansas 2,612,636 172,339 6.60%Kentucky 3,950,704 55,611 1.41%Louisiana 4,329,436 103,771 2.40%Maine 1,251,745 8,976 0.72%Maryland 5,241,087 235,511 4.49%Massachusetts 6,159,307 424,203 6.89%Michigan 9,740,127 318,727 3.27%Minnesota 4,836,367 140,825 2.91%Mississippi 2,762,576 36,572 1.32%Missouri 5,467,596 113,203 2.07%Montana 879,639 16,168 1.84%Nebraska 1,662,378 94,904 5.71%Nevada 2,072,391 425,077 20.51%New Hampshire 1,223,636 19,597 1.60%New Jersey 8,289,599 1,140,886 13.76%New Mexico 1,792,823 765,015 42.67%New York 18,433,370 2,895,976 15.71%North Carolina 7,932,350 375,913 4.74%North Dakota 610,793 6,687 1.09%Ohio 11,074,368 216,561 1.96%Oklahoma 3,347,660 178,525 5.33%Oregon 3,395,357 283,882 8.36%Pennsylvania 11,853,829 384,586 3.24%Rhode Island 1,020,102 91,935 9.01%South Carolina 3,927,982 80,044 2.04%South Dakota 727,968 11,361 1.56%Tennessee 5,592,019 120,199 2.15%Texas 20,764,441 6,882,466 33.15%Utah 2,229,295 204,245 9.16%Vermont 592,321 5,061 0.85%Virginia 6,956,276 337,887 4.86%Washington 5,849,311 455,874 7.79%West Virginia 1,758,747 12,272 0.70%Wisconsin 5,245,913 191,829 3.66%Wyoming 480,332 31,605 6.58%

This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters, which is less than 5 million people. 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. Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile.



Insurance Status-Populations, 2001*

State


MedicaidPopulation

Medicare Population

Privately Insured

Military Insurance

Not Insured

National Total 282,082 31,601 38,043 199,860 9,552 41,207 Alabama 4,388 581 677 3,090 189 573 Alaska 634 84 49 419 95 100 Arizona 5,316 553 679 3,552 287 950 Arkansas 2,657 390 466 1,689 133 428 California 34,488 4,810 3,530 21,943 987 6,718 Colorado 4,410 258 481 3,256 225 687 Connecticut 3,392 245 514 2,679 71 346 Delaware 791 60 117 630 30 73 District of Columbia 554 97 65 377 12 70 Florida 16,348 1,779 2,896 10,740 661 2,856 Georgia 8,289 855 868 5,710 350 1,376 Hawaii 1,213 140 175 888 121 117 Idaho 1,315 161 164 931 57 210 Illinois 12,331 1,129 1,650 9,069 169 1,676 Indiana 6,036 364 925 4,726 116 714 Iowa 2,861 224 429 2,435 56 216 Kansas 2,642 212 447 1,998 165 301 Kentucky 3,996 515 618 2,812 276 492 Louisiana 4,390 532 566 2,753 262 845 Maine 1,279 169 242 914 58 132 Maryland 5,326 323 679 4,213 166 653 Massachusetts 6,322 839 865 4,706 135 520 Michigan 9,892 1,001 1,389 7,733 117 1,028 Minnesota 4,922 376 501 4,121 81 392 Mississippi 2,799 617 362 1,694 131 459 Missouri 5,525 645 746 4,226 167 565 Montana 892 91 148 630 58 121 Nebraska 1,683 151 222 1,313 109 160 Nevada 2,135 133 252 1,555 87 344 New Hampshire 1,258 75 193 1,018 43 119 New Jersey 8,470 675 1,363 6,390 105 1,109 New Mexico 1,804 316 290 1,023 75 373 New York 18,827 2,900 2,634 12,557 332 2,916 North Carolina 8,098 937 1,176 5,547 515 1,167 North Dakota 621 55 91 471 49 60 Ohio 11,191 1,060 1,624 8,611 184 1,248 Oklahoma 3,382 378 477 2,226 180 620 Oregon 3,462 440 431 2,520 91 443 Pennsylvania 12,102 1,240 1,838 9,582 216 1,119 Rhode Island 1,043 139 175 795 26 80 South Carolina 4,009 509 654 2,904 196 493 South Dakota 739 55 117 590 51 69 Tennessee 5,682 1,047 737 3,894 250 640 Texas 21,065 2,165 2,258 13,260 605 4,960 Utah 2,262 182 189 1,708 47 335 Vermont 607 102 78 446 12 58 Virginia 7,105 501 958 5,280 754 774 Washington 5,930 685 800 4,395 276 780 West Virginia 1,772 272 357 1,157 56 234 Wisconsin 5,336 487 817 4,342 89 409 Wyoming 488 46 68 342 33 78

*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. Data provided in thousands.

Source: Bureau of the Census & Bureau of Labor Statistics, Annual Demographic Survey, March Supplement 2002



Insurance Status - Percentages, 2001*

State


% Covered by Medicaid

% Covered by Medicare

% Covered by Private

Insurance

% Covered by Military

Insurance % Not Insured National Total 282,082 11.2% 13.5% 70.9% 3.4% 14.6%Alabama 4,388 13.2% 15.4% 70.4% 4.3% 13.1%Alaska 634 13.2% 7.7% 66.1% 15.0% 15.8%Arizona 5,316 10.4% 12.8% 66.8% 5.4% 17.9%Arkansas 2,657 14.7% 17.5% 63.6% 5.0% 16.1%California 34,488 13.9% 10.2% 63.6% 2.9% 19.5%Colorado 4,410 5.9% 10.9% 73.8% 5.1% 15.6%Connecticut 3,392 7.2% 15.2% 79.0% 2.1% 10.2%Delaware 791 7.6% 14.8% 79.6% 3.8% 9.2%District of Columbia 554 17.5% 11.7% 68.1% 2.2% 12.6%Florida 16,348 10.9% 17.7% 65.7% 4.0% 17.5%Georgia 8,289 10.3% 10.5% 68.9% 4.2% 16.6%Hawaii 1,213 11.5% 14.4% 73.2% 10.0% 9.6%Idaho 1,315 12.2% 12.5% 70.8% 4.3% 16.0%Illinois 12,331 9.2% 13.4% 73.5% 1.4% 13.6%Indiana 6,036 6.0% 15.3% 78.3% 1.9% 11.8%Iowa 2,861 7.8% 15.0% 85.1% 2.0% 7.5%Kansas 2,642 8.0% 16.9% 75.6% 6.2% 11.4%Kentucky 3,996 12.9% 15.5% 70.4% 6.9% 12.3%Louisiana 4,390 12.1% 12.9% 62.7% 6.0% 19.2%Maine 1,279 13.2% 18.9% 71.5% 4.5% 10.3%Maryland 5,326 6.1% 12.7% 79.1% 3.1% 12.3%Massachusetts 6,322 13.3% 13.7% 74.4% 2.1% 8.2%Michigan 9,892 10.1% 14.0% 78.2% 1.2% 10.4%Minnesota 4,922 7.6% 10.2% 83.7% 1.6% 8.0%Mississippi 2,799 22.0% 12.9% 60.5% 4.7% 16.4%Missouri 5,525 11.7% 13.5% 76.5% 3.0% 10.2%Montana 892 10.2% 16.6% 70.6% 6.5% 13.6%Nebraska 1,683 9.0% 13.2% 78.0% 6.5% 9.5%Nevada 2,135 6.2% 11.8% 72.8% 4.1% 16.1%New Hampshire 1,258 6.0% 15.3% 80.9% 3.4% 9.5%New Jersey 8,470 8.0% 16.1% 75.4% 1.2% 13.1%New Mexico 1,804 17.5% 16.1% 56.7% 4.2% 20.7%New York 18,827 15.4% 14.0% 66.7% 1.8% 15.5%North Carolina 8,098 11.6% 14.5% 68.5% 6.4% 14.4%North Dakota 621 8.9% 14.7% 75.8% 7.9% 9.7%Ohio 11,191 9.5% 14.5% 76.9% 1.6% 11.2%Oklahoma 3,382 11.2% 14.1% 65.8% 5.3% 18.3%Oregon 3,462 12.7% 12.4% 72.8% 2.6% 12.8%Pennsylvania 12,102 10.2% 15.2% 79.2% 1.8% 9.2%Rhode Island 1,043 13.3% 16.8% 76.2% 2.5% 7.7%South Carolina 4,009 12.7% 16.3% 72.4% 4.9% 12.3%South Dakota 739 7.4% 15.8% 79.8% 6.9% 9.3%Tennessee 5,682 18.4% 13.0% 68.5% 4.4% 11.3%Texas 21,065 10.3% 10.7% 62.9% 2.9% 23.5%Utah 2,262 8.0% 8.4% 75.5% 2.1% 14.8%Vermont 607 16.8% 12.9% 73.5% 2.0% 9.6%Virginia 7,105 7.1% 13.5% 74.3% 10.6% 10.9%Washington 5,930 11.6% 13.5% 74.1% 4.7% 13.2%West Virginia 1,772 15.3% 20.1% 65.3% 3.2% 13.2%Wisconsin 5,336 9.1% 15.3% 81.4% 1.7% 7.7%Wyoming 488 9.4% 13.9% 70.1% 6.8% 16.0%

*Sum of percentages may be greater than 100 because individuals may have dual coverage and appear in more than one category. Data provided in thousands.

Source: Bureau of the Census & Bureau of Labor Statistics, Annual Demographic Survey, March Supplement 2002.



Income and Employment, 2001

State


Percent Below 100% Poverty Level

PercentUnemployed

National Total 277,017,622 11.5% 6.0%Alabama 4,349,601 14.6% 5.3%Alaska 615,531 8.1% 6.3%Arizona 5,197,474 13.2% 4.7%Arkansas 2,618,137 17.1% 5.1%California 33,681,509 12.6% 5.3%Colorado 4,314,724 9.2% 3.7%Connecticut 3,317,131 7.5% 3.3%Delaware 771,580 7.6% 3.5%District of Columbia 536,260 16.7% 6.5%Florida 16,007,098 11.9% 4.8%Georgia 8,150,008 12.5% 4.0%Hawaii 1,188,615 10.2% 4.6%Idaho 1,289,492 12.0% 5.0%Illinois 12,160,474 10.4% 5.4%Indiana 5,936,550 8.5% 4.4%Iowa 2,818,957 7.8% 3.3%Kansas 2,612,636 9.1% 4.3%Kentucky 3,950,704 12.6% 5.5%Louisiana 4,329,436 16.7% 6.0%Maine 1,251,745 10.2% 4.0%Maryland 5,241,087 7.3% 4.1%Massachusetts 6,159,307 9.4% 3.7%Michigan 9,740,127 9.6% 5.3%Minnesota 4,836,367 6.5% 3.7%Mississippi 2,762,576 17.1% 5.5%Missouri 5,467,596 9.4% 4.7%Montana 879,639 13.7% 4.6%Nebraska 1,662,378 9.0% 3.1%Nevada 2,072,391 7.9% 5.3%New Hampshire 1,223,636 5.5% 3.5%New Jersey 8,289,599 7.7% 4.2%New Mexico 1,792,823 17.7% 4.8%New York 18,433,370 14.0% 4.9%North Carolina 7,932,350 12.5% 5.5%North Dakota 610,793 12.1% 2.8%Ohio 11,074,368 10.3% 4.3%Oklahoma 3,347,660 15.0% 3.8%Oregon 3,395,357 11.3% 6.3%Pennsylvania 11,853,829 9.1% 4.7%Rhode Island 1,020,102 9.9% 4.7%South Carolina 3,927,982 13.1% 5.4%South Dakota 727,968 9.6% 3.3%Tennessee 5,592,019 13.8% 4.5%Texas 20,764,441 15.2% 4.9%Utah 2,229,295 9.1% 4.4%Vermont 592,321 9.9% 3.6%Virginia 6,956,276 8.1% 3.5%Washington 5,849,311 10.8% 6.4%West Virginia 1,758,747 15.6% 4.9%Wisconsin 5,245,913 8.6% 4.6%Wyoming 480,332 9.7% 3.9%

Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile and Current Population Survey; U.S. Department of Labor, Bureau of Labor Statistics, Current Population Survey.



Medicaid/Medicare Certified Facilities, 2002

State Hospitals Skilled Nursing

FacilitiesICFs-MR Facilities

Home Health Agencies

Rural Health Clinics

National Total* 6,017 14,840 6,689 7,007 3,319Alabama 121 224 8 141 58Alaska 24 15 0 16 6Arizona 84 133 13 63 7Arkansas 103 191 41 176 76California 447 1,263 1,084 555 245Colorado 83 199 3 126 42Connecticut 46 244 8 82 0Delaware 11 37 2 13 0District of Columbia 14 20 131 12 0Florida 229 695 107 375 136Georgia 176 332 13 94 108Hawaii 27 41 20 14 0Idaho 45 79 65 48 43Illinois 216 676 315 281 189Indiana 152 499 573 161 52Iowa 120 337 128 183 124Kansas 17 256 38 131 157Kentucky 116 303 14 110 89Louisiana 193 266 473 236 50Maine 42 121 0 34 50Maryland 67 233 5 54 0Massachusetts 116 482 16 121 0Michigan 175 388 1 204 160Minnesota 148 404 240 229 62Mississippi 106 154 13 62 129Missouri 138 464 19 160 212Montana 65 101 2 48 38Nebraska 95 175 4 63 73Nevada 42 42 19 38 6New Hampshire 30 68 15 35 19New Jersey 252 360 9 53 0New Mexico 54 71 44 62 10New York 106 672 738 207 9North Carolina 134 413 331 167 115North Dakota 50 84 66 30 73Ohio 211 916 468 342 19Oklahoma 146 238 59 191 51Oregon 62 122 1 61 32Pennsylvania 249 739 205 302 48Rhode Island 15 97 0 23 1South Carolina 76 176 136 72 89South Dakota 66 90 1 47 53Tennessee 148 301 83 139 35Texas 486 978 904 893 334Utah 49 79 14 41 15Vermont 16 43 1 13 20Virginia 115 241 21 158 56Washington 100 256 15 61 89West Virginia 66 119 62 70 60Wisconsin 142 361 39 122 60Wyoming 28 33 2 38 19

*National total does not include certified facilities in Puerto Rico and U.S. territories.

Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations. January 6, 2003.



Licensed Pharmacies (As of June 30, 2002)*

State Total

Pharmacies

Hospital/ Institutional Pharmacies

Independent Pharmacies

Non-Independent Community Pharmacies

(Four or More)

Out-of-State or Non-Resident

PharmaciesNational Total 74,950 8,328 20,000 15,035 9,852Alabama 1,771 176 734 559 302Alaska 127 (a) 14 (b) - - 156Arizona 974 111 160 676 135Arkansas 746 150 420 326 158California 6,028 519 - - 187Colorado 821 - - - 252Connecticut 582 (c) 45 (c) 165 (c) 417 (c) 235 (c)Delaware 159 11 37 120 239District of Columbia 123 13 27 61 0Florida 6,567 2,097 4098 (d) (d) 341Georgia 3,538 204 (e) (e) -Hawaii 213 - - - 131Idaho 573 54 251 (d,f) - 196Illinois 2,451 342 2,183 (d) (d) 296Indiana 1,350 197 - - 293Iowa 1,198 130 (g) 786 (d,g) (d) 265Kansas 807 171 637 (d) - 302Kentucky 1,438 125 466 671 176Louisiana 1,771 192 576 535 313Maine 290 42 - - 187Maryland 1,384 (h) 70 250 698 263Massachusetts 1,100 (i) 158 346 740 0Michigan 2,505 - - - 125Minnesota 1,409 137 521 526 229Mississippi 962 130 - - 220Missouri 1,570 (j) 160 516 569 274Montana 317 99 - - 153Nebraska 455 N/A - - 235 (k)Nevada 702 47 - - 252New Hampshire 259 32 40 167 208New Jersey 2,489 - - - -New Mexico 612 61 298 (d) - 283New York 4,424 485 1,938 1,987 N/A (l)North Carolina 2024 (g) 156 551 961 229North Dakota 486 45 150 29 262Ohio 2875 (m) 224 483 1,471 275Oklahoma 1,311 89 (c) 893 (d) (d) 308Oregon 1,061 120 300 413 232Pennsylvania 3,166 293 - - 0Rhode Island 191 20 41 150 227South Carolina - - - - -South Dakota 462 43 125 74 220Tennessee 1,807 403 443 865 96Texas 5676 (n) 587 1,654(d) 2,310(d) 252Utah 734 107 415 (d) (d) 235Vermont 155 17 138 - 0Virginia 1,513 - - - 378Washington 1,502 222 (o) 358 710 214West Virginia 826 (i) - - - 270Wisconsin 1,286 - - 0 -Wyoming 128 (g) 30 - - 248

*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: 2002-2003 National Association of Boards of Pharmacy, Survey of Pharmacy Law.



LEGEND a – Includes nine wholesalers drug distributors. b – Drug rooms. c – Approximately. d – Chains included in independent community pharmacies figure. e – 2,123 (2,085 independent and chain pharmacies, 12 nuclear pharmacies, 20 prison pharmacies, 4 clinic pharmacies, and two pharmacy schools). f – Plus 20 limited service and 52 parenteral admixture pharmacies. g – In-state. h – Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV nuclear, research, and other. 89 Pharmacies have waiver (specialty) permits. Board issued 582 distributor permits. i – Total also includes home IV and mail order pharmacies. j – Includes the following pharmacy categories: 27 long-term care, 11 home health, 7 radiopharmaceuticals, 2 renal dialysis, 2 sterile pharmaceuticals. k – Nebraska “registers” out-of-state pharmacies. l – 14 Nuclear pharmacies m – Includes 263 nuclear, clinic, fluid therapy, mail order, specialty, and pharmacies serving nursing homes only. n – Also licenses 873 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacy. o – Includes 107 hospital, 17 nursing home, 25 home infusion, six nuclear, 42 HMO, and 19 other pharmacies.



Physicians, 2001

State Physicians Physicians

Per 1,000 Pop. Office Based

PhysiciansPercent

Office BasedPrimary Care

Physicians* Percent

Primary CareNational Total 727,573 2.6 484,184 66.55% 229,277 31.51%Alabama 9,127 2.1 6,565 71.93% 3,092 33.88%Alaska 1,273 2.1 924 72.58% 469 36.84%Arizona 10,479 2.0 7,558 72.13% 3,198 30.52%Arkansas 5,164 2.0 3,759 72.79% 1,868 36.17%California 86,395 2.6 60,311 69.81% 27,535 31.87%Colorado 10,434 2.4 7,581 72.66% 3,316 31.78%Connecticut 12,150 3.7 7,672 63.14% 3,612 29.73%Delaware 1,894 2.5 1,298 68.53% 585 30.89%District of Columbia 4,222 7.9 1,989 47.11% 1,033 24.47%Florida 38,785 2.4 29,026 74.84% 11,621 29.96%Georgia 17,798 2.2 12,428 69.83% 5,545 31.16%Hawaii 3,461 2.9 2,443 70.59% 1,093 31.58%Idaho 2,069 1.6 1,706 82.46% 713 34.46%Illinois 33,211 2.7 21,072 63.45% 11,231 33.82%Indiana 12,242 2.1 8,878 72.52% 4,159 33.97%Iowa 5,197 1.8 3,614 69.54% 1,819 35.00%Kansas 5,741 2.2 4,015 69.94% 2,020 35.19%Kentucky 8,656 2.2 6,314 72.94% 2,852 32.95%Louisiana 11,386 2.6 7,607 66.81% 3,344 29.37%Maine 3,140 2.5 2,288 72.87% 1,084 34.52%Maryland 21,656 4.1 12,242 56.53% 5,889 27.19%Massachusetts 26,916 4.4 15,074 56.00% 7,625 28.33%Michigan 23,034 2.4 14,595 63.36% 7,359 31.95%Minnesota 12,917 2.7 8,780 67.97% 4,731 36.63%Mississippi 4,931 1.8 3,580 72.60% 1,580 32.04%Missouri 13,120 2.4 8,412 64.12% 3,898 29.71%Montana 1,878 2.1 1,550 82.53% 632 33.65%Nebraska 3,893 2.3 2,667 68.51% 1,430 36.73%Nevada 3,603 1.7 2,823 78.35% 1,124 31.20%New Hampshire 3,011 2.5 2,163 71.84% 985 32.71%New Jersey 25,410 3.1 16,903 66.52% 8,050 31.68%New Mexico 4,059 2.3 2,689 66.25% 1,328 32.72%New York 73,115 4.0 40,675 55.63% 22,101 30.23%North Carolina 19,177 2.4 13,082 68.22% 6,000 31.29%North Dakota 1,464 2.4 1,061 72.47% 561 38.32%Ohio 27,579 2.5 18,246 66.16% 8,963 32.50%Oklahoma 5,854 1.7 4,180 71.40% 1,964 33.55%Oregon 8,027 2.4 6,000 74.75% 2,707 33.72%Pennsylvania 36,150 3.0 22,952 63.49% 10,883 30.11%Rhode Island 3,515 3.4 2,114 60.14% 1,108 31.52%South Carolina 8,851 2.3 6,243 70.53% 2,869 32.41%South Dakota 1,530 2.1 1,170 76.47% 560 36.60%Tennessee 14,185 2.5 9,964 70.24% 4,502 31.74%Texas 43,548 2.1 29,928 68.72% 13,144 30.18%Utah 4,556 2.0 3,199 70.22% 1,399 30.71%Vermont 2,032 3.4 1,271 62.55% 724 35.63%Virginia 18,487 2.7 12,393 67.04% 5,847 31.63%Washington 14,656 2.5 10,533 71.87% 4,926 33.61%West Virginia 4,067 2.3 2,715 66.76% 1,403 34.50%Wisconsin 12,645 2.4 9,234 73.02% 4,463 35.29%Wyoming 883 1.8 698 79.05% 333 37.71%

*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 2002.



Other Providers

State Registered Nurses*

Registered Nurses*per 1,000

Pharmacists** (Licensed by State)

Pharmacists** per 1,000

National Total 2,021,813 7.8 352,727 1.3Alabama 34,073 7.7 6,879 1.6Alaska 4,914 7.8 577 0.9Arizona 32,222 6.3 7,687 1.5Arkansas 18,752 7 3,506 1.3California 184,329 5.4 30,845 0.9Colorado 31,695 7.4 5,317 1.2Connecticut 32,073 9.4 4,393 1.3Delaware 7,337 9.4 1,314 1.7District of Columbia 9,583 16.8 1,564 2.9Florida 125,439 7.8 20,052 1.3Georgia 55,881 6.8 10,534 1.3Hawaii 8,518 7 1,449 1.2Idaho 8,230 6.4 1,530 1.2Illinois 101,660 8.2 13,151 1.1Indiana 46,244 7.6 8,597 1.4Iowa 31,020 10.6 4,993 1.8Kansas 23,779 8.8 3,494 1.3Kentucky 33,655 8.3 4,746 1.2Louisiana 37,275 8.3 5,839 1.3Maine 13,072 10.3 1,267 1.0Maryland 45,323 8.6 6,937 1.3Massachusetts 75,795 11.9 9,940 1.6Michigan 79,353 8 11,322 1.2Minnesota 47,102 9.6 5,853 1.2Mississippi 21,338 7.5 3,483 1.3Missouri 53,730 9.6 7,123 1.3Montana 7,327 8.1 1,463 1.7Nebraska 16,399 9.6 2,555 1.5Nevada 10,384 5.2 8,012 3.9New Hampshire 11,321 9.2 1,886 1.5New Jersey 67,280 8 16,245 2.0New Mexico 11,932 6.6 2,434 1.4New York 160,009 8.4 18,448 1.0North Carolina 69,057 8.6 9,397 1.2North Dakota 7,039 11 2,089 3.4Ohio 100,144 8.8 14,250 1.3Oklahoma 21,905 6.3 4,713 1.4Oregon 27,121 7.9 4,079 1.2Pennsylvania 123,997 10.1 17,439 1.5Rhode Island 11,542 11 1,788 1.8South Carolina 29,226 7.3 5,052 1.3South Dakota 8,511 11.3 1,401 1.9Tennessee 49,626 8.7 7,388 1.3Texas 126,436 6.1 20,803 1.0Utah 13,229 5.9 1,546 0.7Vermont 5,829 9.6 830 1.4Virginia 50,359 7.1 8,438 1.2Washington 43,482 7.4 6,718 1.1West Virginia 15,523 8.6 2,975 1.7Wisconsin 47,895 8.9 5,737 1.1Wyoming 3,849 7.8 1005 2.1

*As of March 2000. ** As of June 30, 2002.

Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, February 2001 and 2002-2003 National Association of Boards of Pharmacy, Survey of Pharmacy Law.





Section 4: Pharmacy Program Characteristics





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.

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.





Drug Expenditures Trends1

State 2000 2001 % Change 2000-2001National Total $20,551,215,451 $24,656,812,921 20.0%Alabama $333,069,288 $386,876,131 16.2%Alaska $44,910,326 $55,754,050 24.1%Arizona $1,627,485 $2,573,205 58.1%Arkansas $206,168,873 $241,558,369 17.2%California $2,472,137,448 $2,984,162,770 20.7%Colorado $143,925,427 $166,000,664 15.3%Connecticut $265,685,933 $304,780,286 14.7%Delaware $66,226,440 $81,156,928 22.5%District of Columbia $55,739,551 $63,504,500 13.9%Florida $1,359,073,656 $1,475,766,739 8.6%Georgia $578,085,759 $735,944,558 27.3%Hawaii $61,762,044 $74,869,859 21.2%Idaho $82,041,976 $102,975,196 25.5%Illinois $805,790,014 $884,018,166 9.7%Indiana $462,862,435 $561,642,082 21.3%Iowa $197,279,041 $234,716,795 19.0%Kansas $165,290,804 $185,017,060 11.9%Kentucky $463,275,891 $592,096,755 27.8%Louisiana $508,229,794 $585,388,809 15.2%Maine $170,901,428 $191,785,942 12.2%Maryland $204,698,146 $244,203,084 19.3%Massachusetts $698,428,250 $797,859,072 14.2%Michigan $396,533,784 $584,670,445 47.4%Minnesota $231,735,404 $265,726,228 14.7%Mississippi $368,769,294 $493,177,297 33.7%Missouri $596,733,995 $675,647,147 13.2%Montana $60,174,213 $72,577,455 20.6%Nebraska $143,192,600 $170,897,014 19.3%Nevada $50,370,705 $61,500,721 22.1%New Hampshire $81,721,512 $91,703,067 12.2%New Jersey $598,193,627 $651,442,945 8.9%New Mexico $48,486,325 $57,995,801 19.6%New York $2,540,602,423 $2,986,292,455 17.5%North Carolina $803,739,171 $984,653,306 22.5%North Dakota $39,031,804 $44,067,986 12.9%Ohio $879,595,616 $1,099,697,768 25.0%Oklahoma $164,022,317 $171,188,873 4.4%Oregon $168,325,265 $228,670,426 35.8%Pennsylvania $594,222,924 $692,665,382 16.6%Rhode Island $89,490,129 $102,708,476 14.8%South Carolina $350,270,353 $438,897,100 25.3%South Dakota $44,180,275 $51,748,770 17.1%Tennessee $273,537,047 $681,454,847 149.1%Texas $1,121,832,241 $1,325,987,804 18.2%Utah $100,910,520 $117,170,006 16.1%Vermont $85,889,049 $104,250,880 21.4%Virginia $387,722,448 $417,689,526 7.7%Washington $394,782,642 $458,332,414 16.1%West Virginia $215,222,053 $259,638,952 20.6%Wisconsin $347,245,591 $382,272,975 10.1%Wyoming $27,472,115 $31,435,835 14.4%

Source: CMS, CMS-64 Report, FY 2000 and FY 2001.

1 Rebates have not been subtracted from these figures.



Ranking Based on Drug Expenditures1

State 2001

Payments 2001

Ranking

% of 2001 NationalMedicaid Drug

Expenditures2000

Payments 2000

RankingNational Total $24,656,812,921 $20,551,215,451 New York $2,986,292,455 12.1% 1 $2,540,602,423 1California $2,984,162,770 12.1% 2 $2,472,137,448 2Florida $1,475,766,739 6.0% 3 $1,359,073,656 3Texas $1,325,987,804 5.4% 4 $1,121,832,241 4Ohio $1,099,697,768 4.5% 5 $879,595,616 5Illinois $984,653,306 4.0% 6 $803,739,171 7North Carolina $884,018,166 3.6% 7 $805,790,014 6Massachusetts $797,859,072 3.2% 8 $698,428,250 8New Jersey $735,944,558 3.0% 9 $578,085,759 12Missouri $692,665,382 2.8% 10 $594,222,924 11Pennsylvania $681,454,847 2.8% 11 $273,537,047 23Georgia $675,647,147 2.7% 12 $596,733,995 10Louisiana $651,442,945 2.6% 13 $598,193,627 9Kentucky $592,096,755 2.4% 14 $463,275,891 14Indiana $585,388,809 2.4% 15 $508,229,794 13Michigan $584,670,445 2.4% 16 $396,533,784 16Washington $561,642,082 2.3% 17 $462,862,435 15Virginia $493,177,297 2.0% 18 $368,769,294 19Mississippi $458,332,414 1.9% 19 $394,782,642 17South Carolina $438,897,100 1.8% 20 $350,270,353 20Wisconsin $417,689,526 1.7% 21 $387,722,448 18Alabama $386,876,131 1.6% 22 $333,069,288 22Tennessee $382,272,975 1.6% 23 $347,245,591 21Connecticut $304,780,286 1.2% 24 $265,685,933 24Minnesota $265,726,228 1.1% 25 $231,735,404 25West Virginia $259,638,952 1.1% 26 $215,222,053 26Arkansas $244,203,084 1.0% 27 $204,698,146 28Maryland $241,558,369 1.0% 28 $206,168,873 27Iowa $234,716,795 1.0% 29 $197,279,041 29Maine $228,670,426 0.9% 30 $168,325,265 31Oregon $191,785,942 0.8% 31 $170,901,428 30Kansas $185,017,060 0.8% 32 $165,290,804 32Oklahoma $171,188,873 0.7% 33 $164,022,317 33Colorado $170,897,014 0.7% 34 $143,192,600 35Nebraska $166,000,664 0.7% 35 $143,925,427 34Utah $117,170,006 0.5% 36 $100,910,520 36Rhode Island $104,250,880 0.4% 37 $85,889,049 38Vermont $102,975,196 0.4% 38 $82,041,976 39Idaho $102,708,476 0.4% 39 $89,490,129 37New Hampshire $91,703,067 0.4% 40 $81,721,512 40Delaware $81,156,928 0.3% 41 $66,226,440 41Hawaii $74,869,859 0.3% 42 $61,762,044 42Montana $72,577,455 0.3% 43 $60,174,213 43Dist. of Columbia $63,504,500 0.3% 44 $55,739,551 44Nevada $61,500,721 0.2% 45 $50,370,705 45New Mexico $57,995,801 0.2% 46 $48,486,325 46Alaska $55,754,050 0.2% 47 $44,910,326 47South Dakota $51,748,770 0.2% 48 $44,180,275 48North Dakota $44,067,986 0.2% 49 $39,031,804 49Wyoming $31,435,835 0.1% 50 $27,472,115 50Arizona $2,573,205 0.0% 51 $1,627,485 51 Source: CMS, HCFA-64 Report, FY 1999 and FY 2000.




Drugs as a Percentage of Total Net Expenditures, 2001

State

Total MedicaidNet Medical Assistance

ExpendituresTotal Drug

Expenditures1% of Total

Net ExpendituresNational Total $ 215,809,899,631.00 $ 24,656,812,912.00 11.4%Alabama $ 2,875,372,953.00 $ 386,876,131.00 13.5%Alaska $ 576,586,201.00 $ 55,754,050.00 9.7%Arizona $ 2,665,261,328.00 $ 2,573,205.00 0.1%Arkansas $ 1,852,176,546.00 $ 241,558,369.00 13.0%California $ 23,870,521,004.00 $ 2,984,162,770.00 12.5%Colorado $ 2,142,029,851.00 $ 166,000,664.00 7.7%Connecticut $ 3,213,848,086.00 $ 304,780,286.00 9.5%Delaware $ 591,974,246.00 $ 81,156,928.00 13.7%District of Columbia $ 979,941,105.00 $ 63,504,500.00 6.5%Florida $ 8,557,796,303.00 $ 1,475,766,739.00 17.2%Georgia $ 5,037,084,881.00 $ 735,944,558.00 14.6%Hawaii $ 634,781,970.00 $ 74,869,859.00 11.8%Idaho $ 693,205,598.00 $ 102,975,196.00 14.9%Illinois $ 7,764,611,352.00 $ 884,018,166.00 11.4%Indiana $ 4,008,812,857.00 $ 561,642,082.00 14.0%Iowa $ 1,666,923,701.00 $ 234,716,795.00 14.1%Kansas $ 1,686,410,544.00 $ 185,017,060.00 11.0%Kentucky $ 3,304,053,663.00 $ 592,096,755.00 17.9%Louisiana $ 4,201,982,590.00 $ 585,388,809.00 13.9%Maine $ 1,315,523,163.00 $ 191,785,942.00 14.6%Maryland $ 3,256,576,882.00 $ 244,203,084.00 7.5%Massachusetts $ 6,619,524,971.00 $ 797,859,072.00 12.1%Michigan $ 7,218,697,113.00 $ 584,670,445.00 8.1%Minnesota $ 3,835,870,579.00 $ 265,726,228.00 6.9%Mississippi $ 2,438,979,981.00 $ 493,177,297.00 20.2%Missouri $ 4,744,963,426.00 $ 675,647,147.00 14.2%Montana $ 482,357,404.00 $ 72,577,455.00 15.0%Nebraska $ 1,187,237,577.00 $ 170,897,014.00 14.4%Nevada $ 674,337,888.00 $ 61,500,721.00 9.1%New Hampshire $ 873,248,831.00 $ 91,703,067.00 10.5%New Jersey $ 7,123,653,988.00 $ 651,442,945.00 9.1%New Mexico $ 1,467,417,736.00 $ 57,995,801.00 4.0%New York $ 31,367,464,639.00 $ 2,986,292,455.00 9.5%North Carolina $ 6,150,681,587.00 $ 984,653,306.00 16.0%North Dakota $ 406,418,593.00 $ 44,067,986.00 10.8%Ohio $ 8,433,412,161.00 $ 1,099,697,768.00 13.0%Oklahoma $ 2,021,033,069.00 $ 171,188,873.00 8.5%Oregon $ 2,658,358,391.00 $ 228,670,426.00 8.6%Pennsylvania $ 10,908,343,146.00 $ 692,665,382.00 6.3%Rhode Island $ 1,187,880,819.00 $ 102,708,476.00 8.6%South Carolina $ 3,019,387,228.00 $ 438,897,100.00 14.5%South Dakota $ 464,455,469.00 $ 51,748,770.00 11.1%Tennessee $ 5,501,312,153.00 $ 681,454,847.00 12.4%Texas $ 11,583,679,558.00 $ 1,325,987,804.00 11.4%Utah $ 833,720,115.00 $ 117,170,006.00 14.1%Vermont $ 601,467,093.00 $ 104,250,880.00 17.3%Virginia $ 3,036,846,387.00 $ 417,689,526.00 13.8%Washington $ 4,305,724,247.00 $ 458,332,414.00 10.6%West Virginia $ 1,548,398,817.00 $ 259,638,952.00 16.8%Wisconsin $ 3,976,142,914.00 $ 382,272,975.00 9.6%Wyoming $ 243,408,927.00 $ 31,435,835.00 12.9%

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




Drugs as a Percentage of Total Net Expenditures, 1999-20011

State 1999 2000 2001 National Total 9.5% 10.5% 11.4% Alabama 11.3% 12.4% 13.5% Alaska 9.8% 9.3% 9.7% Arizona 0.6% 0.1% 0.1% Arkansas 12.1% 13.1% 13.0% California 10.0% 11.7% 12.5% Colorado 6.8% 7.4% 7.7% Connecticut 7.5% 8.5% 9.5% Delaware 11.7% 12.6% 13.7% District of Columbia 4.6% 6.7% 6.5% Florida 15.9% 18.1% 17.2% Georgia 12.7% 13.4% 14.6% Hawaii 7.9% 9.6% 11.8% Idaho 13.3% 14.2% 14.9% Illinois 10.3% 10.8% 11.4% Indiana 12.8% 13.3% 14.0% Iowa 12.3% 12.0% 14.1% Kansas 11.3% 11.7% 11.0% Kentucky 13.5% 15.3% 17.9% Louisiana 13.0% 14.8% 13.9% Maine 12.6% 14.4% 14.6% Maryland 6.0% 6.8% 7.5% Massachusetts 10.4% 11.0% 12.1% Michigan 5.2% 5.9% 8.1% Minnesota 6.3% 7.0% 6.9% Mississippi 15.2% 18.6% 20.2% Missouri 13.3% 15.1% 14.2% Montana 14.0% 13.4% 15.0% Nebraska 12.2% 13.7% 14.4% Nevada 7.2% 8.4% 9.1% New Hampshire 8.4% 10.3% 10.5% New Jersey 8.7% 9.9% 9.1% New Mexico 3.5% 4.0% 4.0% New York 7.3% 8.4% 9.5% North Carolina 12.7% 14.7% 16.0% North Dakota 9.6% 9.1% 10.8% Ohio 11.0% 11.8% 13.0% Oklahoma 12.1% 10.2% 8.5% Oregon 6.5% 8.0% 8.6% Pennsylvania 7.3% 5.7% 6.3% Rhode Island 7.4% 7.8% 8.6% South Carolina 11.8% 13.1% 14.5% South Dakota 9.8% 11.2% 11.1% Tennessee 3.8% 5.5% 12.4% Texas 9.2% 10.6% 11.4% Utah 11.3% 12.5% 14.1% Vermont 12.6% 16.6% 17.3% Virginia 13.4% 14.2% 13.8% Washington 8.5% 10.0% 10.6% West Virginia 14.6% 15.6% 16.8% Wisconsin 10.0% 10.6% 9.6% Wyoming 11.0% 12.6% 12.9% Source: CMS, HCFA-64 Report, FY 1999 - FY 2001.

1 Percentages are based on figures that have not had rebates subtracted from them.



Share of Drug Expenditures by Category, 2001

State Central Nervous

System Drugs Cardiovascular

DrugsAnti-Infective

AgentsGastrointestinal

Drugs

Hormones and Synthetic

SubstitutesNational Total $9,514,948,483 $2,952,096,328 $2,698,567,898 $2,058,242,780 $2,230,229,244Alabama $132,895,568 $52,054,951 $45,647,355 $24,777,125 $40,134,277Alaska $32,697,128 $5,824,661 $7,951,147 $6,633,685 $4,666,987Arizona* $0 $0 $0 $0 $0Arkansas $91,320,873 $27,987,398 $28,570,099 $19,642,545 $22,366,320California $1,114,726,219 $450,481,867 $297,332,016 $258,742,020 $376,033,460Colorado $72,594,684 $17,046,678 $13,299,350 $17,481,965 $13,628,214Connecticut $136,185,638 $36,739,808 $27,998,828 $25,870,137 $21,695,506Delaware $28,803,247 $7,741,026 $12,368,037 $6,515,028 $6,611,821District of Columbia $15,290,824 $8,906,001 $14,742,214 $2,107,315 $4,504,249Florida $478,798,514 $164,233,638 $249,629,123 $113,519,527 $113,619,439Georgia $245,155,701 $84,006,382 $99,414,562 $56,192,428 $64,040,377Hawaii $25,557,359 $10,495,425 $5,760,593 $2,338,731 $6,511,096Idaho $44,517,638 $6,929,074 $8,593,027 $8,907,402 $8,057,335Illinois $343,056,415 $106,160,070 $106,602,927 $80,600,315 $87,188,574Indiana $236,006,313 $52,249,052 $48,811,840 $54,594,975 $45,490,320Iowa $111,783,642 $24,064,353 $19,518,455 $13,971,139 $20,732,932Kansas $86,087,451 $18,937,231 $14,140,224 $15,714,096 $16,008,376Kentucky $215,554,449 $76,124,966 $56,223,047 $74,013,544 $55,005,743Louisiana $175,472,416 $68,428,238 $77,434,222 $43,551,542 $49,093,324Maine $86,310,263 $26,663,339 $13,422,750 $16,130,293 $20,008,404Maryland $125,160,620 $27,807,351 $19,774,232 $17,678,026 $15,022,687Massachusetts $382,101,446 $83,570,990 $80,792,886 $61,029,647 $61,368,868Michigan $300,072,871 $69,663,532 $35,493,519 $40,343,017 $44,269,106Minnesota $139,461,653 $19,993,226 $17,979,015 $22,880,340 $19,726,097Mississippi $148,433,265 $66,370,724 $51,309,046 $45,579,479 $44,433,198Missouri $286,839,181 $76,965,642 $59,696,878 $42,055,819 $59,655,556Montana $32,521,534 $5,960,448 $5,212,804 $7,240,601 $6,037,697Nebraska $72,970,087 $14,845,491 $15,209,955 $16,376,455 $14,167,802Nevada $28,253,982 $7,407,670 $9,293,140 $5,389,733 $5,051,915New Hampshire $35,341,373 $5,051,453 $5,237,290 $5,591,034 $5,057,574New Jersey $219,820,579 $82,186,345 $79,028,779 $55,933,118 $43,559,759New Mexico $22,467,684 $7,590,665 $4,511,289 $6,700,427 $7,347,690New York $935,185,449 $348,673,928 $481,909,973 $214,612,139 $276,237,933North Carolina $347,701,239 $127,345,226 $100,901,732 $111,673,437 $86,508,399North Dakota $20,478,174 $4,430,900 $3,018,788 $3,759,997 $3,694,059Ohio $470,607,371 $118,686,711 $98,831,231 $115,808,039 $94,820,577Oklahoma $86,275,249 $28,560,545 $21,485,242 $14,016,924 $19,257,204Oregon $145,915,907 $17,548,697 $14,325,469 $10,612,940 $16,276,764Pennsylvania $278,076,953 $79,233,042 $61,947,950 $64,007,414 $54,758,587Rhode Island $46,325,891 $13,499,708 $8,542,443 $10,730,457 $8,077,900South Carolina $147,662,272 $59,254,441 $48,943,519 $38,489,200 $42,684,621South Dakota $21,555,113 $4,604,028 $5,130,144 $4,777,056 $4,370,147Tennessee $373,043,097 $104,020,370 $30,595,170 $55,131,204 $52,880,861Texas $455,439,034 $153,447,350 $156,657,650 $95,992,450 $127,445,216Utah $55,241,258 $7,948,732 $9,996,920 $9,605,499 $8,762,196Vermont** $0 $0 $0 $0 $0Virginia $154,069,807 $51,353,050 $36,846,701 $46,355,944 $32,195,004Washington $212,026,836 $46,794,457 $36,046,008 $44,997,617 $41,580,448West Virginia $97,610,517 $32,293,807 $25,030,002 $13,798,635 $25,130,891Wisconsin $187,695,044 $39,701,174 $24,606,426 $32,727,523 $31,895,273Wyoming $13,780,655 $2,212,470 $2,753,883 $3,044,795 $2,558,459*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. **Due to inconsistencies, Vermont data are not included in this table.



Source: CMS, State Drug Utilization Data, FY 2001

Share of Drug Expenditures by Category, 2001 (con't.)

State

Unclassified Therapeutic

Agents Autonomic

DrugsBlood Formation and Coagulation Other Total

National Average $1,063,152,822 $1,028,952,289 $785,918,834 $2,943,352,187 $25,275,460,864Alabama $16,955,251 $18,650,460 $12,004,092 $58,823,365 $401,942,443Alaska $2,566,881 $2,902,600 $6,261,887 $5,702,252 $75,207,226Arizona* $0 $0 $0 $0 $0Arkansas $11,144,000 $11,115,606 $10,883,361 $28,938,742 $251,968,943California $124,581,157 $91,334,228 $93,422,560 $291,956,950 $3,098,610,478Colorado $8,795,844 $7,967,549 $3,432,932 $17,562,417 $171,809,633Connecticut $11,732,148 $10,879,820 $8,794,472 $29,014,156 $308,910,514Delaware $3,811,685 $3,637,319 $2,088,704 $10,285,623 $81,862,490District of Columbia $1,899,260 $1,579,699 $2,413,817 $7,671,551 $59,114,928Florida $69,968,728 $64,556,228 $61,211,843 $196,661,367 $1,512,198,408Georgia $27,495,435 $39,039,132 $22,520,980 $104,097,938 $741,962,934Hawaii $3,575,178 $2,269,442 $2,510,057 $5,655,938 $64,673,820Idaho $4,420,179 $3,563,999 $3,327,150 $9,703,966 $98,019,769Illinois $45,881,686 $40,522,287 $37,814,229 $118,096,377 $965,922,880Indiana $24,101,346 $28,790,598 $28,689,170 $77,289,403 $596,023,018Iowa $11,938,064 $11,652,048 $6,029,279 $24,769,010 $244,458,923Kansas $7,754,377 $9,117,381 $3,139,768 $21,010,491 $191,909,396Kentucky $26,118,631 $38,811,640 $15,480,779 $76,943,751 $634,276,549Louisiana $21,435,938 $29,783,501 $20,051,806 $97,083,682 $582,334,668Maine $9,196,068 $10,005,325 $5,694,133 $17,957,255 $205,387,830Maryland $8,426,414 $6,764,305 $10,229,180 $21,540,807 $252,403,623Massachusetts $30,253,249 $28,374,659 $23,341,885 $76,527,259 $827,360,889Michigan $29,248,137 $22,325,625 $23,231,954 $61,639,188 $626,286,949Minnesota $11,188,028 $10,116,255 $7,419,684 $24,268,247 $273,032,546Mississippi $21,004,683 $21,685,206 $9,715,898 $61,393,881 $469,925,380Missouri $29,339,094 $31,631,025 $23,614,163 $84,533,793 $694,331,151Montana $4,525,672 $3,473,799 $2,276,660 $7,280,917 $74,530,133Nebraska $6,599,038 $8,008,770 $2,547,222 $24,075,547 $174,800,367Nevada $3,734,490 $2,808,787 $935,663 $6,768,659 $69,644,039New Hampshire $2,194,717 $2,322,457 $1,147,658 $6,365,592 $68,309,149New Jersey $28,740,083 $26,279,953 $31,722,908 $77,173,351 $644,444,873New Mexico $3,462,038 $2,487,371 $916,146 $7,318,548 $62,801,857New York $121,792,676 $106,996,809 $99,695,534 $343,225,967 $2,928,330,409North Carolina $40,762,884 $43,077,183 $25,335,051 $134,831,755 $1,018,136,904North Dakota $1,682,824 $1,816,397 $931,188 $5,147,701 $44,960,030Ohio $47,450,121 $54,970,871 $28,847,394 $142,559,328 $1,172,581,643Oklahoma $11,474,788 $11,711,703 $7,396,109 $26,641,391 $226,819,155Oregon $8,736,837 $8,408,534 $2,833,445 $13,936,790 $238,595,384Pennsylvania $32,089,921 $32,256,288 $25,035,011 $77,314,971 $704,720,136Rhode Island $3,758,453 $3,689,513 $1,550,919 $9,987,786 $106,163,069South Carolina $17,234,250 $18,093,111 $9,472,932 $60,874,605 $442,708,952South Dakota $2,400,726 $2,329,163 $1,921,158 $6,338,991 $53,426,526Tennessee $29,336,208 $24,234,955 $8,995,605 $50,680,851 $728,918,321Texas $58,170,851 $57,364,635 $44,675,444 $229,571,576 $1,378,764,205Utah $4,687,680 $4,222,931 $1,365,372 $12,725,157 $114,555,745Vermont** $0 $0 $0 $0 $0Virginia $18,028,216 $18,158,465 $22,019,067 $52,648,431 $431,674,685Washington $21,919,193 $17,980,786 $11,868,778 $45,476,265 $478,690,387West Virginia $11,270,651 $12,926,285 $3,253,119 $29,224,384 $250,538,289Wisconsin $18,803,432 $16,759,088 $6,710,399 $40,317,421 $399,215,780Wyoming $1,465,610 $1,498,497 $1,142,270 $3,738,798 $32,195,437

*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. **Due to inconsistencies, Vermont data are not included in this table. Source: CMS, State Drug Utilization Data, FY 2001.



Share of Prescriptions Processed, 2001

State Central Nervous

System Drugs Cardiovascular

DrugsAnti-Infective

AgentsGastrointestinal

Drugs

Hormones and Synthetic

SubstitutesNational Average 148,167,600 67,270,627 42,384,053 30,370,710 46,662,619 Alabama 2,632,226 1,408,395 993,108 492,874 958,805 Alaska 453,523 152,789 110,488 79,207 121,884 Arizona* - - - - -Arkansas 1,450,177 750,509 613,197 267,050 517,083 California 14,554,053 7,410,590 4,348,940 3,147,638 5,213,101 Colorado 1,204,503 475,725 290,296 227,051 413,954 Connecticut 1,895,984 817,501 257,975 321,045 499,868 Delaware 469,345 167,099 160,147 86,040 148,078 District of Columbia 242,505 199,486 82,466 33,560 91,687 Florida 7,442,614 4,090,249 2,518,170 1,495,157 2,466,850 Georgia 4,318,071 2,198,459 2,072,793 827,868 1,614,395 Hawaii 351,270 229,396 65,234 90,018 132,760 Idaho 614,312 169,098 196,281 86,441 203,689 Illinois 6,124,209 2,720,869 2,000,972 1,670,596 2,052,430 Indiana 3,814,605 1,261,932 1,033,367 930,189 1,028,003 Iowa 1,881,724 648,913 482,333 259,348 542,404 Kansas 1,290,455 507,373 319,855 233,290 420,273 Kentucky 3,653,845 1,831,237 1,296,449 1,113,897 1,257,708 Louisiana 3,209,586 1,661,232 1,439,107 577,116 1,123,467 Maine 1,489,910 752,023 305,474 243,713 529,111 Maryland 1,757,023 661,232 213,705 235,234 371,823 Massachusetts 5,938,419 2,136,144 1,178,007 759,682 1,589,273 Michigan 5,008,103 1,941,774 731,144 836,357 1,195,286 Minnesota 1,817,445 492,449 314,469 433,494 431,029 Mississippi 2,093,166 1,245,034 961,894 439,534 815,924 Missouri 4,392,199 1,873,816 1,012,439 864,704 1,373,516 Montana 513,916 151,908 125,557 96,752 157,029 Nebraska 1,222,641 410,815 389,365 336,796 357,671 Nevada 392,067 172,954 96,066 62,397 127,389 New Hampshire 490,677 117,405 91,567 74,680 108,083 New Jersey 3,103,346 1,777,576 636,290 645,683 912,684 New Mexico 402,425 196,242 95,465 97,354 212,470 New York 13,225,789 7,392,757 4,298,800 3,221,996 4,531,650 North Carolina 5,228,542 2,864,808 1,773,774 1,141,952 1,938,819 North Dakota 321,364 132,232 81,905 48,889 109,144 Ohio 7,969,504 3,142,743 2,051,384 2,084,279 2,358,177 Oklahoma 1,257,616 645,483 441,135 233,985 439,807 Oregon 2,180,700 474,284 256,106 228,998 444,925 Pennsylvania 4,333,444 2,082,914 958,089 943,992 1,372,792 Rhode Island 674,816 310,815 95,133 138,083 186,287 South Carolina 2,062,985 1,089,842 893,095 361,262 850,306 South Dakota 320,058 127,537 126,004 58,525 109,858 Tennessee 7,199,034 2,776,996 604,399 1,024,828 1,459,814 Texas 7,434,516 2,901,484 3,673,574 1,412,480 2,251,273 Utah 921,707 194,613 249,320 167,138 236,902 Vermont** - - - - -Virginia 2,608,563 1,198,943 645,687 729,560 755,656 Washington 3,311,877 1,231,455 661,271 716,726 1,088,681 West Virginia 1,838,082 819,540 610,913 285,159 610,719 Wisconsin 2,851,448 1,197,956 460,372 471,724 872,195 Wyoming 203,213 56,002 70,473 36,371 57,888

*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. **Due to inconsistencies, Vermont data are not included in this table.

Source: CMS, State Drug Utilization Data, FY 2001.



Share of Prescriptions Processed, 2001 (con't)

State

Unclassified Therapeutic

Agents Autonomic

DrugsBlood Formation and Coagulation Other Total

National Average 9,917,396 25,741,156 8,136,530 99,891,784 478,542,474 Alabama 191,742 530,461 166,928 2,318,536 9,693,075 Alaska 26,058 76,971 17,089 178,750 1,216,759 Arizona* - - - - -Arkansas 121,857 264,170 74,655 1,036,079 5,094,777 California 976,543 2,296,093 891,786 9,481,535 48,320,279 Colorado 81,578 223,436 74,831 652,533 3,643,905 Connecticut 99,336 266,004 106,776 877,124 5,141,613 Delaware 31,246 101,286 16,286 324,440 1,503,966 District of Columbia 19,752 43,818 15,107 217,864 946,245 Florida 632,459 1,402,794 421,062 4,949,789 25,419,144 Georgia 316,776 989,002 265,004 3,771,466 16,373,834 Hawaii 44,036 59,866 17,445 225,391 1,215,415 Idaho 37,054 92,026 22,103 311,888 1,732,892 Illinois 398,773 1,208,120 461,794 5,059,230 21,696,993 Indiana 217,574 644,373 216,161 2,699,698 11,845,902 Iowa 101,556 281,134 100,327 962,104 5,259,841 Kansas 79,012 217,311 82,409 742,540 3,892,518 Kentucky 293,621 801,522 220,875 2,991,744 13,460,898 Louisiana 230,800 689,634 221,023 3,134,634 12,286,599 Maine 96,919 264,768 66,380 643,933 4,392,231 Maryland 85,999 212,833 108,911 721,481 4,368,241 Massachusetts 292,673 861,056 222,362 2,420,483 15,398,099 Michigan 279,808 610,323 232,766 2,199,365 13,034,926 Minnesota 83,265 251,948 74,558 846,570 4,745,227 Mississippi 191,469 386,967 128,591 1,795,641 8,058,220 Missouri 269,135 743,357 268,052 2,774,395 13,571,611 Montana 32,260 93,235 18,254 251,324 1,440,235 Nebraska 71,717 195,686 63,797 949,245 3,997,733 Nevada 32,197 71,892 16,750 196,077 1,167,789 New Hampshire 22,183 67,581 9,447 194,805 1,176,425 New Jersey 259,058 535,696 188,043 2,195,522 10,253,898 New Mexico 29,154 67,329 27,006 322,854 1,450,299 New York 1,076,289 2,831,094 687,149 10,852,411 48,117,935 North Carolina 423,271 955,967 260,845 3,915,902 18,503,880 North Dakota 19,149 46,993 18,841 194,413 972,930 Ohio 481,387 1,477,682 466,644 5,889,439 25,921,239 Oklahoma 110,683 254,644 53,030 786,995 4,223,378 Oregon 76,869 227,387 57,419 627,768 4,574,456 Pennsylvania 343,823 730,039 408,395 2,636,945 13,810,433 Rhode Island 39,481 99,538 34,007 361,642 1,939,800 South Carolina 148,234 378,344 92,151 1,619,436 7,495,655South Dakota 21,611 57,884 18,956 220,763 1,061,196 Tennessee 292,887 730,064 269,138 2,599,610 16,956,770 Texas 498,005 1,516,512 389,366 8,008,730 28,085,940 Utah 55,822 123,853 27,327 448,977 2,425,659 Vermont** - - - - -Virginia 184,245 436,572 157,540 1,863,368 8,580,134 Washington 186,442 532,888 153,136 1,772,643 9,655,119 West Virginia 122,510 324,130 68,745 1,045,287 5,725,085 Wisconsin 178,312 432,181 147,306 1,476,859 8,088,353 Wyoming 12,768 34,694 9,959 123,558 604,925





Medicaid Average Cost Per Prescription, 2001

State Drug

PaymentsPrescriptions

Processed Average

Prescription CostNational Average $25,275,460,864 478,542,474 $52.82 Alabama $401,942,443 9,693,075 $41.47 Alaska $75,207,226 1,216,759 $61.81 Arizona* - - -Arkansas $251,968,943 5,094,777 $49.46 California $3,098,610,478 48,320,279 $64.13 Colorado $171,809,633 3,643,905 $47.15 Connecticut $308,910,514 5,141,613 $60.08 Delaware $81,862,490 1,503,966 $54.43 District of Columbia $59,114,928 946,245 $62.47 Florida $1,512,198,408 25,419,144 $59.49 Georgia $741,962,934 16,373,834 $45.31 Hawaii $64,673,820 1,215,415 $53.21 Idaho $98,019,769 1,732,892 $56.56 Illinois $965,922,880 21,696,993 $44.52 Indiana $596,023,018 11,845,902 $50.31 Iowa $244,458,923 5,259,841 $46.48 Kansas $191,909,396 3,892,518 $49.30 Kentucky $634,276,549 13,460,898 $47.12 Louisiana $582,334,668 12,286,599 $47.40 Maine $205,387,830 4,392,231 $46.76 Maryland $252,403,623 4,368,241 $57.78 Massachusetts $827,360,889 15,398,099 $53.73 Michigan $626,286,949 13,034,926 $48.05 Minnesota $273,032,546 4,745,227 $57.54 Mississippi $469,925,380 8,058,220 $58.32 Missouri $694,331,151 13,571,611 $51.16 Montana $74,530,133 1,440,235 $51.75 Nebraska $174,800,367 3,997,733 $43.72 Nevada $69,644,039 1,167,789 $59.64 New Hampshire $68,309,149 1,176,425 $58.07 New Jersey $644,444,873 10,253,898 $62.85 New Mexico $62,801,857 1,450,299 $43.30 New York $2,928,330,409 48,117,935 $60.86 North Carolina $1,018,136,904 18,503,880 $55.02 North Dakota $44,960,030 972,930 $46.21 Ohio $1,172,581,643 25,921,239 $45.24 Oklahoma $226,819,155 4,223,378 $53.71 Oregon $238,595,384 4,574,456 $52.16 Pennsylvania $704,720,136 13,810,433 $51.03 Rhode Island $106,163,069 1,939,800 $54.73 South Carolina $442,708,952 7,495,655 $59.06 South Dakota $53,426,526 1,061,196 $50.35 Tennessee $728,918,321 16,956,770 $42.99 Texas $1,378,764,205 28,085,940 $49.09 Utah $114,555,745 2,425,659 $47.23 Vermont** - - -Virginia $431,674,685 8,580,134 $50.31 Washington $478,690,387 9,655,119 $49.58 West Virginia $250,538,289 5,725,085 $43.76 Wisconsin $399,215,780 8,088,353 $49.36 Wyoming $32,195,437 604,925 $53.22







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 the Department of Health and Human Services (HHS) for States to receive Federal funding for outpatient drugs dispensed to Medicaid patients. (For a detailed account of the debate and genesis of various provisions see Robert Betz’s analysis of the Medicaid Best Price Law and its effect on pharmaceutical manufacturers’ pricing policies.*)

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

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

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

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



pharmaceutical assistance programs, and prices that are nominal in amount, and includes all discounts and rebates.

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

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



Medicaid Drug Rebates, 2001

State

Allocation of Drug Rebate Monies1 Total Rebates2 Federal Share2

National Total $4,948,222,331 $2,852,290,258 Alabama Medicaid Drug Budget $76,624,463 $53,711,251 Alaska General Fund $11,337,883 $6,817,468 Arizona* - - -Arkansas Medicaid General $45,744,406 $33,463,178 California Medicaid Drug Budget $786,113,991 $405,347,024 Colorado General Fund $34,264,574 $17,334,298 Connecticut Medicaid Drug Budget $61,916,192 $30,997,965 Delaware Medicaid General $17,042,045 $8,613,851 District of Columbia Medicaid General $10,446,499 $7,312,880 Florida Medicaid Drug Budget $297,362,792 $169,183,635 Georgia Medicaid General $110,087,285 $65,735,246 Hawaii General Fund, Medicaid Drug Budget $14,363,603 $7,734,801 Idaho Medicaid General $18,841,154 $13,332,002 Illinois Medicaid Drug Budget $170,733,612 $85,686,875 Indiana General Fund $103,148,144 $63,993,109 Iowa General Fund $42,602,101 $26,784,295 Kansas Medicaid General $39,731,568 $23,842,174 Kentucky General Fund $104,759,238 $73,815,957 Louisiana Medicaid Drug Budget $115,254,842 $81,440,444 Maine Medicaid Drug Budget $41,847,632 $27,707,958 Maryland Medicaid General $34,263,429 $23,731,558 Massachusetts Medicaid General $180,517,139 $90,866,756 Michigan Medicaid Drug Budget $111,716,756 $62,886,976 Minnesota General Fund $54,548,714 $27,879,847 Mississippi Medicaid General $88,481,567 $68,095,766 Missouri Medicaid General $133,927,028 $82,365,392 Montana General Fund $13,359,968 $9,792,644 Nebraska Medicaid Drug Budget $30,219,685 $18,481,621 Nevada General Fund $16,330,579 $8,278,764 New Hampshire General Fund $13,934,765 $7,001,525 New Jersey Medicaid Drug Budget $124,127,231 $62,188,060 New Mexico General Fund $12,110,896 $8,937,842 New York General Fund $543,984,948 $271,992,475 North Carolina Medicaid General $207,551,841 $129,996,009 North Dakota Medicaid Drug Budget $8,780,182 $6,156,520 Ohio General Fund $217,702,350 $128,509,697 Oklahoma Medicaid Drug Budget $40,177,945 $28,622,768 Oregon General Fund $34,991,037 $21,217,459 Pennsylvania Outpatient Appropriation $129,265,110 $69,520,225 Rhode Island General Fund $21,467,002 $11,547,100 South Carolina Medicaid Drug Budget $95,438,155 $67,719,218 South Dakota Medicaid Drug Budget $9,405,933 $6,462,840 Tennessee Medicaid General $102,644,077 $65,476,656 Texas Medicaid Drug Budget $268,557,241 $163,037,466 Utah General Fund $21,949,963 $15,701,560 Vermont Medicaid General $22,045,277 $13,823,428 Virginia Medicaid General, Medicaid Drug Budget $79,484,868 $42,334,830 Washington General Fund $91,250,830 $46,412,894 West Virginia Medicaid General $52,402,218 $39,479,831 Wisconsin Medicaid General $79,554,207 $47,158,148 Wyoming Medicaid General $5,809,366 $3,759,972 *Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.

Sources: 1As reported by State drug program administrators in the 2002 NPC Survey. 2CMS, CMS-64 Report, FY 2001.



Medicaid Drug Rebate Trends, 1997-2001

State 1997 1998 1999 2000 2001National Total $2,212,579,458 $2,469,136,949 $3,338,497,983 $3,980,646,518 $4,948,222,331 Alabama $47,135,670 $36,537,095 $49,785,076 $60,984,826 $76,624,463 Alaska $4,900,641 $5,026,624 $7,050,981 $8,594,014 $11,337,883 Arizona* - - - - -Arkansas $24,514,373 $22,518,230 $37,931,853 $40,814,931 $45,744,406 California $307,645,326 $362,808,597 $539,928,783 $600,895,711 $786,113,991 Colorado $16,950,071 $20,424,896 $25,151,080 $28,832,989 $34,264,574 Connecticut $27,318,565 $32,128,587 $38,656,394 $49,164,014 $61,916,192 Delaware $5,851,285 $7,096,836 $9,787,444 $13,780,359 $17,042,045 District of Columbia $6,668,493 $7,100,983 $8,379,982 $9,215,651 $10,446,499 Florida $128,466,755 $150,733,077 $195,512,719 $248,637,014 $297,362,792 Georgia $59,756,017 $64,320,077 $95,237,778 $91,886,605 $110,087,285 Hawaii $4,654,126 $5,992,722 $8,378,292 $10,947,632 $14,363,603 Idaho $8,369,523 $8,614,444 $11,901,778 $13,984,004 $18,841,154 Illinois $85,128,380 $100,811,862 $121,540,781 $143,590,170 $170,733,612 Indiana $43,645,256 $50,710,861 $62,691,135 $84,453,135 $103,148,144 Iowa $21,755,142 $25,265,390 $32,369,409 $36,040,216 $42,602,101 Kansas $11,797,675 $19,852,439 $26,878,486 $31,022,023 $39,731,568 Kentucky $59,890,925 $57,082,387 $72,676,810 $93,688,165 $104,759,238 Louisiana $54,650,344 $65,994,910 $76,147,317 $84,800,897 $115,254,842 Maine $18,246,061 $19,650,719 $30,032,364 $31,598,262 $41,847,632 Maryland $34,567,082 $25,017,660 $32,311,299 $42,081,781 $34,263,429 Massachusetts $73,047,452 $89,011,664 $140,102,747 $146,225,538 $180,517,139 Michigan $74,116,928 $72,526,027 $75,674,128 $75,687,945 $111,716,756 Minnesota $31,873,349 $31,058,740 $37,389,033 $43,228,324 $54,548,714 Mississippi $37,108,638 $39,983,265 $49,332,307 $61,260,326 $88,481,567 Missouri $54,614,194 $66,460,159 $84,620,799 $110,025,619 $133,927,028 Montana $6,775,176 $7,378,206 $9,290,653 $10,985,923 $13,359,968 Nebraska $14,931,313 $16,545,572 $21,609,490 $31,004,940 $30,219,685 Nevada $5,391,025 $5,143,136 $7,727,267 $4,863,879 $16,330,579 New Hampshire $8,788,296 $9,676,461 $12,956,727 $15,073,211 $13,934,765 New Jersey $66,748,605 $70,992,525 $90,472,488 $105,535,091 $124,127,231 New Mexico $13,367,028 $10,670,766 $7,972,600 $8,901,456 $12,110,896 New York $200,157,978 $251,273,382 $356,088,488 $470,317,992 $543,984,948 North Carolina $68,332,867 $81,211,796 $111,326,116 $140,047,825 $207,551,841 North Dakota $4,651,348 $4,990,065 $5,954,387 $6,503,601 $8,780,182 Ohio $84,238,194 $110,484,575 $148,477,399 $171,685,793 $217,702,350 Oklahoma $20,776,998 $23,329,251 $31,992,100 $37,135,809 $40,177,945 Oregon $13,852,833 $14,433,179 $21,360,688 $32,056,386 $34,991,037 Pennsylvania $115,510,606 $95,692,149 $119,340,064 $118,989,849 $129,265,110 Rhode Island $10,121,820 $11,041,552 $14,440,971 $19,223,034 $21,467,002 South Carolina $34,643,502 $39,156,574 $55,971,288 $73,052,676 $95,438,155 South Dakota $4,940,121 $5,070,643 $5,971,015 $7,198,848 $9,405,933 Tennessee** - $840 $22,434,760 $41,302,450 $102,644,077 Texas $130,576,891 $145,635,499 $185,695,267 $222,314,531 $268,557,241 Utah $8,374,299 $9,988,037 $15,145,126 $21,889,639 $21,949,963 Vermont $8,255,707 $8,868,263 $10,579,999 $17,869,053 $22,045,277 Virginia $45,240,474 $51,079,391 $67,715,512 $75,630,717 $79,484,868 Washington $38,326,646 $39,191,376 $54,331,249 $69,782,396 $91,250,830 West Virginia $26,079,819 $26,753,285 $35,941,495 $46,762,149 $52,402,218 Wisconsin $37,146,544 $40,776,543 $51,869,264 $66,358,433 $79,554,207 Wyoming $2,679,097 $3,025,632 $4,364,795 $4,720,686 $5,809,366 *Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply. **Tennessee did not report data for 1997.

Source: CMS, HCFA-64 Report, FY 1997-FY 2001.



Medicaid Drug Rebate Trends Annual Percent Change, 1996-2001

State

% Change 96-97

% Change97-98

% Change98-99

% Change 99-00

% Change00-01

National Total 12.8% 11.6% 35.2% 19.2% 24.3%Alabama 31.9% -22.5% 36.3% 22.5% 25.6%Alaska 34.9% 2.6% 40.3% 21.9% 31.9%

Arizona* - - - - -Arkansas 22.9% -8.1% 68.4% 7.6% 12.1%California 18.5% 17.9% 48.8% 11.3% 30.8%Colorado -2.3% 20.5% 23.1% 14.6% 18.8%Connecticut -11.2% 17.6% 20.3% 27.2% 25.9%Delaware 32.2% 21.3% 37.9% 40.8% 23.7%District of Columbia 17.6% 6.5% 18.0% 10.0% 13.4%Florida 16.5% 17.3% 29.7% 27.2% 19.6%Georgia 5.0% 7.6% 48.1% -3.5% 19.8%Hawaii 25.1% 28.8% 39.8% 30.7% 31.2%Idaho 28.1% 2.9% 38.2% 17.5% 34.7%Illinois 0.0% 18.4% 20.6% 18.1% 18.9%Indiana -4.8% 16.2% 23.6% 34.7% 22.1%Iowa 15.9% 16.1% 28.1% 11.3% 18.2%Kansas 29.3% 68.3% 35.4% 15.4% 28.1%Kentucky 38.8% -4.7% 27.3% 28.9% 11.8%Louisiana -1.9% 20.8% 15.4% 11.4% 35.9%Maine 13.1% 7.7% 52.8% 5.2% 32.4%Maryland 21.3% -27.6% 29.2% 30.2% -18.6%Massachusetts 12.3% 21.9% 57.4% 4.4% 23.5%Michigan 9.0% -2.1% 4.3% 0.0% 47.6%Minnesota 355.8% -2.6% 20.4% 15.6% 26.2%Mississippi 15.3% 7.7% 23.4% 24.2% 44.4%Missouri 6.0% 21.7% 27.3% 30.0% 21.7%Montana 12.3% 8.9% 25.9% 18.2% 21.6%Nebraska 21.1% 10.8% 30.6% 43.5% -2.5%Nevada 22.5% -4.6% 50.2% -37.1% 235.8%New Hampshire 11.1% 10.1% 33.9% 16.3% -7.6%New Jersey 2.1% 6.4% 27.4% 16.6% 17.6%New Mexico 16.1% -20.2% -25.3% 11.7% 36.1%New York 33.0% 25.5% 41.7% 32.1% 15.7%North Carolina 19.7% 18.8% 37.1% 25.8% 48.2%North Dakota 24.6% 7.3% 19.3% 9.2% 35.0%Ohio -18.6% 31.2% 34.4% 15.6% 26.8%Oklahoma 5.5% 12.3% 37.1% 16.1% 8.2%Oregon -29.6% 4.2% 48.0% 50.1% 9.2%Pennsylvania 16.4% -17.2% 24.7% -0.3% 8.6%Rhode Island 8.4% 9.1% 30.8% 33.1% 11.7%South Carolina 13.6% 13.0% 42.9% 30.5% 30.6%South Dakota 52.1% 2.6% 17.8% 20.6% 30.7%Tennessee** - - - 84.1% 148.5%Texas 14.1% 11.5% 27.5% 19.7% 20.8%Utah -8.4% 19.3% 51.6% 44.5% 0.3%Vermont 21.5% 7.4% 19.3% 68.9% 23.4%Virginia 10.2% 12.9% 32.6% 11.7% 5.1%Washington 14.1% 2.3% 38.6% 28.4% 30.8%West Virginia -4.4% 2.6% 34.3% 30.1% 12.1%Wisconsin 7.7% 9.8% 27.2% 27.9% 19.9%Wyoming 2.1% 12.9% 44.3% 8.2% 23.1% *Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply. **Tennessee did not report data for 1997.

Source: CMS, CMS-64 Report, FY 1996 – FY 2001.



Rebates as Percent Drug Expenditures, 2001

*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, CMS-64 Report, FY 2001

State Drug Expenditures RebatesRebates as % Drug

ExpenditureNational Total $24,656,812,921 $4,948,222,331 20.1%Alabama $386,876,131 $76,624,463 19.8%Alaska $55,754,050 $11,337,883 20.3%Arizona* $2,573,205 - -Arkansas $241,558,369 $45,744,406 18.9%California $2,984,162,770 $786,113,991 26.3%Colorado $166,000,664 $34,264,574 20.6%Connecticut $304,780,286 $61,916,192 20.3%Delaware $81,156,928 $17,042,045 21.0%District of Columbia $63,504,500 $10,446,499 16.5%Florida $1,475,766,739 $297,362,792 20.1%Georgia $735,944,558 $110,087,285 15.0%Hawaii $74,869,859 $14,363,603 19.2%Idaho $102,975,196 $18,841,154 18.3%Illinois $884,018,166 $170,733,612 19.3%Indiana $561,642,082 $103,148,144 18.4%Iowa $234,716,795 $42,602,101 18.2%Kansas $185,017,060 $39,731,568 21.5%Kentucky $592,096,755 $104,759,238 17.7%Louisiana $585,388,809 $115,254,842 19.7%Maine $191,785,942 $41,847,632 21.8%Maryland $244,203,084 $34,263,429 14.0%Massachusetts $797,859,072 $180,517,139 22.6%Michigan $584,670,445 $111,716,756 19.1%Minnesota $265,726,228 $54,548,714 20.5%Mississippi $493,177,297 $88,481,567 17.9%Missouri $675,647,147 $133,927,028 19.8%Montana $72,577,455 $13,359,968 18.4%Nebraska $170,897,014 $30,219,685 17.8%Nevada $61,500,721 $16,330,579 26.6%New Hampshire $91,703,067 $13,934,765 15.2%New Jersey $651,442,945 $124,127,231 19.1%New Mexico $57,995,801 $12,110,896 20.9%New York $2,986,292,455 $543,984,948 18.2%North Carolina $984,653,306 $207,551,841 21.1%North Dakota $44,067,986 $8,780,182 19.9%Ohio $1,099,697,768 $217,702,350 19.8%Oklahoma $171,188,873 $40,177,945 23.5%Oregon $228,670,426 $34,991,037 15.3%Pennsylvania $692,665,382 $129,265,110 18.7%Rhode Island $102,708,476 $21,467,002 20.9%South Carolina $438,897,100 $95,438,155 21.7%South Dakota $51,748,770 $9,405,933 18.2%Tennessee $681,454,847 $102,644,077 15.1%Texas $1,325,987,804 $268,557,241 20.3%Utah $117,170,006 $21,949,963 18.7%Vermont $104,250,880 $22,045,277 21.1%Virginia $417,689,526 $79,484,868 19.0%Washington $458,332,414 $91,250,830 19.9%West Virginia $259,638,952 $52,402,218 20.2%Wisconsin $382,272,975 $79,554,207 20.8%Wyoming $31,435,835 $5,809,366 18.5%



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.

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

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

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

• Name and description of the medication;

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

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

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

• Techniques for self-monitoring prescription therapy;

• Proper storage;

• Prescription refill information; and

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

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

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

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



• Pharmacist comments relevant to the individual’s pharmaceutical therapy.

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.





Pharmacy Advisory Committees

State Pharmacy Advisory Committee Meetings Preferred Product Introduction Process Alabama Pharmacy & Therapeutic Committee Quarterly Introductory letter Alaska None - Introductory letter Arizona* - - Inform health plans directly Arkansas None - Introductory letter California Medical Contract Drug Advisory Committee Ad Hoc Petition with specific content requirements Colorado DUR Board advises Semiannually Introductory letter Connecticut Pharmacy Review Panel Quarterly Introductory letter Delaware DUR Board advises Bi-Monthly Introductory letter District of Columbia N/A - Introductory letter Florida None - Introductory letter Georgia Yes Quarterly Introductory letter Hawaii DUR Board advises Quarterly Package insert, Formulary kit Idaho None - Introductory letter, Product information Illinois None - Contact First DataBank Indiana DUR Board advises Monthly Introductory letter Iowa DUR Board advises Monthly Introductory letter Kansas DUR Board advises Bi-Monthly Introductory letter Kentucky Pharmacy and Therapeutic Advisory Board Bi-Monthly Introductory letter, Package insert Louisiana Pharmaceutical and Therapeutic Committee Semiannually Introductory letter Maine Pharmacy Advisory Group Quarterly Introductory letter Maryland None - Introductory letter Massachusetts DUR Committee Quarterly Introductory letter Michigan Pharmacy and Therapeutics Committee Semiannually State form Minnesota Drug Formulary Committee Quarterly Introductory letter Mississippi Pharmacy and Therapeutics Committee Monthly E-mail to Pharmacy Committee Missouri Pharmacy Subcommittee Quarterly Introductory letter Montana DUR Board advises Monthly Introductory letter Nebraska None - Introductory letter Nevada DUR Board - Introductory letter New Hampshire None - Introductory letter New Jersey None - Introductory letter New Mexico None - Introductory letter New York Pharmacy Advisory Committee Quarterly Introductory letter North Carolina Medical Care Advisory Committee - Introductory letter, Package insert North Dakota DUR Board advises Bi-Monthly Manufacturer’s preference Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter Oklahoma DUR Board Monthly E-mail Oregon DUR Board Quarterly Contact First DataBank Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter Rhode Island None - Introductory letter South Carolina None - Formulary packet South Dakota None - Introductory letter Tennessee* TennCare Advisory Board Bi-Monthly Introductory letter Texas None - State form Utah None - Introductory letter Vermont DUR Committee Bi-Monthly Introductory letter Virginia Pharmacy Liaison Committee Bi-Monthly Introductory letter Washington Drug Utilization and Education Council Bi-Monthly AMCP format dossier West Virginia Medical Services Fund Advisory Council Quarterly Introductory product packet Wisconsin None - Introductory letter Wyoming DUR Board Bi-Monthly Introductory letter *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.

Source: As reported by State drug program administrators in the 2002 NPC Survey.



Pharmacy Benefit Design - Coverage

State Cosmetics Fertility Drugs Experimental Drugs Alabama Not Covered Not Covered Not Covered Alaska Covered with Restrictions Not Covered Not Covered Arizona* - - - Arkansas Not Covered Not Covered Not Covered California Not Covered Not Covered Not Covered Colorado Not Covered Not Covered Not Covered Connecticut Not Covered Not Covered Not Covered Delaware Not Covered Not Covered Not Covered District of Columbia N/A N/A N/A Florida Not Covered Not Covered Not Covered Georgia Not Covered Not Covered Not Covered Hawaii Not Covered Not Covered Not Covered Idaho Not Covered Not Covered Not Covered Illinois Not Covered Not Covered Not Covered Indiana Not Covered Not Covered Not Covered Iowa Not Covered Not Covered Not Covered Kansas Not Covered Not Covered Not Covered Kentucky Not Covered Not Covered Not Covered Louisiana Not Covered Not Covered Not Covered Maine Not Covered Not Covered Not Covered Maryland Not Covered Not Covered Not Covered Massachusetts Not Covered Not Covered Not Covered Michigan Not Covered Not Covered Not Covered Minnesota Not Covered Not Covered Not Covered Mississippi Not Covered Not Covered Not Covered Missouri Not Covered Not Covered Not Covered Montana Not Covered Not Covered Not Covered Nebraska Not Covered Not Covered Not Covered Nevada Not Covered Not Covered Not Covered New Hampshire Not Covered Not Covered Not Covered New Jersey Not Covered Not Covered Not Covered New Mexico Not Covered Not Covered Not Covered New York Not Covered Not Covered Not Covered North Carolina Not Covered Not Covered Not Covered North Dakota Not Covered Not Covered Not Covered Ohio Not Covered Not Covered Not Covered Oklahoma Not Covered Not Covered Not Covered Oregon PA Required Not Covered Not Covered Pennsylvania Not Covered Not Covered Not Covered Rhode Island Not Covered Not Covered Not Covered South Carolina Not Covered Not Covered Not Covered South Dakota Not Covered Not Covered Not Covered Tennessee* - - - Texas Not Covered Not Covered Not Covered Utah Not Covered Not Covered Not Covered Vermont Not Covered Not Covered Not Covered Virginia Not Covered Not Covered Not Covered Washington Not Covered Not Covered Not Covered West Virginia Not Covered Not Covered Not Covered Wisconsin Not Covered Not Covered Not Covered Wyoming Not Covered Not Covered Not Covered *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.

PA = Prior Authorization, DME = Durable Medical Equipment




Pharmacy Benefit Design - Coverage (con’t)

State Prescribed Insulin Disposable Needles for Insulin Use

Syringe Combinations for Insulin Use

Blood Glucose Test Strips

Alabama Covered Covered Covered Covered as DME Alaska Covered Covered Covered Covered Arizona* - - - - Arkansas Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered California Covered Covered Covered Covered Colorado Covered DME DME DME Connecticut Covered Covered Covered Covered Delaware Covered Covered Covered Covered District of Columbia Covered Covered Covered N/A Florida Covered Covered Covered Covered Georgia Covered Covered Covered Covered with Restrictions Hawaii Covered Covered Covered Covered Idaho Covered Covered Covered DME Illinois Covered Covered Covered with Restrictions Covered Indiana Covered Covered Covered Covered Iowa Covered Not Covered Not Covered Not Covered Kansas Covered Covered as DME Covered as DME Covered as DME Kentucky Covered Not Covered Covered Not Covered Louisiana Covered Covered Covered Covered Maine Covered Covered Covered Covered with Restrictions Maryland Covered Covered Not Covered Not Covered Massachusetts Covered Covered Covered Covered Michigan Covered Covered Covered Covered Minnesota Covered Covered Covered Covered Mississippi Covered Covered Covered Covered Missouri Covered Covered Covered Covered as DME Montana Covered Not Covered Not Covered Not Covered Nebraska Covered Covered in Supplier Program Covered (med. necess.) Covered (med. necess.) Nevada Covered Covered Covered Covered New Hampshire Covered Covered Covered Covered New Jersey Covered Covered Covered Covered New Mexico Covered Covered Covered Covered New York Covered Covered Covered Covered North Carolina Covered Covered as DME Covered as DME Covered as DME North Dakota Covered Covered Covered Covered Ohio Covered Covered as DME Covered as DME Covered as DME Oklahoma Covered Covered as DME Covered as DME Covered as DME Oregon Covered Covered as DME Covered Covered as DME Pennsylvania Covered Covered Covered Covered Rhode Island Covered Covered Covered Covered as DME South Carolina Covered Covered Covered Covered as DME South Dakota Covered Covered Covered Covered Tennessee* - - - - Texas Covered Covered Covered Not Covered Utah Covered Covered Covered with Restrictions Covered Vermont Covered Covered Covered Covered Virginia Covered Covered Covered Covered with Restrictions Washington Covered Covered Covered Covered West Virginia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Wisconsin Covered Covered Covered Covered Wyoming Covered Covered Covered Covered *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA = Prior Authorization, DME = Durable Medical Equipment




Pharmacy Benefit Design - Coverage (con’t)

State Urine Ketone Test Strips

Total Parenteral Nutrition

Interdialytic Parenteral Nutrition

Alabama Covered as DME Covered as DME Covered as DME Alaska Covered Covered Not Covered Arizona* - - - Arkansas Not Covered Not Covered Not Covered California Covered PA Required Not Covered Colorado DME PA Required Not Covered Connecticut Covered Covered Covered Delaware Covered Covered Not Covered District of Columbia N/A N/A N/A Florida Covered with Restrictions Covered Not Covered Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions Hawaii Covered Covered, PA Required Covered, PA Required Idaho DME DME Not Covered Illinois Covered Covered with Restrictions Covered with Restrictions Indiana Covered Covered Covered Iowa Not Covered Not Covered Not Covered Kansas Covered as DME Covered as DME Not Covered Kentucky Not Covered Covered with Restrictions Covered with Restrictions Louisiana Covered Covered as DME Covered as DME Maine Covered Not Covered Not Covered Maryland Not Covered Covered Covered Massachusetts Covered Covered with Restrictions Not Covered Michigan Covered Covered as DME Covered as DME Minnesota Covered Covered Covered Mississippi Covered Covered with Restrictions Covered with Restrictions Missouri Covered as DME Covered as DME Covered as DME Montana Not Covered Not Covered Covered in Supplier Program Nebraska Covered in Supplier Program Covered in Supplier Program Not Covered Nevada Covered Covered as DME Covered as DME New Hampshire Covered Covered Covered New Jersey Covered Covered Covered New Mexico Covered Covered Covered with Restrictions New York Covered Covered Covered North Carolina Covered as DME Covered Covered North Dakota Covered Covered Not Covered Ohio Covered as DME Not Covered Not Covered Oklahoma Covered as DME Covered with Restrictions N/A Oregon Covered as DME PA Required PA Required Pennsylvania Covered Covered Covered Rhode Island Covered Covered as DME, PA required Covered as DME, PA Required South Carolina Covered as DME Covered as DME Covered as DME South Dakota Covered Not Covered Not Covered Tennessee* - - - Texas Not Covered Not Covered Not Covered Utah Covered Covered as DME Covered as DME Vermont Covered Covered Covered Virginia Covered as DME Covered Not Covered Washington Covered Covered Covered West Virginia Covered with Restrictions Covered as DME Not Covered Wisconsin Covered Covered Covered Wyoming Covered Covered as DME Covered as DME *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PA= Prior Authorization, DME = Durable Medical Equipment




Coverage of Injectables

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

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

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




Coverage of Vaccines and Unit Dose

State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose Alabama EPSDT, VCP Yes Alaska EPSDT, VCP Yes Arizona* - - Arkansas VCP Yes California VCP Yes Colorado EPSDT No Connecticut CHIP No Delaware VCP, CHIP No District of Columbia EPSDT No Florida VCP Yes Georgia EPSDT, VCP Yes Hawaii EPSDT, CHIP, VCP Yes Idaho ESPDT, CHIP, VCP Yes Illinois VCP No Indiana EPSDT, CHIP, VCP Yes Iowa EPSDT, VCP Yes Kansas CHIP, VCP No Kentucky EPSDT, CHIP, VCP, Pharmacy Services Yes Louisiana EPSDT, VCP Yes Maine EPSDT, CHIP No Maryland VCP No Massachusetts EPSDT, Department of Public Health No Michigan EPSDT, CHIP Yes Minnesota EPSDT, CHIP, VCP Yes Mississippi EPSDT, CHIP No Missouri EPSDT, CHIP, VCP Yes Montana EPSDT, CHIP, VCP Yes Nebraska EPSDT, CHIP, VCP No Nevada EPSDT Yes New Hampshire EPSDT, CHIP, VCP Yes New Jersey EPSDT, VCP Yes, LTC New Mexico Admin. only reimbursable, Vaccines free through Health Dept. No New York EPSDT, CHIP, VCP No North Carolina EPSDT, VCP No North Dakota EPSDT No Ohio VCP No Oklahoma ESPDT, VCP Yes Oregon VCP Yes Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No Rhode Island VCP No South Carolina VCP Yes South Dakota VCP Yes Tennessee* - - Texas EPSDT, CHIP, VCP Yes Utah VCP No Vermont EPSDT Yes Virginia VCP Yes Washington EPSDT Yes West Virginia CHIP, VCP Yes Wisconsin VCP Yes Wyoming EPSDT, CHIP, VCP No ^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children Program (VCP), or other. LTC = Long Term Care *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.




Coverage of Over-the-Counter Medications

State Allergy, Asthma, and Sinus Analgesics Cough and Cold Smoking Deterrents

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




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

State Digestive Products (no H2 antagonists) H2 Antagonists Feminine Products Topical Products

Alabama Covered Covered Not Covered Covered with Restrictions Alaska Not Covered Not Covered Limited Coverage Limited Coverage Arizona* - - - - Arkansas Limited Coverage Covered Limited Coverage Limited Coverage California Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Connecticut Covered with Restrictions Covered with Restrictions Not Covered Covered Delaware Covered Covered Limited Coverage Limited Coverage District of Columbia N/A N/A N/A N/A Florida Not Covered Not Covered Covered with Restrictions Not Covered Georgia Not Covered Not Covered Not Covered Not Covered Hawaii Limited Coverage Limited Coverage N/A Limited Coverage Idaho Not Covered Not Covered Not Covered Not Covered Illinois PA Required Not Covered Not Covered PA Required Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Iowa Not Covered Not Covered Not Covered Covered with Restrictions Kansas Not Covered Covered Not Covered Not Covered Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Louisiana Not Covered Not Covered Not Covered Not Covered Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Maryland Not Covered Not Covered Limited Coverage Not Covered Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage Mississippi Limited Coverage Covered with Restrictions Limited Coverage Limited Coverage Missouri Covered Covered Not Covered Not Covered Montana Covered with Restrictions Covered with Restrictions Not Covered Not Covered Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Nevada Covered Covered Not Covered Covered with Restrictions New Hampshire Covered Covered Covered Covered New Jersey Not Covered Not Covered Not Covered Limited Coverage New Mexico Covered Covered Not Covered Covered with Restrictions New York Limited Coverage Not Covered Limited Coverage Limited Coverage North Carolina Not Covered Not Covered Not Covered Not Covered North Dakota Covered Covered Not Covered Not Covered Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage Oklahoma Not Covered Not Covered Not Covered Not Covered Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Pennsylvania Not covered Covered with Restrictions Covered Covered Rhode Island Covered Not Covered Covered with Restrictions Covered with Restrictions South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions South Dakota Not Covered Not Covered Not Covered Not Covered Tennessee* - - - - Texas Covered Covered Covered Covered Utah Not Covered Limited Coverage Covered with Restrictions Limited Coverage Vermont PA Required PA Required PA Required PA Required Virginia Covered Covered Covered with Restrictions Covered with Restrictions Washington Covered Not Covered Limited Coverage Limited Coverage West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage Wisconsin Covered Not Covered Not Covered Not Covered Wyoming Not Covered Covered Covered Covered with Restrictions *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.

PA= Prior Authorization




Prior Authorization Process and Procedures

State PA Procedure Prior Authorization Committee Members Meetings Alabama Yes Pharmacy & Therapeutics 9 Quarterly Alaska Yes No - - Arizona* - - - - Arkansas Yes DUR Board 8 Quarterly California Yes No - - Colorado Yes No - - Connecticut No - - - Delaware Yes No - - District of Columbia Yes N/A N/A N/A Florida Yes No - - Georgia Yes N/A N/A N/A Hawaii Yes DUR Board 9 Quarterly Idaho Yes Pharmacists on staff and Medical Director 5 104/year Illinois Yes Committee on Drugs and Therapeutics Varies Quarterly Indiana Yes No - - Iowa Yes DUR Board 10 Monthly Kansas Yes No - - Kentucky Yes Pharmacy and Therapeutics Advisory Committee 14 Bimonthly Louisiana Yes Pharmaceutical and Therapeutics Committee 21 Quarterly Maine Yes No - - Maryland Yes No - - Massachusetts Yes No - - Michigan Yes No - - Minnesota Yes Drug Formulary Committee 9 Quarterly Mississippi Yes Pharmacy and Therapeutics Committee 12 Monthly Missouri Yes Prior Authorization Committee 7 Quarterly Montana Yes Yes 5 Monthly Nebraska Yes No - - Nevada Yes No - - New Hampshire Yes Pharmacy and Therapeutics Advisory Committee 12 Quarterly New Jersey Yes No - - New Mexico Yes No - - New York Yes Pharmacy and Therapeutics Committee 11 Quarterly North Carolina Yes No - - North Dakota No No - - Ohio Yes No - - Oklahoma Yes DUR Board 10 Monthly Oregon Yes DUR Board 12 Quarterly Pennsylvania Yes No - - Rhode Island Yes No - - South Carolina Yes No - - South Dakota Yes No - - Tennessee* - - - - Texas Yes No - - Utah Yes DUR Board 12 Monthly Vermont Yes No - - Virginia Yes No - - Washington Yes Drug Utilization Review Team 16 Daily West Virginia Yes Pharmaceutical and Therapeutics Committee 11 Quarterly Wisconsin Yes No - - Wyoming Yes DUR Board 12 Bimonthly *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.




Prior Authorization Process and Procedures (Con’t)

State Initiated By: Annual Requests % ApprovedAlabama M.D., R.Ph. N/A N/AAlaska M.D., R.Ph. 1,200 85%Arizona* - - -Arkansas M.D., R.Ph. 136,750 65%California M.D., R.Ph. 2,060,000 88%Colorado M.D. 166,000 80%Connecticut N/A N/A N/ADelaware M.D., R.Ph. 200 90%District of Columbia N/A N/A N/AFlorida M.D. 40,000 78%Georgia M.D., R.Ph. 104,000 92%Hawaii M.D., R.Ph. N/A N/AIdaho M.D., R.Ph. N/A N/AIllinois M.D., R.Ph. 500,000 20%Indiana M.D., R.Ph. N/A N/AIowa M.D., R.Ph. 56,000 93%Kansas M.D., R.Ph. N/A N/AKentucky M.D., R.Ph. 623,000 50%Louisiana M.D. 70,000 95%Maine M.D. 44,000 91%Maryland M.D., R.Ph 5,300 95%Massachusetts M.D 29,000 40%Michigan M.D. 18,000 82%Minnesota R.Ph. 6,000 N/AMississippi M.D. 255,000 87%Missouri M.D. 35,000 N/AMontana M.D., R.Ph., Pharm. Tech. 25,000 79%Nebraska M.D., R.Ph. 24,000 40%Nevada M.D. - -New Hampshire M.D. 7,500 75%New Jersey R.Ph., DME Supplier 351,000 97%New Mexico M.D. 400 98%New York Ordering Provider N/A N/ANorth Carolina M.D. N/A N/ANorth Dakota M.D., R.Ph. 600 90%Ohio M.D. 31,000 99%Oklahoma R.Ph. 99,000 68%Oregon M.D. 31,750 80%Pennsylvania M.D., Other Licensed Prescriber N/A N/ARhode Island M.D. N/A 85%South Carolina M.D. 37,700 60%South Dakota M.D., R.Ph. 28 100%Tennessee* - - -Texas M.D., R.Ph. 2,000 75%Utah M.D., R.Ph. N/A N/AVermont M.D. N/A 99%Virginia M.D. 416 30%Washington M.D., R.Ph., Pharm. Tech. 1,618,000 80%West Virginia M.D., R.Ph. 160,000 78%Wisconsin R.Ph. 50,000 95%Wyoming M.D., R.Ph., Pharm. Tech. 18,000 90% *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.




Prior Authorization Process and Procedures (Con’t)

State Reviewer Review Time Response Vehicle Alabama R.N., M.D., R.Ph. 24 hours Phone, fax, mail, e-mail Alaska R.N., R.Ph., Pharm. Tech. 24 hours Phone, fax Arizona* - - - Arkansas Voice Response 1-3 minutes Voice Response System California R.Ph. <24 hours Fax or telephone inquiry system Colorado Pharm. Tech. 24 hours Phone, fax, mail Connecticut N/A N/A N/A Delaware R.N., M.D., R.Ph. 1 working day Fax District of Columbia N/A N/A N/A Florida R.Ph., Pharm. Tech. 3 minutes Verbal, at time of request Georgia PBM 24 hours or less Phone, mail Hawaii R.N., R.Ph., Pharm. Tech. 24 hours Fax Idaho M.D., R.Ph. 24 hours Fax Illinois M.D., R.Ph. 4-8 hours Automated phone Indiana N/A N/A N/A Iowa R.Ph. 24 hours or less Phone, fax Kansas R.N., R.Ph. 24 hours or less Phone, mail Kentucky R.Ph. 24 hours Phone, fax Louisiana R.Ph. 3-5 minutes Fax, e-mail Maine R.Ph., Pharm. Tech. 2-4 hours Fax, mail Maryland M.D., R.Ph. 24 hours or less Phone, fax Massachusetts R.Ph. 24 hours Phone, mail Michigan Health Care Analysts 24 hours or less Phone Minnesota R.N. 24 hours or less Phone, mail Mississippi M.D., R.N., R.Ph., Pharm. Tech. 2.5 hours Phone, fax, mail Missouri R.N., Medicaid Tech. Within 24 hours Phone, fax, mail Montana M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax, mail Nebraska M.D., R.Ph., Pharm, Tech. 24 hours Phone, fax, mail Nevada R.Ph., Pharm. Tech. 24 hours Phone New Hampshire R.Ph., Pharm. Tech. 24 hours Phone, fax with written follow-up of denials New Jersey R.N., R.Ph., First Health Minutes Phone New Mexico R.Ph. 24 hours Phone, Requestor notified if PA is denied New York Voice interactive system Processed during call PA issued to prescriber by phone North Carolina ACS (PBM) 24 hours Phone, fax, e-mail North Dakota R.Ph. 1 business day E-mail Ohio R.Ph., Pharm. Tech. Immediate Phone Oklahoma R.Ph., Pharm. Interns 24 hours Fax Oregon R.Ph. 3-4 minutes Phone, fax Pennsylvania R.N., M.D. Immediately to 24 hours Phone Rhode Island M.D., R.Ph. Within 24 hours Online adjudication or verbally South Carolina R.Ph., First Health Per OBRA ‘90 guidelines Phone, fax South Dakota R.Ph. 24 hours Phone, fax, mail, e-mail Tennessee* - - - Texas R.Ph. 72 hours Phone, fax Utah Nurse 48 hours Mail Vermont R.N. 24 hours Phone, mail Virginia M.D. 15 minutes Phone, fax, mail Washington Drug Utilization Review Team** <24 hours Phone, fax; denial through mail West Virginia R.Ph. 3 minutes to 2 hours Phone, fax Wisconsin Done electronically Immediate Online Wyoming ACS Clinical Supervisor 24 hours Phone, fax, mail, e-mail *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. **Reviewer also includes Medical Claims Examiner.




Prior Authorization

State Anabolic Steroids Analgesics, Antipyretics, NSAIDs Anorectics

Alabama Covered Covered, PA Required Covered Alaska Covered Covered, PA Required Not Covered Arizona* - - - Arkansas Covered Partial Coverage, PA Required Not Covered California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required Colorado Covered, PA Required Covered, PA Required Not Covered Connecticut Covered Covered Not Covered Delaware Covered Covered Not Covered District of Columbia N/A N/A N/A Florida Covered Covered Partial Coverage Georgia Covered, PA Required Covered, PA Required Not covered Hawaii Covered, PA Required Partial Coverage, PA Required Partial Coverage, PA Required Idaho Covered, PA Required Covered, PA Required Not Covered Illinois N/A Covered Not Covered Indiana** N/A N/A N/A Iowa Covered Covered, PA Required Not Covered Kansas Covered Covered Partial Coverage, PA Required Kentucky Covered, PA Required Covered, PA Required Covered, PA Required Louisiana Covered Covered, PA Required Partial Coverage Maine Covered Covered, PA Required Covered, PA Required Maryland Covered Covered Not Covered Massachusetts Covered Partial Coverage, PA Required Not Covered Michigan Not Covered Covered Not Covered Minnesota Covered Covered, PA Required Not Covered Mississippi Covered Covered, PA Required Not Covered Missouri Covered Covered Not Covered Montana Covered Partial Coverage, PA Required Partial Coverage, PA Required Nebraska Covered Partial Coverage, PA Required Not Covered Nevada Partial Coverage Covered Not Covered New Hampshire Covered Covered Covered, PA Required New Jersey Partial Coverage Covered PA for ADD Diagnosis New Mexico Covered Covered Covered, PA Required New York Covered Covered Not Covered North Carolina Covered Covered Covered North Dakota Covered Covered Partial Coverage, PA Required Ohio Partial Coverage, PA Required Partial Coverage, PA Required Not Covered Oklahoma Not Covered Covered, PA Required Not Covered Oregon Covered Covered Covered Pennsylvania Covered Covered Not Covered Rhode Island Covered Covered Covered, PA Required South Carolina Covered Covered Covered South Dakota Covered Covered Covered Tennessee* - - - Texas Covered Covered Not Covered Utah Partial Coverage, PA Required Covered Covered, PA Required Vermont Covered Covered Covered Virginia Not Covered Partial Coverage Partial Coverage, PA Required Washington Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required West Virginia Covered Partial Coverage, PA Required Not Covered Wisconsin Covered Covered, PA Required Covered Wyoming Not Covered Covered, Some require PA Not Covered *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. ** All coverage in accordance with OBRA'90 and OBRA'93. PA = Prior Authorization




Prior Authorization (Con’t)

State Antihistamines Anxiolytics, Sedatives, and Hypnotics

Prescribed Cold Medications

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




Prior Authorization (Con’t)

State Growth Hormones Miscellaneous GI Products

Prescribed Smoking Deterrents

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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. **All coverage in accordance with OBRA ’90 and OBRA ’93. PA = Prior Authorization




Drug Utilization Review

State State Contact Telephone In-House or Contracted PRODUR Implemented

Alabama Louise Jones 334-242-5039 Contracted Jul-96 Alaska Dave Campana, R.Ph. 907-334-2425 Contracted Jun-95 Arizona* - - - - Arkansas Pamela Ford, P. D. 501-683-4120 Contracted Mar-97 California Vic Walker, R.Ph., B.C.P.P. 916-657-0785 In-House Aug-95 Colorado Dima Ahram, Pharm.D. 303-866-2468 In-House Dec-98 Connecticut James Zakszewski, R.Ph. 860-424-5150 Contracted Sep-96 Delaware Cynthia Denemark 302-453-8453 Contracted Feb-94 District of Columbia Donna Bovell 202-442-5988 In-House Sep-96 Florida Jerry F. Wells 850-487-4441 Contracted Jul-93 Georgia Jean Cox, R.Ph. 404-657-7241 In-House Oct-00 Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997 Idaho Tamara Eide, Pharm.D. 208-364-1821 Contracted Jan-98 Illinois Marvin Hazelwood 217-524-5565 In-House Jan-93 Indiana Karen Clifton 317-232-4391 Contracted Mar-96 Iowa Julie Kuhle, R.Ph. 515-270-0713 Contracted Jul-97 Kansas Mary H. Obley 785-296-8406 Contracted Nov-96 Kentucky Debra Bahr, R.Ph. 502-564-7940 In-House 1987 Louisiana Mary Terrebonne, P.D. 225-342-9768 Contracted Apr-66 Maine Director of Pharmacy 207-287-4018 Contracted Dec-95 Maryland Judith Geisler, P.D. 410-767-1455 Contracted Jan-93 Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95 Michigan Mary Sandusky 517-335-5280 Contracted Jul-00 Minnesota Mary Beth Reinke, Pharm.D. 651-215-1239 In-House Feb-96 Mississippi Rickey Mallory 601-359-6296 Contracted Oct-93 Missouri Jayne Zemmer 573-751-6963 Contracted Feb-93 Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94 Nebraska Beth Wilson 402-420-1500 Contracted Apr-95 Nevada Dionne Coston, R.N. 702-684-3775 Contracted 2003 New Hampshire Lisè Farrand 603-271-4419 Contracted Jul-95 New Jersey Edward Vaccaro, R.Ph. 609-588-2726 In-House Oct-96 New Mexico Neal Solomon, M.P.H., R.Ph. 505-827-3174 Both Oct-93 New York Michael Zegarelli 518-474-6866 In-House Mar-95 North Carolina Sharman Leinwand 919-857-4034 Contracted Oct-96 North Dakota Brendan K. Joyce, Pharm.D. 701-328-4023 In-House Jul-96 Ohio Jan Lawson 614-466-9698 In-House Feb-00 Oklahoma Ronald Graham, Pharm.D. 405-271-6614 Contracted 2000 Oregon Mariellen Rich 503-391-1980 Contracted Mar-94 Pennsylvania N/A - Contracted Jun-93 Rhode Island Paula Avarista, R.Ph. 401-4642-6390 Contracted Dec-94 South Carolina Caroline Sojourner, R.Ph. 803-898-2876 Contracted Nov-00 South Dakota Michael Jockheck, R.Ph. 605-773-6439 In-House 1996 Tennessee* Jeffrey G. Stockard, D.Ph. - Contracted Jul-01 Texas Curtis Burch, R.Ph. 512-338-6922 In-House Feb-95 Utah Duane Parke 801-538-6452 In-House 1994 Vermont Gloria Jacobs 802-241-2763 Contracted Nov-93 Virginia MariAnne McNeil, R.Ph. 804-783-2196 In-House Jul-94 Washington Nicole Nguyen, Pharm.D. 360-725-1757 In-House Mar-96 West Virginia Vicki M. Cunningham, R.Ph. 304-588-1700 Contracted Mar-95 Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3348 Contracted 2001 Wyoming Debra Devereuax, R.Ph. 307-766-6750 Contracted Oct-95 *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. PRODUR = Prospective Drug Utilization Review System




Prescribing/Dispensing Limits

State Limits on

Rx Limits on Number, Quantity, and Refills of Prescriptions Alabama Yes 5 refills per Rx, 30 day supply per Rx Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics Arizona* - - Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months California Yes 6 Rx per month, maximum 100 day supply for most medications Colorado Yes 30 day quantity supply per Rx; 100 day supply for maint. meds. Other limits for stadol & oxycontin Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater) District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds Florida Yes 4 brand name Rxs per month (with exceptions) Georgia Yes 31 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override) Hawaii Yes 30 day supply or 100 unit doses/50# gms per Rx Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control Illinois Yes Medically appropriate monthly quantity Indiana Yes 34 day supply for maintenance drugs Iowa No Maximum 30 day supply except select maintenance drugs (90 days) Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per

recipient per month Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription Maryland Yes 34 day supply per Rx; 2 refills per Rx Massachusetts Yes Maximum 5 refills per prescription Michigan Yes 100 day supply, No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days Minnesota Yes Max 3 month supply Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum Missouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximum Montana Yes 34 day supply or 100 unit doses per Rx (whichever is greater) Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. New Hampshire Yes 30 day supply, 90 day supply on maintenance medications New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months New Mexico No 34 day supply, except contraceptives (100 days) New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override) North Carolina Yes 34 day supply per Rx, with exceptions; 6 Rx per month North Dakota Yes 34 day supply per Rx; max 12 refills per script; one refill on PPIs Ohio Yes 34 day supply (acute) and 102 unit doses (chronic) Oklahoma Yes 3 Rx per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx Oregon Yes 15 day supply for initial Rx for chronic conditions Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override) South Dakota No - Tennessee* - - Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx Virginia No 34 day supply per Rx Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs West Virginia Yes 34 day supply; 5 refills per Rx with quantity limits on some drugs Wisconsin Yes 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period Wyoming No 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.




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



Pharmacy Payment and Patient Cost Sharing

State Dispensing Fee Ingredient Reimbursement Basis Copayment Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00 Alaska $3.45 minimum AWP-5% $2.00 Arizona* - - - Arkansas $5.51 AWP-10.5% $0.50 - $5.00 California $4.05 AWP-10% $1.00 Colorado $4.00; $1.89 for Institutions AWP-13.5% or WAC+18%, whichever is

lowest; AWP-35% (for generics) G: $0.75, B: $3.00

Connecticut $3.85 AWP-12% None Delaware $3.65 AWP-12.9% None DC $3.75 AWP-10% $1.00 Florida $4.23-$4.73 (LTC) AWP-13.25%; WAC+7% None Georgia $4.63 + $0.50 (for generics) AWP-10% G/P: $0.50, B/NP: $0.50 - $3.00Hawaii $4.67 AWP-10.5% None Idaho $4.94 ($5.54 for unit dose) AWP-12% None Illinois G: $5.10, B: $4.00 B: AWP-11%, G: AWP-20% $1.00 Indiana $4.90 B: AWP-13.5%, G: AWP-20% $0.50 - $3.00 Iowa $5.17 AWP-10% $1.00 Kansas $3.40 B: AWP-15%, G: AWP-27% IV AWP-50%,

blood AWP-30% $3.00

Kentucky $4.51 AWP-12% $1.00 Louisiana $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00 Maine $3.35 (+extra fees for compounding) AWP-13% $0.50 - $3.00 Maryland $4.21 Lowest of :WAC+10%, direct+10%, AWP-10% $1.00 Massachusetts B: $3.50 G: $5.00 WAC+5% $2.00 Michigan $3.72 AWP-13.5% (1-4 stores), AWP-15.1%

(5+stores) $1.00

Minnesota $3.65 AWP-9% None Mississippi $3.91 AWP-12% $1.00 - $3.00 Missouri $4.09 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some

1115 waiver pop. Montana $2.00 - $4.70 AWP-15%, direct price for some labelers $1.00 - $5.00 Nebraska $3.27 - $5.00 AWP-11% $2.00 Nevada $4.76 AWP-15% None New Hampshire $2.50 AWP-12% G: $0.50, B: $1.00 New Jersey $3.73 - $4.07 AWP-10%, WAC+30%, AAC for injectables None New Mexico $3.65 AWP-12.5% None (except CHIP and

working disabled) New York B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00 North Carolina B: $4.00 G: $5.60 AWP-10% G: $1.00, B: $3.00 North Dakota $5.10 AWP-10% $3.00 (Brand) Ohio $3.70 WAC + 9% None Oklahoma $4.15 AWP-12.0% $1.00 - $2.00 Oregon Retail: $3.50 Inst./NF: $3.80 AWP-13% None Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for Gas) Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None South Carolina $4.05 AWP-10% $3.00 South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00 Tennessee* - - - Texas (EAC+$5.27)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None Utah $3.90-$4.40 (based on area) AWP-15% $3.00 - $5.00/mo. Vermont $4.25 AWP-11.9% $1.00 - $2.00 Virginia $4.25 AWP-10.25% G: $1.00, B: $2.00 Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $2.00 Wisconsin $4.88 (to a maximum $40.11) AWP-11.25% $1.00, max $5/recip/pharm/mo Wyoming $5.00 AWP-11% $2.00

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. *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 2002 NPC Survey.



Maximum Allowable Cost (MAC) Programs

State Federal Upper Limits

State-Specific Upper Limits MAC Override Provisions

Alabama Yes Yes Dispense as written, brand medically necessary Alaska Yes No Brand medically necessary and reason for medical necessity Arizona* - - - Arkansas Yes Yes Brand medically necessary, prior authorization California Yes Yes Medically necessary and other products unavailable at MAC rate Colorado Yes Yes Brand medically necessary Connecticut Yes No Brand medically necessary Delaware Yes Yes Brand medically necessary District of Columbia Yes No Brand medically necessary plus an explanation Florida Yes Yes If drug is on Florida Negative Formulary Georgia Yes Yes Prior authorization Hawaii Yes No brand Medically necessary Idaho Yes Yes Prior authorization Illinois Yes Yes Prior authorization request by M.D. or R.Ph. Indiana Yes Yes Brand medically necessary, prior authorization Iowa Yes Yes Brand medically necessary, Med Watch form and prior authorization Kansas Yes Yes N/A Kentucky Yes No Brand necessary, brand medically necessary, PA on some drugs Louisiana Yes Yes Brand necessary, brand medically necessary Maine Yes Yes Medically necessary, brand Medically necessary PA on some drugs Maryland Yes Yes Brand medically necessary and reason for medical necessity Massachusetts Yes Yes Dispense as written, brand medically necessary, prior authorization Michigan Yes Yes Dispense as written and prior authorization Minnesota Yes Yes Brand medically necessary or dispense as written. Brand medically

necessary must be handwritten on the prescription by the prescriber, no pre-printed DAW allowed.

Mississippi Yes No Prior authorization for brand multi-source Missouri Yes Yes Prior authorization Montana Yes No Brand necessary, prior authorization Nebraska Yes Yes Medically necessary Nevada No No Brand medically necessary New Hampshire Yes Yes Brand medically necessary, MedWatch form for PA New Jersey Yes No Brand medically necessary New Mexico Yes Yes Medically necessary, Brand necessary New York Yes No Dispense as written, brand necessary, or brand medically necessary North Carolina Yes Yes Brand medically necessary North Dakota Yes Yes Dispense as written Ohio Yes Yes Prior authorization Oklahoma Yes Yes Brand medically necessary Oregon Yes No Dispense as written, brand medically necessary Pennsylvania Yes Yes Brand necessary, brand medically necessary, or prior authorization Rhode Island Yes No Brand medically necessary with medical justification South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and P.A. South Dakota Yes Yes Brand medically necessary Tennessee* - - - Texas Yes Yes Brand necessary, brand medically necessary Utah Yes Yes Brand medically necessary plus prior approval Vermont Yes Yes Dispense as written Virginia Yes Yes Brand necessary Washington No Yes Brand medically necessary West Virginia Yes No Brand medically necessary (hand written by prescriber) Wisconsin No Yes Brand medically necessary Wyoming Yes Yes Brand medically necessary

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by State drug program administrators in the 2002 NPC Survey.



Mandatory Substitution

State Incentive Fee for Generic Substitution

Dispensing of Generic Multi-Source Required

Dispensing of Lowest Cost Multi-Source Required

Alabama No No No Alaska No Yes No Arizona* - - - Arkansas No Yes No California No No Yes Colorado No No No Connecticut $0.50 No No Delaware No - - District of Columbia No No Yes Florida No Yes No Georgia $0.50 Yes (brand PA required) No Hawaii No Yes (if AB rated & not against State law/regs) No Idaho No Yes No Illinois No No Yes Indiana No Yes Yes Iowa No Yes Yes Kansas No No No Kentucky No Yes Yes Louisiana No No No Maine No Yes No Maryland No Yes Yes Massachusetts No Yes No Michigan No No No Minnesota No Yes No Mississippi No Yes No Missouri No No No Montana No Yes No Nebraska No No No Nevada No Yes No New Hampshire No Yes No New Jersey No Yes No New Mexico No No Yes New York $1.00 Yes No North Carolina No Yes Yes North Dakota No No No Ohio No No No Oklahoma No Yes No Oregon No Yes No Pennsylvania No Yes No Rhode Island No Yes No South Carolina No Yes No South Dakota $10.00 No No Tennessee* - - - Texas No Yes No Utah No Yes No Vermont No Yes No Virginia No Yes No Washington No Yes No West Virginia No Yes No Wisconsin No Yes No Wyoming No Yes No *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by State drug program administrators in the 2002 NPC Survey.



Counseling Requirements and Payment for Cognitive Services

State Patient Counseling Required1 Medicaid Payment for Cognitive Services2

Alabama All Yes, Clozaril case management Alaska All No Arizona All - Arkansas All No California All No Colorado Medicaid Only No Connecticut Medicaid Only No Delaware All No District of Columbia Medicaid Only, Pending for others No Florida All No Georgia All No Hawaii Medicaid Only No Idaho All No Illinois All No Indiana All No Iowa All No Kansas All No Kentucky All No Louisiana All No Maine All No Maryland Medicaid Only No Massachusetts All No Michigan All No Minnesota All No Mississippi All Yes Missouri All Yes (diabetes education) Montana All No Nebraska All No Nevada All No New Hampshire All No New Jersey All Yes New Mexico All No New York All No North Carolina All No North Dakota All No Ohio All No Oklahoma All No Oregon All No Pennsylvania All No Rhode Island All No South Carolina Medicaid Only No South Dakota All No Tennessee All - Texas All No Utah All No Vermont All No Virginia All No Washington All Yes (emergency contraceptive counseling) West Virginia All No Wisconsin All Yes Wyoming All No Source: 12001-2002 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug program administrators in the 2002 NPC Survey.



Prescription Price Updating

State Contact Telephone Updated Alabama Beverly Churchwell 334-242-5034 Biweekly Alaska Dave Campana 907-334-2425 Weekly Arizona* - - - Arkansas First DataBank 650-588-5454 Weekly California EDS Federal Corp. 916-636-1000 Monthly Colorado First DataBank 650-588-5454 Weekly Connecticut Electronic Data Systems 800-832-5858 Monthly Delaware Cynthia Denemark 302-453-8453 Biweekly District of Columbia First DataBank 650-588-5454 Monthly Florida First DataBank 650-588-5454 Weekly Georgia Express Scripts 952-837-5326 Weekly Hawaii First DataBank 800-633-3453 Weekly Idaho Kaydeen Burkett, R.Ph. 208-364-1826 Biweekly Illinois First DataBank 650-588-5454 Weekly Indiana First DataBank 650-588-5454 Weekly Iowa Sherry Swanson 515-327-0950 Weekly Kansas Mary H. Obley 785-296-8406 Weekly Kentucky Unisys Provider Services 502-226-1140 Weekly Louisiana Maggie Vick, Unisys Corp. 225-237-3251 Weekly Maine Medispan - Weekly Maryland First DataBank 650-588-5454 Weekly Massachusetts First DataBank 650-588-5454 Weekly Michigan First DataBank 650-588-5454 Weekly Minnesota First DataBank 650-588-5454 Weekly Mississippi Rickey Mallory 601-359-6296 Weekly Missouri First DataBank 650-588-5454 Weekly Montana First DataBank 650-588-5454 Weekly Nebraska First DataBank 650-588-5454 Weekly Nevada First DataBank 650-588-5454 Monthly New Hampshire First Health Services Corp. 603-224-2083 Weekly New Jersey First DataBank 650-588-5454 Weekly New Mexico Neil Solomon, M.P.H., R.Ph. 505-874-3174 Weekly New York Carl Cioppa, Pharm.D.. 518-486-3209 Monthly North Carolina Sharon Greeson, R.Ph.. 919-816-4475 Weekly North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-4023 Biweekly Ohio First DataBank 650-588-5454 Monthly Oklahoma First DataBank 800-633-3453 Weekly Oregon Kathy Franklin, First DataBank 650-588-5454 Biweekly Pennsylvania First DataBank 800-633-3453 Monthly Rhode Island Paula Avarista, R.Ph. 401-462-6390 Biweekly South Carolina First DataBank 650-588-5454 Weekly South Dakota Mark Petersen, R.Ph. 605-773-3495 Biweekly Tennessee* - - - Texas Martha McNeill, R.Ph. 512-338-6965 Continuously Utah RaeDell Ashley, R.Ph. 801-538-6495 Biweekly Vermont Christine Dapkiewicz 802-879-4450 Biweekly Virginia David Shepherd, R.Ph. 804-786-8056 Weekly Washington Tom Zuchlewski 360-725-1837 Bimonthly West Virginia Becky Garrigan 770-352-8592 Weekly Wisconsin First DataBank 800-633-3453 Bimonthly Wyoming First DataBank 800-633-3453 Weekly *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by State drug program administrators in the 2002# NPC Survey.





Section 5: State Pharmacy Program Profiles





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

A. Benefits Provided and Groups Eligible B. Expenditures for Drugs C. Administration D. 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





Section 6: State Pharmacy Assistance Programs





State Pharmacy Assistance Programs

As of June 2003, at least 35 States had authorized some type of program to provide pharmaceutical coverage or assistance. Historically these programs have focused primarily on the low-income elderly and/or persons with disabilities who do not qualify for Medicaid, but some recent programs have been open to all seniors or even to all state residents. These programs range from providing access to State-negotiated discounts to State subsidies and tax credits for prescription drug expenditures.

Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted

Prescription Medication Coverage Pilot Program 2001† Arizona Arizona Prescription Discount Program 2003

Arkansas ARx Senior Program (formerly Prescription Drug Access Improvement Act) 2001†

Discount Prescription Medication Program 1999 California Golden Bear State Pharmacy Assistance Program 2001†

Connecticut Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) 1985

Nemours Health Clinic Pharmaceutical Assistance Program 1981

Delaware Delaware Prescription Drug Assistance Program (DPAP) 1999

Silver SaveRx (formerly Pharmaceutical Expense Assistance Program for Seniors and Ron Silver Senior Drug Program)

2002 Florida

Medicare Prescription Discount Program 2000 Hawaii Rx 2002† Hawaii Medicaid Prescription Drug Expansion Program 2002† Pharmaceutical Assistance Program, “Circuitbreaker” 1985 Illinois Rx SeniorCare 2001 Illinois Senior Citizens and Disabled Persons Prescription Drug Discount Program 2003†

Indiana Indiana Prescription Drug Program, “HoosierRx” 2000 Iowa Iowa Priority Prescription Savings Program 2001 Kansas Senior Pharmacy Assistance Program 2000

Maine Rx 2000* Maine Rx Plus 2004* Healthy Maine Prescription Drug Program 2001 Maine Low Cost Drugs for the Elderly and Disabled Program (DEL) 1975

Maryland Pharmacy Assistance Program 1979 Short-Term Prescription Drug Subsidy Plan 2000 Maryland Maryland Pharmacy Discount Program 2001†

Massachusetts Prescription Advantage 2000+ Michigan Elder Prescription Insurance Coverage Program 2001 Minnesota Prescription Drug Program 1999 Missouri SeniorRx Program 2001 Montana Prescription Drug Expansion Program 2003† Nevada Senior Rx 2000



New Hampshire Senior Prescription Drug Discount Program 2000

Pharmaceutical Assistance to the Aged and Disabled (PAAD) 1975 New Jersey Senior Gold Prescription Discount Program 2001 Senior Prescription Drug Program 2002† New Mexico Prescription Drug Waiver Program 2003†

New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program 1987

Prescription Drug Assistance Program 1999 North Carolina Senior Care (formerly Carolina CaRxes) 2001

Ohio Golden Buckeye Prescription Drug Program 2002† Oregon Senior Prescription Drug Assistance Program 2001†

Pharmaceutical Assistance Contract for the Elderly (PACE) 1984 Pennsylvania PACE Needs Enhancement Tier (PACENET) 1996

Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) 1985

South Carolina SilveRxCard Senior Prescription Drug Program 2000 South Dakota Senior Citizen Prescription Drug Program 2003 Texas State Prescription Drug Program 2001†

VSCRIPT 1989 VSCRIPT Expanded 1999 Vermont Health Access Plan (VHAP) 1996

Vermont

Healthy Vermonters Program 2002† West Virginia Gold Mountaineer Discount Card Program 2000

Wisconsin Wisconsin SeniorCare Prescription Drug Assistance Program 2001

Wyoming Prescription Drug Assistance Program 2002 †Program not yet operational. *MaineRx is expected to be abandoned and replaced with MaineRx Plus. +Program enrollment closed due to budget restrictions.

The following pages provide profiles of the State pharmacy assistance 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 in addition to the National Conference of State Legislatures (NCSL) website, http://www.ncsl.org/programs/health/drugaid.htm, a good source for the most up-to-date information.



Arizona Prescription Medication Coverage Pilot Program

Program Type: Discount Law Enacted: 2001∗∗∗∗

Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes: Participants must be either residents of a county that does not have a

Medicare HMO or residents of a county that has a Medicare HMO that does not provide prescription medication coverage.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund Budget (FY 02-03): None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: $500 for incomes 100-149% of FPL and $1,000 for incomes 150-

200% of FPL. Copayment Amount: None Dispensing Fee: Not Available Notes: Program covers 50% of pharmaceutical costs after deductible has been

paid.

DRUGS COVERAGE

Formulary: None Drugs Covered: All FDA-approved drugs purchased within the U.S. Drug Coverage Restrictions: Only FDA-approved drugs purchased within the U.S.

PROGRAM CONTACT

Del Swan Arizona Health Care Cost 801 E. Jefferson St. Phoenix, AZ 85034

Containment System Phone: 602/417-4726

∗ This program has not been implemented because funding for the program was repealed in a special budget session. The law creating the program is set to expire on October 1, 2003.



Arizona Arizona Prescription Discount Program

Program Type: Discount Year Operational: 2003

Projected Number of Recipients: 600,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes Eligible Income Level (Single): All Eligible Income Level (Married): All Other Eligibility Notes: Discounts available to Medicare enrollees, 65+ or disabled


Funding Source: Not Available Budget (FY 02-03): None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: $9.95 annually Deductible Amount: Not Available Copayment Amount: None Dispensing Fee: Not Available Notes:

DRUGS COVERAGE

Formulary: Not Available Drugs Covered: Not Available Drug Coverage Restrictions: Not Available

PROGRAM CONTACT

Del Swan Arizona Health Care Cost 801 E. Jefferson St. Phoenix, AZ 85034

Containment System Phone: 602/417-4726



Arkansas ARx Senior Program

(Formerly Prescription Drug Access Improvement Act) Program Type: Direct Assistance (1115 Waiver)

Law Enacted: 2001∗∗∗∗ Projected Number of Recipients: Not Available


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 90% of FPL Eligible Income Level (Married): 90% of FPL Other Eligibility Notes: Program provides prescription drug coverage to Qualified Medicare

Beneficiary (QMB) seniors lacking prescription drug coverage. After June 30, 2003, the upper income eligibility limit increases to 100% of FPL.


Funding Source: State General Revenue Fund and Federal matching funds Budget: Not Available Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Not Available Enrollment Fee: $25.00 per year Deductible Amount: None Copayment Amount: $10.00 for generic drugs and $20.00 for brand-name drugs Dispensing Fee: Not Available

DRUGS COVERAGE

Formulary: Not Available Drugs Covered: Legend drugs and controlled substances Drug Coverage Restrictions: Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT

Suzette Bridges Arkansas Department of Human Services Division of Medical Services, Slot 415 P.O. Box 1437 Little Rock, AR 72203-1437

Phone: 501/683-4120 Fax: 501/683-4124 E-mail: [email protected]

∗ Program implementation is contingent upon CMS approval of 1115 waiver application. As of December 2002, no communications from CMS had been received. As a result, no projected implementation date for this program was available at the time of publication.



California Discount Prescription Medication Program

Program Type: State-Negotiated Discounts Year Operational: 2000

Estimated Eligibles (November 2002): 1.3 million


Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes Eligible Income Level (Single): All income levels Eligible Income Level (Married): All income levels Other Eligibility Notes: Program covers pharmaceuticals not covered by a private insurer. Anyone who

has a Medicare card is eligible.


Funding Source: State General Revenue Fund Budget (FY 2002-03): $380,000 Cost per Participant: Not Available # of Rx’s Per Participant: 850,000 price inquiries per month∗ Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $4:05 per prescription (-50 cents to help balance the FY 02-03 State

budget, + 15 cents for switching costs) Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program must

also allow Medicare recipients to purchase drugs for the same price paid by Medi-Cal. Pharmacies must participate in this program in order to participate in the Medi-Cal program.

DRUGS COVERAGE

Formulary: No formulary Drugs Covered: All prescription drugs Drug Coverage Restrictions: 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: 916/657-4302 E-Mail: [email protected]

∗ Price inquires do not always result in sales because customers may elect not to purchase a pharmaceutical once its price has been quoted.



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 Age (Elderly): See notes Eligibility Age (Disabled): See notes Eligible Income Level (Single): All income levels Eligible Income Level (Married): All income levels Other Eligibility Notes: Program covers pharmaceuticals not covered by a private insurer or other State

program. Anyone who has a Medicare card is eligible; however, unlike the California Discount Prescription Medication Program, enrollment is required to receive services.


Funding Source: Manufacturer negotiated discounts Budget: None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid rebate plus manufacturer-negotiated discounts Ingredient Cost Calculation: AWP – 10% Enrollment Fee: Not Available Deductible Amount: None Copayment Amount: None Dispensing Fee: $4:05 per prescription (-50 cents to help balance the FY 2002-03 State

budget, + 15 cents for switching costs) Notes: Medi-Cal collects a 99-cent per Rx administrative fee from drug

manufacturers and reimburses pharmacies with the remainder of the negotiated discount.

DRUGS COVERAGE

Formulary: No formulary Drugs Covered: Prescription drugs for which the State has negotiated manufacturer

discounts that supplement the Medi-Cal discount already mandated under the California Discount Prescription Medication Program.

Drug Coverage Restrictions: Only prescription drugs with manufacturer-negotiated discounts.

PROGRAM CONTACT

Janice Hall Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814

Phone: 916/657-4302 E-Mail: [email protected]

* Not yet operational.



Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled

(ConnPACE)

Program Type: Direct Assistance Year Operational: 1986

Number of Recipients (January 2003): 50,037 (Elderly: 43,193; Disabled: 6,844)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): $20,300 Eligible Income Level (Married): $27,500 Other Eligibility Notes: The Connecticut Department of Social Services has also submitted an

1115 waiver application that, if approved by the Centers for Medicare and Medicaid Services, would increase eligible income levels for both single and married individuals to 300% of FPL.


Funding Source: State General Revenue Fund Budget (FY 03): $63.8 million Cost per Participant (FY 02): $944.69 # of Rx’s Per Participant (FY 02): 18.6 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 12% Enrollment Fee: $30.00 per year Deductible Amount: None Copayment Amount: $16.25 Dispensing Fee: $3.60

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All prescription drugs and insulin. Drug Coverage Restrictions: ConnPACE does not cover drugs prescribed for cosmetic purposes,

experimental drugs, drugs FDA has determined are ineffective, antihistamines, contraceptives, cough preparations, anti-obesity drugs, multi-vitamin combinations, smoking cessation gum, vaccines obtained free of charge from the Department of Health Services, prescription drugs in excess of manufacturer’s recommendations with documented legal justification, drugs for lock-in clients from other than lock-in pharmacy, and over-the-counter drugs (with certain exceptions). Other drugs may not be covered if pharmaceutical manufacturers opt not to participate in the Drug Rebate Program. ConnPACE restricts beneficiaries to 120 units or a 30-day supply, whichever is greater.



Notes: Generic drugs must be substituted for brand-name drugs, unless otherwise indicated by the prescribing physician.

PROGRAM CONTACT

Evelyn A. Dudley Manager Department of Social Services 25 Sigourney Street Hartford, CT 06106




Delaware Nemours Health Clinic Pharmaceutical Assistance Program

Program Type: Private Discount Year Operational: 1981

Number of Enrollees (November 2002): 8,616


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+ Eligible Income Level (Single): $12,500 Eligible Income Level (Married): $17,125 Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware.


Funding Source: Nemours Foundation Budget: Not Available Cost per Enrollee: Not Available # of Rx’s Per Enrollee (FY 02): 1.7 Manufacturer Rebate Type: None Ingredient Cost Calculation: Not Available Enrollment Fee: None Deductible Amount: None Copayment Amount: 20% of drug cost Dispensing Fee: $5.00 Notes: Maximum annual benefit is $2,000.00 per enrollee.

DRUGS COVERAGE

Formulary: None Drugs Covered: Due to severe budgetary constraints, covered drugs are chosen

individually, based on physician recommendations. Drug Coverage Restrictions: As many recommended drugs as allowed by the budget are purchased

and made available to enrollees. Notes: One central pharmacy distributes all drugs by courier to branch

locations where citizens can pick up a 2-3 month supply.

PROGRAM CONTACT

W. Frank Morris, Jr. Nemours Clinic Pharmacy Assistance 1801 Rockland Road Wilmington, DE 19803




Delaware Prescription Drug Assistance Program (DPAP)


Number of Recipients (December 2002): 5,510


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware. Disabled, must be

eligible for SSDI.


Funding Source: Tobacco Settlement Fund Budget: Not Available; not subject to budget appropriation Cost per Participant (FY 02): $1159.56 # of Rx’s Per Participant (FY 02): 4.0 per month Manufacturer Rebate Type: Negotiated between the State and individual manufacturers Ingredient Cost Calculation: Lower of AWP – 12.9% or Federal Upper Limit or State MAC Enrollment Fee: None Deductible Amount: None Copayment Amount: Greater of $5.00 or 25% of the cost of the prescription Dispensing Fee: $3.48 Notes: Annual maximum benefit of $2,500.00 per recipient

DRUGS COVERAGE

Formulary: Open Drugs Covered: Same as Medicaid (medically necessary prescription drugs) Drug Coverage Restrictions: Only drugs from manufacturers that agree to participate in State rebate

program.

PROGRAM CONTACT

Cynthia R. Denemark Division of Social Services 248 Chapman Road Suite 100 Newark, DE 19702




Florida

Silver SaveRx∗∗∗∗

Program Type: Direct Assistance (1115 waiver) Year Operational: 2002

Number of Enrollees (May 2003): 46,312


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 120% of FPL Eligible Income Level (Married): 120% of FPL Other Eligibility Notes: Must be dually-eligible Medicare-Medicaid.


Funding Source: State General Revenue Fund, Federal matching funds, and manufacturer rebates

Budget (FY 03): $109.0 million Cost per Enrollee : Not Available # of Rx’s Per Enrollee: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 13.25% Enrollment Fee: None Deductible Amount: None Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the preferred

drug list, and $15.00 for brand name drugs not on the preferred drug list

Dispensing Fee: $4.23 Notes: Enrollees receive a cash benefit of up to $160.00 per month.

DRUGS COVERAGE

Formulary: Preferred drug list Drugs Covered: Same as Medicaid Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Matthew Dull Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308-7703

Phone: 850/414-8306 E-mail: [email protected]

∗ On August 1, 2002, Florida replaced its state-funded Pharmaceutical Expense Assistance Program with the Ron Silver Senior Drug Program, now known as the Silver SaveRx.



Florida Medicare Prescription Discount Program∗∗∗∗


Estimated Participants: Not Available


Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes Eligible Income Level (Single): All income

levels Eligible Income Level (Married): All income

levels Other Eligibility Notes: Anyone who has a Medicare card is eligible.


Funding Source: None Budget: None Cost per Participant: N/A # of Rx’s Per Participant: N/A Manufacturer Rebate Type: N/A Ingredient Cost Calculation: AWP – 9% Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.50 Notes: Pharmacies that participate in Medicaid must offer participants a

discount based on AWP – 9% + $4.50 dispensing fee.

DRUGS COVERAGE

Formulary: None Drugs Covered: All prescription drugs Drug Coverage Restrictions: None

PROGRAM CONTACT

Matthew Dull Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308-7703


∗ By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.



Hawaii

Hawaii Rx

Program Type: Direct Discount Projected Operational Date: July 1, 2004



Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): All income


levels Other Eligibility Notes: Open to all Hawaii residents, regardless of income.


Funding Source: State General Fund Budget (FY 02-03): $200,000 for plan development and implementation Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Efforts will be made to obtain an initial rebate amount equal to or

greater than the rebate calculated for Medicaid. Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: Not Available Copayment Amount: Not Available Dispensing Fee: Not less than fee provided under the State Medicaid program.

DRUGS COVERAGE

Formulary: Not Available Drugs Covered: Not Available Drug Coverage Restrictions: Not Available Notes: Each pharmacy participating in the program will discount the price of

drugs covered by the program and sold to program participants. Participating pharmacies will submit claims to the Department of Human Services and will be reimbursed for the discounted drugs.

PROGRAM CONTACT

Department of Human Services Medquest 1390 Miller Street Room 209 Honolulu, HI 96813

Phone: 808/692-8050



Hawaii

Medicaid Prescription Drug Expansion Program

Program Type: Direct Discount Projected Operational Date: Not Available*



Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): 300 % FPL Eligible Income Level (Married): 300% FPL Other Eligibility Notes:


Funding Source: Medicaid Rebates Budget (FY 02-03): $1,500,000 Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: Not Available Copayment Amount: Not Available Dispensing Fee: Not Available

DRUGS COVERAGE

Formulary: Not Available Drugs Covered: Not Available Drug Coverage Restrictions: Not Available Notes:

PROGRAM CONTACT

Department of Human Services Medquest 1390 Miller Street Room 209 Honolulu, HI 96813

Phone: 808/692-8050

* Not yet operational. Program is comparable to Maine Rx program, which U.S. Supreme Court ruled could go into effect (May 19, 2003, see laws.findlaw.com/us/000/01-188.html for full text of ruling).



Illinois Pharmaceutical Assistance Program, “Circuitbreaker”


Number of Recipients (May 2003): 57,444


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+ Eligible Income Level (Single): $21,218 (’03) Eligible Income Level (Married): $28,480 (’03) Other Eligibility Notes: A widow or widower who turns 63 or 64 before a deceased enrollee’s death

is eligible for PAP. Also, a married couple with a $35,740 annual household income would be eligible if they were filing with one other resident. An individual would be eligible with a $35,740 annual household income if they were filing with two other residents.


Funding Source: State General Revenue Fund and Tobacco Settlement Budget (FY 03): $83 million Cost per Participant (2001): $1,040.00 # of Rx’s Per Participant (2001): 29.0 Manufacturer Rebate Type Negotiated by a PBM on behalf of State Ingredient Cost Calculation: AWP – 10% or MAC if generic is available Enrollment Fee: $5.00 if income is below 100% of FPL and $25.00 if income is at or above

100% of FPL Deductible Amount: None Copayment Amount: For income less than 100% of FPL, there is no copayment until annual drug

cost exceeds $2,000; then copayment is 20% of drug cost. For income at 100% of FPL or greater, there is a $3.00 copayment until annual drug cost exceeds $2,000.00; then copayment is 20% of drug cost.

Dispensing Fee: $3.60

DRUGS COVERAGE

Formulary: Preferred product formulary Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease, Parkinson’s

disease, glaucoma, lung disease and smoking-related diseases, cardiovascular, arthritis, diabetes, and osteoporosis

Drug Coverage Restrictions Participants are able to receive brand-name drugs even if generics are available provided the doctor marks “dispense as written” on the prescription and the drug is classified as a “Narrow Therapeutic Index Drug.”

PROGRAM CONTACT

Susan Rohrer Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021




Illinois Illinois Rx SeniorCare

Program Type: Direct Assistance (1115 Waiver) Year Operational: 2002



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): not eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes:


Funding Source: State General Revenue Fund and Tobacco Settlement Budget (FY 03): $102 million Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type Negotiated by PBM on behalf of State Ingredient Cost Calculation: AWP- 10% or MAC if generic is available Enrollment Fee: None, but participants must reapply every year. Deductible Amount: None Copayment Amount: If the participant is a single individual with an income of no more than

$8,859 a year or if the participants are a married couple with a household income of no more than $11,939 a year, SeniorCare pays up to $1,750 per person for covered medications. After that limit is met, the participant pays 20% of the cost of each prescription. If the participant is a single individual with an income of $8,860 to $17,720 a year, or if the participants are a married couple with a total household income of $11,940 to $23,880 a year, SeniorCare pays for the first $1,750 per person. The participants are also required to pay $1 for a generic drug and $4 for each brand name drug. After the $1,750 limit is met, the participants continue to pay $1 for a generic drug and $4 for each brand name drug plus 20% of the cost of each prescription. If a generic drug is available but the participant requests a brand name drug, participants must pay $1 for each prescription plus the difference in price between the generic and the brand-name drug.


DRUGS COVERAGE

Formulary: Preferred product formulary plus over-the-counter medications like analgesics, stool softeners, laxatives and antacids.



Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease, Parkinson’s disease, glaucoma, lung disease and smoking-related diseases, cardiovascular, arthritis, diabetes, osteoporosis and the over-the-counter medications listed above.

Drug Coverage Restrictions Only covered medications

PROGRAM CONTACT

Susan Rohrer Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021




Illinois Senior Citizens and Disabled Persons Prescription Drug Discount

Program Program Type: Discount

Projected Operational Date: 2003 Projected Number of Recipients: not available


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): all ages Eligible Income Level (Single): all Eligible Income Level (Married): all Other Eligibility Notes: Circuitbreaker participants will be automatically enrolled


Funding Source: Not available Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available

Manufacturer Rebate Type: State negotiated Ingredient Cost Calculation: AWP – 12% for brand name drugs and newly released generics,

AWP – 35% for all other generics Enrollment Fee: $25 annually Deductible Amount: None Copayment Amount: Not available Dispensing Fee: $3.50 for brand name drugs and newly released generics, $4.25 for all

other generics Notes:

DRUGS COVERAGE

Formulary: Not available Drugs Covered: Not available Drug Coverage Restrictions: Not available

PROGRAM CONTACT



Indiana Indiana Prescription Drug Program, “HoosierRx”

Program Type: Point of Sale Year Operational: 2000



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 144% of FPL Eligible Income Level (Married): 135% of FPL Other Eligibility Notes: Must be an Indiana resident for at least 90 days in the past 12 months,

without prescription drug coverage through an insurance plan, Medicaid or Medicaid with a spend-down. Benefit is available for one year. Recipients must submit a new application to re-enroll.


Funding Source: Tobacco Settlement Fund Budget (FY 03): $20.8 million Cost per Participant (FY 02): $1,156.00 # of Rx’s Per Participant (FY 02): 10.0-15.0 (estimated)

Manufacturer Rebate Type: Currently only commercial rebates. Once CMS approves 1115 Pharmacy Plus Waiver, OBRA 90 rebates will be applied.

Ingredient Cost Calculation: AWP – 13.5% for brand name drugs, AWP – 20% for generics Enrollment Fee: None Deductible Amount: None Copayment Amount: 50% of HoosierRx negotiated price, up to the maximum benefit limit

($500.00, $750.00 or $1,000.00 per year, depending on income) Dispensing Fee: $4.90 Notes: Once maximum benefit limit is reached, recipients may continue to

receive the HoosierRx discounted rate during the rest of the enrollment year.

DRUGS COVERAGE

Formulary: None Drugs Covered: All legend drugs, as well as insulin Drug Coverage Restrictions: OTC drugs, fertility enhancement drugs and cosmetic drugs

PROGRAM CONTACT

Lola Sawyerr 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]



Iowa Iowa Priority Prescription Savings Program

Program Type: Negotiated Discount Year Operational: 2002

Number of Enrollees (December 2002): 25,000


Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes Eligible Income Level (Single): All income


levels Other Eligibility Notes: Open to all Medicare eligibles. Medicaid recipients are not eligible.


Funding Source: Federal grant Budget (FY 03): $1.2 million Cost per Enrollee: $48.00 # of Rx’s Per Enrollee (FY 02): 36.0 Manufacturer Rebate Type: A pharmacy benefit manager company negotiates discounted

prescription costs rather than setting mandatory price reductions. Ingredient Cost Calculation: AWP – 10% (in certain cases up to AWP – 20%) Enrollment Fee: $20.00 per year Deductible Amount: None Copayment Amount: None Dispensing Fee: $2.50 for brand name drugs and $3.25 for generics Notes: Discounts are available on participating manufacturers’ drugs (Bristol-

Myers Squibb, Merck and Schering-Plough).

DRUGS COVERAGE

Formulary: Preferred drug list Drugs Covered: Allergy (antihistamines, nasal steroids), cholesterol lowering agents,

dermatological products (topical steroids), hypertension/high blood pressure and cardiovascular (ACE inhibitors, alpha/beta blockers, angiotensin receptor blockers, potassium supplements, nitrates), diabetes (biguanides), arthritis and analgesia (COX-2 inhibitors), asthma (Beta-2 agonists, leukotiene blockers), enlarged prostate treatment, osteoporosis treatment, glaucoma

Drug Coverage Restrictions: 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]



Kansas Kansas Senior Pharmacy Assistance Program

Program Type: Reimbursement Year Operational: 2001

Number of Enrollees (September 2002): 1,286


Eligibility Age (Elderly): 67+ Eligibility Age (Disabled): 67+ Eligible Income Level (Single): 135% of FPL Eligible Income Level (Married): 135% of FPL Other Eligibility Notes: Must be a Kansas resident; not covered under a private prescription

reimbursement plan; not eligible for or enrolled in any other local, state, or Federal prescription program; not have voluntarily canceled a local, State, Federal, or private prescription drug program within six months of application to the program. Must be current recipient of benefits through the Qualified Medicare Beneficiary Program or Specified Low Income Medicare Beneficiary Program.


Funding Source: State General Revenue Fund Budget (FY 03): $1.2 million Cost per Enrollee (FY 02): $933.00 # of Rx’s Per Enrollee: Not Available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: 30% of pharmaceutical cost Dispensing Fee: None Notes: Maximum annual benefit is $1,200.00 per enrollee.

DRUGS COVERAGE

Formulary: None Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare, and

prescription drugs that treat chronic illness Drug Coverage Restrictions: Program does not cover over-the-counter and lifestyle drugs.

PROGRAM CONTACT

Gail Smith Department on Aging 503 S. Kansas Avenue Topeka, KS 66603-3404




Maine Maine Rx


Estimated Eligibles (FY 02): Approximately 325,000


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): All income


levels Other Eligibility Notes: All Maine residents who do not have third-party drug coverage are

eligible.


Funding Source: Not Available Budget: None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: N/A Enrollment Fee: None Deductible Amount: None Copayment Amount: Program combines discounts from participating pharmacies with

negotiated rebates from manufacturers Dispensing Fee: None

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All prescription drugs with manufacturer rebate agreements. Drug Coverage Restrictions: Drugs from manufacturers without rebate agreements are not covered.

PROGRAM CONTACT

Ed Bauer Department of Human Services 11 State House Station Augusta, ME 04333-0011


∗ On May 19, 2003, the U.S. Supreme Court ruled the Maine Rx Program could go into effect (see laws.findlaw.com/us/000/01-188.html for full text of ruling). At press time, however, it is anticipated that MaineRx will be abandoned and replaced by MaineRx Plus.



Maine Maine Rx Plus


Estimated Eligibles: Approximately 275,000


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): $31,400

(350% FPL) Eligible Income Level (Married): $42,420

(350% fPL) Other Eligibility Notes: Discounts would also be extended to families whose prescription drug

costs are at least 5% of their household income or whose medical expenses are at least 15% of their household income.


Funding Source: Not Available Budget: Not Available Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: N/A Enrollment Fee: None Deductible Amount: None Copayment Amount: Program combines discounts from participating pharmacies with

negotiated rebates from manufacturers Dispensing Fee: None

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All prescription drugs with manufacturer rebate agreements. Drug Coverage Restrictions: Drugs from manufacturers without rebate agreements are not covered.

PROGRAM CONTACT



∗ On May 19, 2003, the U.S. Supreme Court ruled the Maine Rx Program could go into effect (see laws.findlaw.com/us/000/01-188.html for full text of ruling). At press time, however, it is anticipated that MaineRx Plus will replace MaineRx.



Maine Healthy Maine Prescription Drug Program

Program Type: Subsidy and Discount (1115 Waiver)± Year Operational: 2001

Number of Recipients (September 2002): 115,000 (36,000 subsidy and 79,000 discount)


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL Other Eligibility Notes: All Maine residents with incomes up to 300% of FPL are eligible.

Individuals with full Maine Care benefits are not eligible. It is estimated that 225,000 residents are eligible for the Healthy Maine Program.


Funding Source: State appropriations and subsidies Budget: $20 million∗ Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP –13% Enrollment Fee: None Deductible Amount: None Copayment Amount: 84% of drug cost Dispensing Fee: $3.35

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All prescription drugs from manufacturers with Federal rebate

agreements. Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for generic

drugs. Some prescriptions require prior approval to assure quality, dose strength, and cost effectiveness.

PROGRAM CONTACT



± Discount program struck down by federal court 12/24/02 ∗ This budget is allocated for both Healthy Maine and the Maine Low Cost Drugs for the Elderly and Disabled Program (DEL).



Maine Low Cost Drugs for the Elderly and Disabled Program (DEL)∗∗∗∗

Program Type: Subsidy and Discount Year Operational: 2001



Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 19+ Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL Other Eligibility Notes: This program is made available to Maine residents fitting the age and

income eligibility criteria. Individuals with full Maine Care benefits are not eligible. Medicare recipients are not necessarily excluded.


Funding Source: State appropriations and subsidies Budget: $20 million∗∗ Cost per Participant (7/1/02- 12/11/02):

$400.00

# of Rx’s Per Participant (7/1/02- 12/11/02):

15.5

Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP –13% Enrollment Fee: None Deductible Amount: None Copayment Amount: Greater of $2.00 or 20% of the cost of generic drugs. Greater of $2.00

or 20% of the cost of prescriptions for select medical conditions. 84% of the cost of other covered prescriptions

Dispensing Fee: $3.35 Notes: A $1,000.00 catastrophic spending limit is one additional component

of this program where the State pays for 80% of the cost of additional prescriptions once a person exceeds this dollar limit.

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All prescription drugs from manufacturers with Federal rebate agreements. Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for generic drugs.

Some prescriptions require prior approval to assure quality, dose strength, and cost effectiveness.

∗ The Maine Low Cost Drugs for the Elderly Program is operated within the Healthy Maine Prescription Drug Program. ∗∗ This budget is allocated for both the Healthy Maine Prescription Drug Program and DEL.



PROGRAM CONTACT





Maryland Maryland Pharmacy Assistance Program


Projected Number of Recipients (FY 03): 47,700


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): $10,000∗ Eligible Income Level (Married): $10,850∗∗ Other Eligibility Notes: No age restrictions on eligibility. The following groups are ineligible

for participation: people detained in a correctional (Federal, State, local) system, Medicaid recipients, and non-residents. $4500 maximum assets.


Funding Source: State General Revenue Fund Budget (FY 03): $73.2 million Cost per Participant (FY 02): $1,534.00 # of Rx’s Per Participant (FY 02): 29.0 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: For brand name drugs, lower of AWP-10%, Wholesalers Acquisition

Cost (WAC) +10%, Direct Manufacturer’s Cost (DMC)+10%, or Direct Cost (DC)+10%. For generic drugs, lower of Estimated Acquisition Cost (EAC), State MAC, or Federal MAC.

Enrollment Fee: None Deductible Amount: None Copayment Amount: $5.00 per prescription Dispensing Fee: $4.21

DRUGS COVERAGE

Formulary: Closed formulary Drugs Covered: Specified categories of maintenance drugs used to treat chronic

conditions, anti-infective drugs, and insulin syringes and needles Drug Coverage Restrictions: Prior authorization for certain medications, including steroids and some

controlled substances. 75% utilization required for prescription refill.

PROGRAM CONTACT

Paul A. Roeger Division Chief, Office of Operations & Eligibility Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201


∗ Eligible income/asset scale for 1-person household. ∗∗ Eligible income/asset scale for 2-person household.



Maryland Short-Term Prescription Drug Subsidy Plan

Program Type: Direct Assistance Year Operational: 2001∗∗∗∗



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL Other Eligibility Notes: Program open to all Medicare recipients.


Funding Source: 37.5% of Substantial Availability and Affordability Coverage (SAAC) Differential, plus additional funding from MAMSI and Aetna.

Budget (FY 02): $18 million Cost per Participant (FY 02): $65.12 member/month # of Rx’s Per Participant (FY 02): 28.1 Manufacturer Rebate Type: Negotiated with individual drug companies Ingredient Cost Calculation: Negotiated with contracted pharmacies Enrollment Fee: $10 monthly premium Deductible Amount: None Copayment Amount: $10 for generics, $20 for branded products, $35 non-preferred brand Dispensing Fee: Varies between contracted pharmacy chains. Notes: Maximum benefit is $1,000 per enrollee per 12-month period.

Funding information for this program will change on April 1, 2003. The program will then receive funding through CareFirst alone. It is estimated that the budget will change at that time to $20 million.

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: Most generic and brand drugs approved by the Food and Drug

Administration (FDA) are included under this program. Drug Coverage Restrictions: Anorexants are excluded. Over the counter drugs are excluded.

Quantity limits on certain drugs such as Viagra, migraine medicines and Oxycontin. Prior authorizations on certain drugs such as growth hormones.

PROGRAM CONTACT

Robin Vahle Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201


∗ The program is ending June 30, 2003.



Maryland Maryland Pharmacy Discount Program

Program Type: Discount (1115 Waiver) Projected Operational Date: July 1, 2003 Projected Number of Recipients: 105,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes Eligible Income Level (Single): 175% of FPL Eligible Income Level (Married): 175% of FPL Other Eligibility Notes: Must be a Medicare recipient and a Maryland resident. Disabled are

eligible.


Funding Source: State General Revenue Fund and Federal matching funds Budget: Not Available Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Medicaid price less rebates Enrollment Fee: None Deductible Amount: None Copayment Amount: 65% of the Medicaid price Dispensing Fee: $1.00 per prescription

DRUGS COVERAGE

Formulary: Open Drugs Covered: Anything included under Medicaid Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Paul A. Roeger Division Chief Office of Operations & Eligibility Department of Health and Mental Hygiene 201 West Preston Street Baltimore, MD 21201




Massachusetts Prescription Advantage+


Number of Recipients (August 2002): 83,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): 188% of

FPL∗∗ Eligible Income Level (Married): 188% of

FPL** Other Eligibility Notes: Individuals receiving drug coverage from MassHealth or

CommonHealth are not eligible.


Funding Source: Tobacco Settlement Fund Budget (FY 03): $95.6 million Cost per Participant (FY 02): $90.44 per member per month # of Rx’s Per Participant (FY 02): No limit. Average is 2.7 per member per month. Manufacturer Rebate Type: Advance PCS negotiates price and rebates with drug manufacturers. Ingredient Cost Calculation: AWP-14% Enrollment Fee: Single: $0-$99 per month per enrollee, depending on income; Married: $0-

$74 per month per enrollee, depending on income Deductible Amount: $0-$500 annually, depending on income. Payments are accepted quarterly. Copayment Amount: 30-day prescriptions retail:

Generic-$6 or $10 Brand-Name-$16 or $28 Additional Brand-Name-the greater of 50% or $40. 90-day prescriptions mail: Generic-$12 or $20 Brand-Name-$32 or $56 Additional Brand-Name-the greater of 50% or $60.

Dispensing Fee: $2.40 per prescription Notes: 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 married members who are both enrolled in the plan; when not joining as a couple, a married member must pay the individual rate.

+ Program enrollment closed as of February 1, 2003, due to budget reductions. ∗ The first year of the plan was extended through June 30, 2002, and totaled 15 months in order to synchronize with the State’s fiscal year. ∗∗Upper Income eligibility levels apply only to disabled applicants under the age of 65.



DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All therapeutic classes, except those excluded from MassHealth.

Includes all FDA approved oral drugs as well as many injectable drugs, including insulin and disposable insulin syringes with needles.

Drug Coverage Restrictions: Some drugs require prior authorization.

PROGRAM CONTACT

David Morales Massachusetts Executive Office of Elder Affairs One Ashburton Place Boston, MA 02108

Phone: 617/727-7750 800/AGE-INFO 800/243-4636 Fax: 617/727-9368 [email protected]



Michigan Elder Prescription Insurance Coverage (EPIC) Program


Number of Enrollees (May 2003): 13,034


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes: 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 $17,910

(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. Additionally, the Appropriations Act for FY 02-03 provides authorization for the Department of Community Health to accept additional Federal revenues either as the result of the approval of a Pharmacy Plus waiver or Federal legislation providing pharmaceutical assistance to seniors.


Funding Source: State General Fund plus rebate revenue Budget (FY 01-02): $50 million. Budget for FY 2002-03 has not been determined as of

November 2002; it depends on whether a Pharmacy Plus waiver is sought.

Cost per Enrollee: Not Available # of Rx’s Per Enrollee: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Lesser of usual and customary charge, AWP – 15.1% or 13.5%

(depending on the pharmacy), or the State MAC price Enrollment Fee: $25.00 Deductible Amount: Based on the participant’s total annual household income. Maximum

annual amount is divided into twelfths so that a monthly amount must be met.



Copayment Amount: If a brand name drug is prescribed and dispensed when a generically equivalent drug is available, a $15.00 copayment in addition to the monthly out-of-pocket share is charged.


DRUGS COVERAGE

Formulary: Drugs not on the Michigan Pharmaceutical Products List (MPPL) may require prior authorization before they are paid for by EPIC. The use of generic drugs is encouraged.

Drugs Covered: Most prescription drugs plus insulin and syringes for diabetics, with some exceptions.

Drug Coverage Restrictions: The EPIC program does not cover the following types of drugs: products used for weight loss or weight gain; fertility or infertility drugs; drugs used to treat erectile dysfunction; drugs or products used for contraception; products used to promote hair growth or for other cosmetic purposes; drugs used to treat the skin aging process; smoking cessation products; cold and cough preparations; fluoride preparations; experimental and investigational drugs; 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.

PROGRAM CONTACT

Doris Gellert Department of Community Health 611 West Ottawa, P.O. Box 30676 Lansing, MI 48909-8176




Minnesota Prescription Drug Program∗∗∗∗


Number of Enrollees (November 2002): 6,180 (Elderly: 5,230; Disabled: 950)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64 Eligible Income Level (Single): 120% of FPL Eligible Income Level (Married): 120% of FPL Other Eligibility Notes: On July 1, 2002, the program expanded to include coverage for

persons on Medicare due to a disability. To be eligible, enrollees must:

• Be a Medicare enrollee, age 65 or older, or disabled; • Be a Minnesota resident for six months; • Have liquid assets (other than home, car, burial funds, etc.) Of

$10,000 or less for one person or $18,000 or less for a married couple;

• Not have eligibility 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 Specified Low-Income Medicare Beneficiary (SLMB).


Funding Source: State General Revenue Fund plus rebates Budget (FY 02-03): $5.4 million appropriated for FY 2002 and $8.5 million appropriated

for FY 2003 Cost per Enrollee (2002): $1,200.00 # of Rx’s Per Enrollee (2002): 31.0 Manufacturer Rebate Type: Same as Medicaid less any Consumer Price Index add-on Ingredient Cost Calculation: AWP – 9% Enrollment Fee: None Deductible Amount: $35.00 per month Copayment Amount: None Dispensing Fee: $3.65

DRUGS COVERAGE

Formulary: Closed formulary

∗ Formerly the Senior Citizen Drug Program.



Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs rebate agreement with Department of Human Services. Covers over-the-counter drugs for antacid, insulin products, smoking cessation products, lice medication and vitamins.

Drug Coverage Restrictions: Most other over-the-counter drugs are not covered.

PROGRAM CONTACT

Steve Hamilton Prescription Drug Program Rebate Analyst Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853




Missouri SeniorRx Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): $17,000 Eligible Income Level (Married): $23,000 Other Eligibility Notes: Applicant must be a Missouri resident and have lived in the State for

12 months by July 1, 2003. Applicants may not receive Medicaid or veterans pharmacy benefits or have prescription insurance that is equivalent to or greater than the Missouri SenioRx Program.


Funding Source: Funding comes from the Missouri SenioRx Fund, which consists of all rebates received through the program; funds that are appropriated to it by the general assembly; and funds from Federal or other sources.

Budget (FY 02-03): $35 million Cost Per Enrollee (FY 02): $1,178.00 # of Rx’s Per Enrollee: Not Available Manufacturer Rebate Type: 15% of AWP Ingredient Cost Calculation: AWP – 20% Enrollment Fee: $25.00 to $35.00, depending on income level Deductible Amount: $250.00 to $500.00, depending on income level Copayment Amount: 40% of prescription cost Dispensing Fee: $4.09 Notes: Maximum annual benefit of $5,000.00

DRUGS COVERAGE

Formulary: None Drugs Covered: Most prescription medications used for outpatient purposes;

Prescription insulin; prescription strength prenatal vitamins; fluoride preparations; prescription compounds; Drug Efficacy Study Implementation (DESI) drugs.

Drug Coverage Restrictions: The following drugs are not covered: drugs manufactured by companies that do not participate in the Missouri SenioRx rebate program; over-the-counter (OTC) products; drugs used for weight gain or anorexia; drugs used to promote fertility; cosmetic and hair growth agents; cough and cold preparations; prescription strength vitamins; barbiturates; benzodiazepines; insulin syringes and diabetic supplies; food supplements; and medical equipment, devices and supplies. Use of generics is encouraged.



Notes: An enrollee may receive a name-brand drug when a generic drug is available only if both the physician and enrollee request that the name-brand drug be dispensed and the enrollee covers the copayment for the generic drug plus the difference in cost between the name-brand drug and the generic drug. Discount cards cannot be used in conjunction with the program.

PROGRAM CONTACT

Jerry Simon Health and Senior Services Department P.O. Box 570 Jefferson City, MO 65102

Phone: 573/522-3066



Montana Prescription Drug Expansion Program

Program Type: Discount Projected Operational Date: 2004

Projected Number of Recipients: not available


Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): 200% FPL Eligible Income Level (Married): 200% FPL Other Eligibility Notes:


Funding Source: Discounts only through Medicaid Budget: Not available Cost per Enrollee: Not available # of Rx’s Per Enrollee: Not available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not available Deductible Amount: Not available Copayment Amount: Not available Dispensing Fee: Not available

DRUGS COVERAGE

Formulary: Not available Drugs Covered: Not available Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available



Nevada Senior Rx

Program Type: Subsidy Year Operational: 2001

Number of Recipients (November 2002): 7,500


Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): see notes Eligible Income Level (Married): see notes Other Eligibility Notes: Must be a Nevada resident for at least one year and not eligible for full

Medicaid benefits. Family income eligibility: $21,500


Funding Source: Tobacco Settlement Fund Budget (FY 02-03): $7.6 million Cost per Enrollee (FY 01-02): $1,023.00 # of Rx’s Per Enrollee (FY 01-02): 36.0 Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: None Deductible Amount: None Copayment Amount: $10.00 for generics; $25.00 for preferred drugs or medically necessary

brand name drugs; and provider’s discounted rate for all other drugs Dispensing Fee: Average of $2.25 Notes: Maximum benefit of $5,000.00 per year. An annual per enrollee

deductible of $100.00 is paid by the State to Pharmaceutical Care Network, the Pharmacy Benefit Manager that manages the program.

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: Most prescription drugs Drug Coverage Restrictions: 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




New Hampshire

Senior Prescription Drug Discount Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): All income


levels Other Eligibility Notes: Must be a New Hampshire resident.


Funding Source: Rebates and incentives from pharmaceutical manufacturers negotiated through National Prescription Administrators, a division of Express Scripts, which operates the program.

Budget: The State has not had to fund the program, since it is based on rebates and incentives

Cost Per Enrollee: There is no associated cost per enrollee. # of Rx’s Per Enrollee: Not Available Manufacturer Rebate Type: Rebates negotiated with manufacturer. Ingredient Cost Calculation: Not Available Deductible Amount: None Enrollment Fee: None Copayment Amount: Participant receives discount and must pay remainder of cost of

prescription. Dispensing Fee: None Notes: Discounts vary depending on pharmacy and medication. Discounts can

be up to 40% for generics and up to 15% for brand name products.

DRUGS COVERAGE

Formulary: No formulary Drugs Covered: All prescription drugs Drug Coverage Restrictions: Over-the-counter drugs are not covered

PROGRAM CONTACT

Kim Hadank Health And Human Services Division Of Elderly And Adult Svcs 129 Pleasant Street Concord, NH 03301

Phone: 603/271-7857



New Jersey Pharmaceutical Assistance to the Aged and Disabled (PAAD)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 21 Eligible Income Level (Single): $19,739 Eligible Income Level (Married): $24,203 Other Eligibility Notes: For calendar year 2003, eligible income levels for the program will

increase to $20,016 for single individuals and $24,524 for married individuals. Disabled individuals are only eligible if they receive Title II Social Security Disability benefits.


Funding Source: State General Fund and Casino Revenue Fund Budget (FY 03): $312.9 million Projected Cost per Participant (FY 03):

Senior: $2,200.00 Disabled: $4,200.00

Projected # of Rx’s Per Participant (FY 03):

Senior: 34.0 Disabled: 45.0

Manufacturer Rebate Type: Medicaid less Consumer Price Index Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: $5.00 per prescription Dispensing Fee: $3.73 to $4.07

DRUGS COVERAGE

Formulary: No formulary Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing

materials, 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. DESI drugs are not covered.

PROGRAM CONTACT

Jennifer Barron PAAD/Senior Gold Operations P.O. Box 715 Trenton, NJ 08625-0715




New Jersey Senior Gold Prescription Discount Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64 Eligible Income Level (Single): $29,739 Eligible Income Level (Married): $34,203 Other Eligibility Notes: For calendar year 2003, eligible income levels for the program will

increase to $30,016 for single individuals and $34,542 for married individuals. 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.


Funding Source: Tobacco Settlement Fund Budget (FY 03): $32.8 million Projected Cost Per Participant (FY 03):

Senior: $574.00 Disabled: $764.00

Projected # of Rx’s Per Participant (FY 03):

Senior: 21.0 Disabled: 26.0

Manufacturer Rebate Type: Medicaid less Consumer Price Index Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: $15.00 plus 50% of the remaining cost of the prescription or the actual

cost if less than $15.00. After unreimbursed out of pocket costs reach $2,000.00 for an individual, or $3,000.00 for a couple, copayments for additional prescriptions that year are $15.00.

Dispensing Fee: $3.73 to $4.07 Notes: Once an enrollee incurs in one year unreimbursed out-of-pocket costs

of $2,000.00, if single, or $3,000.00, if married, prescriptions may be obtained for the balance of that eligibility period for a flat $15.00 copayment or the actual price, if less than $15.00.

DRUGS COVERAGE

Formulary: No formulary Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing

materials, 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. DESI drugs are not covered.



PROGRAM CONTACT

Jennifer Barron PAAD/Senior Gold Operations P.O. Box 715 Trenton, NJ 08625-0715




New Mexico Senior Prescription Drug Program

Program Type: Discount Projected Operational Date: Unknown∗∗∗∗

Number of Recipients: N/A




levels Other Eligibility Notes: Must be a New Mexico resident and have no other prescription drug

benefit through private insurance or other government programs.


Funding Source: None Budget: None∗∗ Cost per Recipient: Not Available # of Rx’s Per Recipient: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not to exceed $60.00 per year Deductible Amount: None Copayment Amount: See notes Dispensing Fee: None Notes: Cost of prescription to recipient is contracted discounted price plus

dispensing fee.

DRUGS COVERAGE


PROGRAM CONTACT

Milton Sanchez Executive Director New Mexico Retiree Health Care Authority 810 West San Mateo, Suite D Santa Fe, NM 87505

Phone: 505/986-8556 Fax: 505/983-8667

∗ Because of difficulties in locating funding for the program, the projected operational date of the program is unknown. ∗∗ On December 4, 2002, the State Agency on Aging issued a statement committing $30,000 for fund administration costs.



New Mexico Prescription Drug Waiver Program

Program Type: Direct Assistance Projected Operational Date: Unknown

Number of Recipients: N/A


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not Available

Eligible Income Level (Single): 185% FPL Eligible Income Level (Married): 185% FPL Other Eligibility Notes:


Funding Source: Not Available Budget: Not Available Cost per Recipient: Not Available # of Rx’s Per Recipient: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: Not Available Copayment Amount: Not Available Dispensing Fee: Not Available Notes:

DRUGS COVERAGE


PROGRAM CONTACT

Milton Sanchez Executive Director New Mexico Retiree Health Care Authority 810 West San Mateo, Suite D Santa Fe, NM 87505

Phone: 505/986-8556 Fax: 505/983-8667



New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level, Fee Plan (Single):

$20,000 Eligible Income Level, Fee Plan (Married):

$26,000

Eligible Income Level, Deductible Plan (Single):

$20,001-$35,000

Eligible Income Level, Deductible Plan (Married):

$26,001-$50,000

Other Eligibility Notes: Medicaid enrollees are not eligible.


Funding Source: State General Fund Budget (FY 03-04): $610.0 million Cost per Participant (FY 02): $1,970.00 # of Rx’s Per Participant (FY 02): 36.0 Manufacturer Rebate Type: Full Medicaid rate (base rate plus Consumer Price Index penalty) Ingredient Cost Calculation: Federal upper limit, when available, on generics and AWP - 10% on

brands Enrollment Fee: $2.00 - $75.00 per quarter, based on income level Deductible Amount: $530.00 - $1,715.00 annually, based on income level Copayment Amount: $3.00 (prescription cost up to $15.00); $7.00 (prescription cost from

$15.01 to $35.00); $15.00 (prescription cost from $35.01 to $55.00); and $20.00 (prescription cost over $55.00)

Dispensing Fee: $4.50 for generics and $3.50 for brand-name drugs

DRUGS COVERAGE

Formulary: None Drugs Covered: All legend drugs, insulin and insulin syringes and needles Drug Coverage Restrictions: DESI drugs and non-participating manufacturers excluded.

PROGRAM CONTACT

Julie A. Naglieri Acting Director NYS EPIC Program 1 Corporate Plaza 260 Washington Avenue Ext. Albany, NY 12203




North Carolina Prescription Drug Assistance Program


Number of Recipients (FY 2002): 1,800∗∗∗∗∗∗∗∗


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% FPL Other Eligibility Notes: Individuals must have cardiovascular disease and/or diabetes


Funding Source: State General Revenue Fund Budget (FY 03): Approximately $900,000 Cost per Participant (FY 02): Approximately $2,476.00 # of Rx’s Per Participant (FY 02): Approximately 26.0 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: $6.00 Dispensing Fee: $5.60 (40 cents retained by claims processor)

DRUGS COVERAGE

Formulary: Limited formulary (category based) Drugs Covered: All drugs used to treat cardiovascular disease and/or diabetes Drug Coverage Restrictions: Program will not pay for over-the-counter drugs, potassium

supplements, or cholesterol lowering drugs. Notes: Prescriptions may be issued for up to a 100-day supply.

PROGRAM CONTACT

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

Phone: 919/733-2040

∗ This program will be ending on June 2, 2003. Enrollees will be eligible for Senior Care ∗∗ Enrollment was closed on March 1, 2002 due to budget limitations.



North Carolina Senior Care∗∗∗∗

Program Type: Direct Assistance Year Operational: 2002∗∗∗∗∗∗∗∗

Number of Recipients: 4,000∗∗∗∗∗∗∗∗∗∗∗∗


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes: Individuals must be diagnosed with cardiovascular disease, chronic

obstructive pulmonary disease and/or diabetes, and must not be eligible for Medicaid benefits or have other coverage for drugs covered by Senior Care.


Funding Source: North Carolina Health and Wellness Trust Fund Budget (FY 03): $32 million Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: $6.00 Dispensing Fee: $5.60 (40 cents retained by claims processor) Notes: Maximum annual prescription benefit of $600.00. Senior Care pays for 60%

of the first $1,000.00 of prescription costs, and members pay the remaining 40%.

DRUGS COVERAGE

Formulary: Limited formulary (category based) Drugs Covered: All drugs used to treat cardiovascular disease and/or diabetes Drug Coverage Restrictions: This program will not pay for over-the-counter drugs or potassium

supplements.

PROGRAM CONTACT

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

Phone: 919/733-2040

∗ Previously referred to as Carolina CaRxes in State legislation. ∗∗ Program benefits began on November 1, 2002. This program replaces the pilot program, North Carolina’s Prescription Drug Assistance Program. ∗∗∗ Full enrollment is expected to be approximately 100,000.



Ohio Golden Buckeye Prescription Drug Program

Program Type: Negotiated Discounts Projected Operational Date: 2003 Estimated Eligibles: up to 500,000


Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): no age limit Eligible Income Level (Single): All income


levels Other Eligibility Notes: Must be an Ohio resident.


Funding Source: Manufacturer negotiated rebates, 50% of which go to a PBM for running the program.

Budget: None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers Ingredient Cost Calculation: For drugs purchased in a pharmacy, AWP – 13% for brand names and

AWP – 20% for generics. For drugs purchased via mail order, AWP – 17% for brand names and AWP – 40% for generics.

Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $3.50

DRUGS COVERAGE

Formulary: None Drugs Covered: Drugs for which the PBM has negotiated rebates with manufacturers. Drug Coverage Restrictions: None

PROGRAM CONTACT

Gary Panek Manager of Golden Buckeye Program Department of Aging 50 W. Broad Street, 9th Floor Columbus, OH 43215




Oregon Senior Prescription Drug Assistance Program

Program Type: Discount Projected Operational Date: not available*

Projected Number of Recipients: up to 100,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL Other Eligibility Notes: Individuals must not be covered under any public or private

prescription drug benefit program for the previous six months and must have less than $2,000.00 in liquid resources. Enrollees are issued enrollment cards that entitle them to Medicaid prices.


Funding Source: Enrollment fees Budget: N/A Cost per Participant: N/A # of Rx’s Per Participant: N/A Manufacturer Rebate Type: N/A Ingredient Cost Calculation: AWP – 14% Enrollment Fee: $50.00 annually Deductible Amount: None Copayment Amount: None Dispensing Fee: May not exceed Medicaid dispensing fee. Pharmacies designated

“critical access” may charge an additional $2.00 dispensing fee. Notes : The law authorizing the program allows for coverage up to 50% of

pharmaceutical cost, with a maximum annual benefit of $2,000.00. However, because the program was not funded in FY 02 or FY 03, the program will operate as a discount program. The program will operate as a direct assistance program when funding is available.

DRUGS COVERAGE

Formulary: None Drugs Covered: All legend drugs.

PROGRAM CONTACT

Sandy Wood, Program Manager Office of Medical Assistance Programs 500 Summer St. NE Salem, OR 97301-107

Phone: 503/945-6530 Email: [email protected]

* Postponed due to lack of funds.



Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE)

Type of Program: Direct Assistance Year Operational: 1984



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): $14,000 Eligible Income Level (Married): $17,200 Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the

date of application.


Funding Source: State Lottery, Tobacco Settlement Fund Budget (FY 03-04): $507 million Cost per Participant (FY 02-03): $2,144.00 # of Rx’s Per Participant (FY 02-03): Approximately 4.0-5.0 per month Manufacturer Rebate Type: Flat 17% of AMP plus inflation penalty indexation Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary Enrollment Fee: None Deductible Amount: None Copayment Amount: $6.00 Dispensing Fee: $3.50 on AWP-reimbursed claims Notes: A penalty rebate is applied if year-to-year price inflation exceeds

Consumer Price Index

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,

drugs for baldness and wrinkles, over-the-counter drugs, or most off-label uses. Mandatory generic substitution for A-rated (therapeutically equivalent) products. DESI drugs require documentation of medical necessity.

PROGRAM CONTACT

Thomas Snedden Director, PACE Program PA Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919




Pennsylvania PACE Needs Enhancement Tier (PACENET)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): $14,000 -

$17,000 Eligible Income Level (Married): $17,200 -

$20,200 Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the date

of application


Funding Source: State Lottery, Tobacco Settlement Funds Budget (FY 03-04): $507 million Cost per Participant (FY 02): $1,412.00 # of Rx’s Per Participant (FY 02): Approximately 4.0-5.0 per month Manufacturer Rebate Type: Flat 17% of AMP plus inflation penalty indexation Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary Enrollment Fee: None Deductible Amount: $500.00 per year Copayment Amount: $15.00 for brand name drugs and $8.00 for generics Dispensing Fee: $3.50 on AWP-reimbursed claims Notes: A penalty rebate is applied if year-to-year price inflation exceeds

Consumer Price Index

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,

drugs for baldness and wrinkles, over-the-counter drugs, or most off-label uses. Mandatory generic substitution for A-rated (therapeutically equivalent) products. DESI drugs require documentation of medical necessity.

PROGRAM CONTACT

Thomas Snedden Director, PACE Program PA Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919




Rhode Island Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE)

Program Type: Direct Assistance, Discount Year Operational: 1985

Number of Enrollees (July 2002): 39,568


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65 Eligible Income Level (Single): 420% of FPL Eligible Income Level (Married): 420% of FPL Other Eligibility Notes: Income levels exclude income spent on medical expenses if greater

than 3% of total income. Eligible social security disability recipients between the ages of 55-65 may receive the program’s discount price or the Federal MAC price for their prescriptions, whichever is lower; they do not receive a subsidy.


Funding Source: State General Revenue Fund and manufacturer rebates Budget (FY 03): $12.6 million Cost per Enrollee (FY 02): $290.00 # of Rx’s Per Enrollee (FY 02): 13.5 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 13% Enrollment Fee: None Deductible Amount: None Copayment Amount: Copayment covers 40%, 70%, or 85% of prescription cost depending

on income. 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.


DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and

chronic respiratory conditions, cancer, circulatory insufficiency, depression, diabetes (including insulin syringes), heart problems, high cholesterol, hypertension, Parkinson’s disease, glaucoma, prescription mineral and vitamin supplements for renal patients, urinary incontinence, and osteoporosis

Drug Coverage Restrictions: Non-cosmetic Food and Drug Administration approved drugs that were not previously listed are covered at the program’s discount price or at the Federal MAC price, whichever is lower.



PROGRAM CONTACT

Dennis Costa Rhode Island Dept. Of Elderly Affairs Benjamin Rush Building #55 35 Howard Avenue Cranston, RI 02920




South Carolina SilveRxCard Senior Prescription Drug Program

Program Type: Direct Assistance (1115 waiver)∗∗∗∗ Year Operational: 2003



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL Other Eligibility Notes: Must be a South Carolina resident. Must be ineligible for Medicaid

with no prescription benefits from any other source.


Funding Source: Tobacco Settlement Fund and Federal matching funds Budget (FY 03): $81.0 million Cost per Enrollee (FY 02): $500.00 # of Rx’s Per Enrollee (FY 02): 54.0 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: $500.00 per calendar year Copayment Amount: Members receive a small discount, up to 10%, on prescriptions while

meeting the deductible. After the $500.00 deductible is met, the copayment is $10.00 for generic drugs, $15.00 for brand name drugs, and $21.00 for drugs requiring prior authorization.


DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: Same as Medicaid Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Ray Sharpe SilverRxCard Manager Office of Insurance Services 1201 Main Street, Suite 350 Columbia, SC 29201


∗ The SilveRxCard program previously operated as a non-CMS waiver program funded only by State revenue. The waiver program begins on January 1, 2003.



South Dakota Senior Citizen Prescription Drug Benefit Program

Program Type: Discount Year Operational: Not Yet Operational

Number of Enrollees: Not Available


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): no age limit Eligible Income Level (Single): no limit Eligible Income Level (Married): no limit Other Eligibility Notes:


Funding Source: Not Available Budget (FY 03): Not Available Cost per Enrollee (FY 02): Not Available # of Rx’s Per Enrollee (FY 02): Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: Not Available Copayment Amount: Not Available Dispensing Fee: Not Available

DRUGS COVERAGE


PROGRAM CONTACT

Not Available



Texas State Prescription Drug Program

Program Type: State-Subsidy Law Enacted: 2001∗∗∗∗

Estimated Eligibles: N/A


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL Other Eligibility Notes: Upper income limits may increase if funding becomes available.

However, the categories most likely to receive qualify for the program at proposed FY 04-05 funding levels are Qualified Medicare Beneficiaries (QMBS) and Specified Low-Income Medicare Beneficiaries (SLMBS).


Funding Source: State General Revenue Fund, unless funds are available under Federal law to fund all or part of the program

Budget (FY 02-03): None Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: Not Available Deductible Amount: Not Available Copayment Amount: Not Available Dispensing Fee: Not Available Notes: According to statute, the Health and Human Services Commission

may require a cost-sharing payment.

DRUGS COVERAGE

Formulary: Not Available

Drugs Covered: Not Available

Drug Coverage Restrictions: Not Available

∗ Since implementation of this program is contingent on funding availability, and no funding was forthcoming in FY 2002-03, no action has been taken to implement the program. The Texas Health and Human Resources Commission is seeking an appropriation of $35 million in the FY 2003-04 budget.



Notes: The Health and Human Services Commission may require that, unless the practitioner’s signature on a prescription clearly indicates that the prescription must be dispensed as written, the pharmacist may select a generic equivalent of the prescribed drugs. The Health and Human Resources Commission is also authorized to establish a formulary, prior authorization requirements, and a drug utilization program.

PROGRAM CONTACT

Charles Stewart Health and Human Services Commission P.O. Box 13247 Austin, TX 787111-3247

Phone: 512/424-6514



Vermont VSCRIPT

Program Type: Direct Assistance (1115 Waiver) Year Operational: 1989∗∗∗∗

Number of Recipients (October 2002): 3,032


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages Eligible Income Level (Single): 150% - 175%

of FPL Eligible Income Level (Married): 150% - 175%

of FPL


Funding Source: State General Fund Budget (FY 03): $5.1 million Cost per Participant (FY 02): $1,603.00 # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: None Deductible Amount: None Copayment Amount: $5.00 for generic drugs, $10.00 for brand-name drugs. Once a

maximum of $100.00 in copayments is reached in a calendar quarter, no further copayments are required for the rest of the quarter.


DRUGS COVERAGE

Formulary: Preferred Drug List Drugs Covered: Maintenance drugs covered by Medicaid. Drug Coverage Restrictions: No experimental or over-the-counter drugs.

PROGRAM CONTACT

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


∗ This program was integrated into the VHAP (1115 waiver) program in 1999.



Vermont VSCRIPT Expanded


Number of Recipients: 3,200


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages Eligible Income Level (Single): 175% - 225%

of FPL Eligible Income Level (Married): 175% - 225%

of FPL


Funding Source: State General Fund Budget (FY 03): $2.0 million Cost per Participant (FY 02): $530.00 # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: None Deductible Amount: $275.00 per year Copayment Amount: The coinsurance rate for maintenance prescriptions is 41%. Once the

maximum annual coinsurance contribution of $2,500.00 is reached, there is no charge for rest of the year. (July 1-June 30)


DRUGS COVERAGE

Formulary: Preferred Drug List Drugs Covered: Medicaid covered maintenance drugs Drug Coverage Restrictions: No experimental or over-the-counter drugs Notes: Same coverage as V-SCRIPT basic program

PROGRAM CONTACT





Vermont Vermont Health Access Plan (VHAP)

Program Type: Direct Assistance (1115 Waiver) Year Operational: 1996



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPL Other Eligibility Notes: This program is for individuals not eligible for Medicaid.


Funding Source: State Revenue Fund Budget (FY 03): $16.3 million Cost per Participant (FY 02): $1,752.00 # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: None Deductible Amount: None Copayment Amount: $3.00 copayment for generic drugs; $6.00 copayment for brand-name

drugs. Once a maximum of $50.00 in copayments is reached in a calendar quarter, no further copayments are required for the rest of the quarter.


DRUGS COVERAGE

Formulary: Preferred Drug List Drugs Covered: All drugs covered by Vermont Medicaid, including insulin and insulin

syringes, and eyeglasses and the services to obtain them Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT





Vermont

Healthy Vermonters Program* Program Type: Direct Assistance (1115 Waiver)

Year Operational: 2002 Number of Recipients (November 2002): 7,140

(Healthy Vermonters: 440; VSCRIPT, VSCRIPT Expanded participants: 6,700)


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages Eligible Income Level (Single): 400% of FPL Eligible Income Level (Married): 400% of FPL Other Eligibility Notes: Vermont residents of any age who have an income 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. VSCRIPT and VSCRIPT Expanded beneficiaries will be automatically enrolled and have the advantage of Healthy Vermonters benefits for prescriptions not covered under the VSCRIPT programs.


Funding Source: State Revenue Fund Budget (FY 03): $200,000 Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: None Deductible Amount: None Copayment Amount: See note below Dispensing fee: $4.25 Note: Participant pays the Medicaid rate for drugs.

DRUGS COVERAGE

Formulary: Medicaid Formulary Drugs Covered: Maintenance drugs covered by Medicaid Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Jackie Levine Department of PATH 103 South Main Street Waterbury, CT 05676


* The Healthy Maine program, which allowed seniors to purchase prescriptions through a Medicaid waiver, was halted by a U.S. Court of Appeals ruling on December 24, 2002. The Healthy Vermonters Program may be affected by this ruling. Currently, participants receive the Medicaid rate for prescription drugs, with no additional discounts. Additional discounts were planned based on manufacturers’ rebates and the State’s contribution.



West Virginia Gold Mountaineer Discount Card Program


Number of Recipients (October 2002): 17,061




levels Other Eligibility Notes: Must be a resident of West Virginia.


Funding Source: Lottery funds and State General Fund Budget (FY 03): $12,420 Cost per Participant (2002): $0.69 # of Rx’s Per Participant (2002): 35.00 Manufacturer Rebate Type: Rebates negotiated by PBM with individual manufacturers Ingredient Cost Calculation: AWP – 13% for brand name drugs and generics and AWP – 60% for

MAC drugs. Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $3.50 Notes: Enrollees will receive discounts set by PBM.

DRUGS COVERAGE

Formulary: None Drugs Covered: All FDA Federal legend pharmaceuticals and diabetic supplies Drug Coverage Restrictions: None

PROGRAM CONTACT

Kim Fetty Bureau of Senior Services Holly Grove, Building No. 10 Charleston, WV 25305-0160 Lansing, MI 48909-8176

Phone: 304/558-3317



Wisconsin Wisconsin SeniorCare Prescription Drug Assistance Program


Estimated Enrollment (December 2002): 73,000


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): 240% of FPL Eligible Income Level (Married): 240% of FPL Other Eligibility Notes: Person must not be a recipient of medical assistance and must be a

resident of the State. Wisconsin residents with incomes exceeding 240% of FPL may participate by “spending down” to 240% of FPL level.


Funding Source: State funded, unless funds are available under Federal law to fund all or part of the program

Budget (FY 02-03): $49.9 million Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Not Available Enrollment Fee: $20.00 Deductible Amount: $500.00 (unless household income is less than 160% of FPL, in which

case no deductible is required) Copayment Amount: $5.00 for generic drugs, $15.00 for name-brand drugs Dispensing Fee: Not Available

DRUGS COVERAGE

Formulary: None Drugs Covered: Most prescription drugs Drug Coverage Restrictions: The program does not cover: prescription drugs administered in a

physician’s office; drugs that are experimental or have a cosmetic, not a medical, purpose; over-the-counter drugs such as vitamins and aspirin, even if prescribed, except for insulin; prescription drugs for which prior authorizations has been denied. If a drug is available in generic form, the brand-name form is covered only when medically necessary. Reimbursement for most drugs is limited to a 34-day supply. Some maintenance drugs may be provided in a 100-day supply.



PROGRAM CONTACT

Roma Rowlands Division of Health Care Financing 1 West Wilson Street P.O. Box 309 Madison, WI 53701-3380




Wyoming Prescription Drug Assistance Program




Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL Other Eligible Groups: Medicaid enrollees are not eligible. No more than $1000 in resources,

home and one car exempt.


Funding Source: General Revenue Fund Budget (FY 03-04): $2.1 million Cost per Participant (FY 02): $1,611.96 # of Rx’s Per Participant (FY 02): 23.0 Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: AWP – 4% Enrollment Fee: None Deductible Amount: None Copayment Amount: $10.00 for generics and $25.00 for brand-name drugs Dispensing Fee: None Notes: Maximum 3 prescriptions per month and oxygen services if needed

DRUGS COVERAGE

Formulary: Open formulary Drugs Covered: Any FDA approved prescription medications Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant

products, or fertility promotion agents. One month supply restriction.

PROGRAM CONTACT

Roxanne Homar, R.Ph. Community and Family Health Division Hathaway Bldg, Rm 157 2300 Capitol Ave. Cheyenne, WY 82002


∗ Absorbed the Minimum Medical Program.




National Pharmaceutical Council Alabama-1

ALABAMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN) Other

Aged Blind/ Disabled

Child Adult Aged Blind/ Disabled

Child Adult SFO

Prescribed Drugs � � � �

Inpatient Hospital Care � � � �

Outpatient Hospital Care � � � �

Laboratory & X-ray Service � � � �

Nursing Facility Services � � � �

Physician Services � � � �

Dental Services � � � �

B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expended Recipients TOTAL $331,574,388 438,529 $385,168,230 465,236 RECEIVING CASH ASSISTANCE TOTAL $244,874,432 209,643 Aged $36,886,212 28,320 Blind/Disabled $194,628,187 122,355 Child $6,923,518 43,011 Adult $6,436,515 15,957 MEDICALLY NEEDY, TOTAL $0 0 Aged $0 0 Blind/Disabled $0 0 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $33,759,075 189,144 Aged $740,219 829 Blind/Disabled $703,166 808 Child $30,621,597 172,402 Adult $1,694,093 15,105 Total Other Expenditures/Recipients* $52,940,881 39,742

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2000 and Alabama Medicaid Statistical Information System, FY 2001.

Note: Alabama estimates 2002 drug expenditures to be approximately $451 million and the number of Medicaid drug recipients to be 505,000.


2-Alabama National Pharmaceutical Council

C. ADMINISTRATION

Alabama Medicaid Agency.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin, disposable needles used for insulin; and syringe combinations for insulin (considered OTC). Products covered as DME: blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for: Retin A, Accutane, Dipyridamole. Products not covered: cosmetics; fertility drugs and experimental drugs. Over-the-Counter Product Coverage: Products covered if prescribed by a physician: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; prenatal vitamins; hemorrhoidal products. Partial coverage for: topical products. Products not covered: smoking deterrent products and feminine products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anoretics; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic) and thyroid agents. Partial coverage for: anti-psychotics; prescribed cold medications; and contraceptives. Prior authorization required for: analgesics, antipyretics, and (brand name) NSAIDs; antihistamine drugs (adult only); ENT anti-inflammatory agents; growth hormones; and nutritional supplements. Therapeutic categories not covered: prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable as part of the EPSDT service and the Vaccines for Children Program. Adult vaccines are available through the Health Department. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization

Formulary: Open formulary.

Prior Authorization: State currently has a formal prior authorization procedure. Review by Medicaid’s Medical

Director required for appeal of prior authorization decisions.

Prescribing or Dispensing Limitations

Prescription Refill Limit: 30 day supply, maximum of five refills.


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


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.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires “Dispense as Written” and “Brand Medically Necessary.”

Incentive Fee: None.

Patient Cost Sharing: Variable copayment.

Drug Ingredient Cost Copayment $0.00 to $10.00 $0.50

$10.01 to $25.00 $1.00 $25.01 to $50.00 $2.00 $50.01 or more $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: Clozaril care management fee of $3.00.

E. USE OF MANAGED CARE

Does not use MCOs to deliver services to Medicaid recipients.



F. STATE CONTACTS State Drug Program Administrator Louise F. Jones Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5039 F: 334/353-7014 E-mail: [email protected] Internet Address: www.medicaid.state.al.us

Prior Authorization Contact Louise F. Jones, 334/242-5039

DUR Contact Louise Jones, 334/242-5039

Medicaid DUR Board John Searcy, M.D. Medical Director Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36130 334/242-5619 Jimmy Jackson, R.Ph. 1874 Cherokee Road Alexander City, AL 35010 256/234-2538 Johnny Brooklere, R.Ph. 3600 Main Street Adamsville, AL 35005 205/674-1400 John E. Brandon, M.D. Intersection Highway 82 and 86 P.O. Box 390 Gordo, AL 35466 205/364-7135 Kathy B. Portner, M.D. 251 Cox Street Suite 100 Mobile, AL 36604 251/415-1566 Richard Freeman, M.D. 411 B Opelika Road Auburn, AL 36830 334/821-4766

Roger Lander, Pharm.D. (Vice-chair) School of Pharmacy Samford University 800 Lakeshore Drive Birmingham, AL 35229 205/726-2102 Frank Skinner, R.Ph. 90 County Road 1310 Vinemont, AL 35179 256/734-4933 W. Thomas Geary, Jr., M.D. (Chair) 2801-B Zelda Road Montgomery, AL 36106 334/395-5372 Steven Rostand, M.D. University of Alabama Birmingham Division of Nephrology 2RB 606 1530 3rd Avenue South Birmingham, AL 35294 205/934-2646 Margaret Thrower, Pharm.D. Auburn University 105 Walker Building Auburn University, AL 36849 334/844-8287 Rob Colburn, R.Ph. 909 McFarland Boulevard Northport, AL 35476 205/339-5800 Jefferson Underwood, III, M.D. 2171 Normandie Drive Montgomery, AL 36111 334/288-7531

Prescription Price Updating Beverly R. Churchwell, Administrator Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5424 T: 334/242-5034 F: 334/353-7014 E-mail: [email protected]



Medicaid Drug Rebate Contacts Gladys Gray, Associate Director Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery AL 36103-5624 T: 334/242-2327 F: 334/353-7014 E-mail: [email protected]

Claims Submission Contact Keith Hollis Account Manager, EDS 301 Technacenter Dr. Montgomery, AL 36117 334/215-0111

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

Physician-Administered Drug Program Contact Mary G. McIntyre, M.D. 334/242-5574

Alabama Medicaid Agency Officials Mike Lewis Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5600 F: 334/242-0556 E-mail: [email protected] 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 Alabama State Government Representatives Dr. Milissa Mauser-Galvin Executive Director, Department of Senior Services P.O. Box 301851 Montgomery, AL 36130-1851 334/242-5743 Bill Fuller, Commissioner Alabama Department of Human Resources 50 Ripley Street, 2nd Floor Montgomery, AL 36130 334/242-1160 Kathy Sawyer, Commissioner Alabama Department of Health and Mental Retardation P.O. Box 301410 Montgomery, AL 36130-1410 334/242-3107 Donald Williamson, M.D. State Health Officer P.O. Box 303017 Montgomery, AL 36130-3017 334/206-5200 Steve Shivers Alabama Department of Rehabilitation Services 2129 East South Boulevard Montgomery, AL 36116-2455 334/281-8780 Medical Association of State of Alabama Marsha D. Raulerson, M.D. 1205 Belleville Avenue Brewton, AL 36426-1304 251/867-3609 Wilburn Smith, Jr., M.D. 2023 Normandie Drive Montgomery, AL 36111 334/281-2633 Cary J. Kuhlmann, Executive Director Medical Association of the State of Alabama P.O. Box 1900-C Montgomery, AL 36104 334/263-6441 Alabama Nursing Home Association Mr. Louis E. Cottrell, Jr., Executive Director 4156 Carmichael Road Montgomery, AL 36106



334/271-6214 Alabama State Medical Association Roosevelt McCorvey, M.D. 3088 Rosa L. Parks Avenue Montgomery, AL 36105 334/262-0259 J.A. Powell, M.D. 2212 Mallard Lane SE Decatur, AL 35602 256/340-1068 Alabama Chap. Am. Academy of Family Physicians Holly Midgley, Executive Vice President P.O. Box 1900 19 South Jackson Street Montgomery, AL 36102-1900 334/263-6441 Alabama Pharmacy Association William S. Eley, II, Executive Director 1211 Carmichael Road Montgomery, AL 36106 334/271-4222 Page Dunlap P.O. Box 354 Hartselle, AL 35640 256/773-5421 Alabama Chap. American Academy of Pediatrics Karin Scott, Executive Director 735 Montgomery Highway, Suite 323 Birmingham, AL 35216 205/824-0888 Alabama Dietetic Association Gayle Mask Alabama Department of Public Health RSA Tower, Suite 1300 P.O. Box 303017 Montgomery, AL 36130-3017 334/206-2922 Alabama Hospital Association J. Michael Horsley, President East Station P.O. Box 210759 Montgomery, AL 36121 334/272-8781 Jody Pigg, CEO Baptist Health Services P.O. Box 11010 Montgomery, AL 36111-0010

334/273-4404 Alabama Optometric Association Amanda Jones, Executive Director 400 South Union Street, Suite 435 Montgomery, AL 36104 334/834-1057 Alabama Association of Home Health Agencies Melane Golson Office of Executive Director P.O. Box 40 Montgomery, AL 36101 334/395-9949 Alabama Primary Health Care Association Al Fox, Executive Director 6008 East Shirley Lane, Suite A Montgomery, AL 36117 334/271-7068 Alabama Academy of Ophthalmology Leigh Jones P.O. Box 11455 Montgomery, AL 36111-0455 334/269-9900 Assisted Living Association of Alabama Frank Holden, President 400 S. Union Street, Suite 235 Montgomery, AL 36104 334/262-5523 Alabama Hospice Organization David Stone, Executive Director P.O. Box 1835 Calera, AL 35040 205/668-0460 Alabama State Nurses Association Karen Pakkala, Executive Director 360 North Hill Street Montgomery, AL 36104-3658 334/262-8321 Consumer Representatives Lawrence F. Gardella Senior Staff Attorney Montgomery Regional Office Legal Services Corporation of Alabama 600 Bell Building, 207 Montgomery Street Montgomery, AL 36104 334/832-4570 Bill Chandler General Director Montgomery YMCAs P.O. Box 2336



Montgomery, AL 36102-2336 334/269-4362

Teresa Easterling 325 Spigener Road Titus, AL 36080 334/567-5020 Linda McWilliams Top of Alabama Regional Council of Governments (TARCOG) 115 Washington Street, SE Huntsville, AL 35801 205/533-3330 Rogene W. Parris 2061 Fire Pink Court Birmingham, AL 35244 205/987-0338 Louise Pittman 3355 Lexington Road Montgomery, AL 36106 334/264-8780

Pharmacy and Therapeutics Committee A. Z. Holloway, M.D. 2611 Woodley Park Drive Montgomery, AL 36116 334/288-0009 Richard Freeman, M.D. 411 B Opelika Road Auburn, AL 36830 334/821-4766 Ben Main, R.Ph. 302 North Prairie Street Union Springs, AL 36089 334/738-2020 Gary Magouirk, M.D. 110 23rd Street NW Fayette, AL 35555 205/932-3891 Ray Thweatt, M.D. University of Alabama Birmingham 433 CPM 1713 6th Avenue South Birmingham, AL 35294-0018 205/934-6737

Jefferson Underwood, III, M.D. (Chair) 2171 Normandie Drive Montgomery, AL 36111 334/288-7531 W. Thomas Geary, Jr., M.D. 2801-B Zelda Road Montgomery, AL 36111-1103 334/395-5372 Rob Colburn, R.Ph. 909 McFarland Blvd. Northport, AL 35476 205/339-5800 John Searcy, M.D. Medical Director Alabama Medicaid Agency 501 Dexter Avenue Montgomery, AL 36104 334/242-5619 Dane Yarbrough, R.Ph. 8750 Ashford Circle Tuscaloosa, AL 35406 205/391-3636

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 of Treasure P.O. Box 1857 U.S. Highway 43 Winfield, AL 35594 T: 205/487-7556 F: 205/487-7559 Internet Address: www.aloma.org Alabama State Medical Association Joel Powell, M.D., President 1408 5th Avenue, SE Suite 1 Decatur, AL 35601 T: 256/340-9445 F: 256/350-0499 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 State Board of Pharmacy Jerry Moore Executive Director 1 Perimeter Park South, Suite 425 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 Michael Horsley President 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




National Pharmaceutical Council Alaska-1

ALASKA





Child Adult

SFO








B. DRUG PAYMENTS AND RECIPIENTS 2000 2001** Expended Recipients Expended Recipients TOTAL $51,196,685 60,273 $64,923,574 65,278 RECEIVING CASH ASSISTANCE TOTAL $42,312,292 33,977 $52,946,651 33,640 Aged $7,815,093 4,574 $9,954,837 4,747 Blind/Disabled $26,292,009 8,385 $33,634,846 8,964 Child $1,717,322 10,368 $1,778,759 9,519 Adult $6,487,868 10,650 $7,578,209 10,410 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $3,540,104 20,691 $5,303,090 25,775 Aged $3,280 5 $6,244 8 Blind/Disabled $411 1 $368 2 Child $2,935,102 16,590 $4,319,775 20,919 Adult $601,311 4,095 $976,703 4,846 TOTAL OTHER EXPENDITURES/RECIPTENTS* $5,344,289 5,605 $6,673,833 5,863

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change.

Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Alaska National Pharmaceutical Council

C. ADMINISTRATION

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

D. PROVISIONS RELATING TO DRUGS Benefit Design

Drug Benefit Product Coverage: Products covered: cosmetics (covered with restrictions); prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parental nutrition. Prior authorization required for: Clorazil; Lupron Depot; ADC infant vitamins; some DME; Synagis; Pauretin; and Actig Naltrexone. Products not covered: fertility drugs; experimental drugs; and intedialytic parenteral nutrition.

Over-the Counter Product Coverage: Products covered with restrictions: topical products (vasatrace ointment). Products not covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations, digestive products; feminine products; and smoke deterrent products.

Therapeutic Category Coverage: Categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; miscellaneous GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: anoretics; prescribed cold medications. Prior authorization required for: analgesics, antipyretics, and NSAIDs; growth hormones. Categories not covered: 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 and through physician payment when used in physician offices. No information provided on reimbursement for non-self-administered injectable medicines in home health care or in extended care facilities.

Vaccines: Vaccines reimbursable at cost as part of EPSDT services and the Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable.


Formulary: No formulary.

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.


Monthly Quantity Limit: Prescriptions are limited to 30-day supplies. Dispensing of generic multi-source product is required. Maximum number of units for about 50 therapeutic classes and 40 narcotic analgesics.


PRODUR system implemented in June 1995. State currently has a DUR Board that meets nine times per year.


Dispensing Fee: No less than $3.45 and no more than the 90th percentile of all dispensing fees determined under the formula:

1) $23,192 added to the number resulting from multiplying total prescriptions filled by that pharmacy in the previous calendar year by 5.070;

2) to 1), add the result of multiplying total Medicaid prescriptions filled in the previous calendar year by 12.44;

3) from 2), subtract the result of multiplying the total floor space volume of the pharmacy in sq. ft. by 2.103;

4) divide 3) by total prescriptions filled by that pharmacy

5) add $0.73 to 4)

Ingredient Reimbursement Basis: EAC = AWP - 5%.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” and the reason of necessity.


Cognitive Services: Does not pay for cognitive services.

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



F. STATE CONTACTS Medicaid Drug Program Administrator Dave Campana, R.Ph. Pharmacy Program Manager


National Pharmaceutical Council Alaska-3

Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected]

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] Bob Labbe, Director Division of Medical Assistance, DHSS P.O. Box 110660 Juneau, AK 99811-0660 T: 907/465-3355 F: 907/465-2204 E-mail: [email protected] Jack Nielson, Director Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 907/334-2400

Prior Authorization Contact Dave Campana, 907/334-2425

DUR Contact Dave Campana, 907/334-2425 Prescription Price Updating Dave Campana, 907/334-2425

Medicaid Drug Rebate Contact Peter Yan Accountant 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] Claims Submission Contact Linda Walsh Systems Administrator Division of Medical Assistance 4501 Business Park Blvd, Suite 24 Anchorage, AK 99503 T: 907/334-2441 F: 907/561-1684 E-mail: [email protected]

Disease Management Program/Initiative Contact Teri Keklak Health Policy Manager Division of Medical Assistance 4501 Business Park Blvd, Suite 24 Anchorage, AK 99503 T: 907/334-2424 F: 907/561-1684 E-mail: [email protected]

Mail Order Pharmacy Benefit Yes, for Medicaid recipients living in rural areas.

Physician-Administered Drug Program Contact Dave Campana, 907/334-2425 Alaska Medical Care Advisory Committee Patty Hong, R.N., Chair School of Nursing University of Alaska Anchorage 3211 Providence Drive Anchorage, AK 99508

Alaska DUR Committee Dave Campana, R.Ph. Anchorage, AK 99503 Richard Reem, M.D. Fairbanks, AK 99701-3639 Heide Brainerd, P.H. Anchorage, AK Arthur Hansen, D.D.S. Fairbanks, AK 99712 Greg Polston, M.D. Fairbanks, AK.

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 Cheryl Richards Executive Secretary


4-Alaska National Pharmaceutical Council

P.O. Box 3887 Palmer, AK 99645 907/745-8202 E-mail: [email protected] Internet Address: www.nwosteo.org/alaska.html Alaska Pharmaceutical Association Nancy Davis, Executive Director 4107 Laurel Street 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 Barbara Roche Lic. 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 Laraine L. Derr 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


National Pharmaceutical Council Arizona-1

ARIZONA ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

(AHCCCS - PRONOUNCED "ACCESS")

AHCCCS FEATURES

The Arizona Health Care Cost-Containment System (AHCCCS) is a Title XIX (Medicaid) demonstration project, jointly funded by the federal government and the State of Arizona. Begun in October 1982, it serves as a model for providing medical services to the indigent in a managed care system rather than through fee-for-service arrangements. Typically, Medicaid programs have incorporated the traditional hallmarks of the U.S. health care system: namely, independent providers and fee-for-service reimbursement. In contrast, organized health plans and capitation mark the AHCCCS model.

In traditional Medicaid programs, the States assume responsibility for contracting with individual pharmacies and reimbursing them. In the AHCCCS model however, the State contracts instead with pre-paid health plans, HMOs and HMO-like entities. These plans are paid on a capitation basis and are responsible for providing all of the services covered by the program. Thus, the delivery of pharmacy services is the responsibility of each prepaid plan.

GENERAL INFORMATION

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

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

Government Primary Care Physicians as Gatekeepers

AHCCCS legislation provided that all members must be under the care and supervision of a primary care physician who assumed the role of gatekeeper. A statewide network

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

Prepaid Capitated Financing

It was the intent of the AHCCCS legislation that health plans and their providers offer all covered services to groups of members within a geographical area for a fixed price, for a definite period. The law allowed for the establishment of a statewide bidding process to accomplish this. Services are provided on a county-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-for-service arrangements. It is intended, however, that capped fee-for-service will be authorized as a last resort only.

In essence, AHCCCS prepaid health plans (PHPs), health maintenance organizations (HMOs), and other types of organized health delivery systems charge a fixed fee per individual enrolled (i.e., a capitation rate) and assume responsibility for providing a broad array of health care services to members. The plan or contractor is then “at risk” to deliver the necessary services within the capitated amount. AHCCS 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 conventional negotiation processes, provides accessible cost-effective delivery of health care without sacrificing quality performance.

The AHCCCS administration issues an invitation to qualified health plans once every five years. Qualified health plans may bid to offer the full range of AHCCCS services in one or more counties.

Cost Sharing

The fourth major device for containing costs in the AHCCCS model is a provision for cost sharing by users. A statewide co-payment schedule was developed for this


2-Arizona National Pharmaceutical Council

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

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

IMPLEMENTATION OF AHCCCS

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

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 fee-for-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.

The Organizational Role of AHCCCS Administration

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

The AHCCCS Administration develops the Rules and Regulations; manages the health plan bidding processes; awards the contracts; provides technical assistance to providers for the purpose of forming consortia to contract with AHCCCS; and monitors the overall operation of the program.

The Operational Role of the AHCCCS Administration

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

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

• Eligibility Oversight • Procurement of Health Plans • Quality Management



• Health Plan Oversight • Provider, Member Call Center • Grievances and Complaints • Fee for Service for IHS

AHCCCS became effective December 1, 1981, and services commenced October 1, 1982. Services include: inpatient, outpatient, laboratory, x-ray, prescription drugs, medical supplies, prosthetic devices, emergency dental care including extractions and dentures, treatment of eye conditions and EPSDT.

Though AHCCCS was a three-year experiment that was to end in October 1985, the Federal government continues to extend funding for the program. In 1988, AHCCCS received a five-year extension from the Federal government and in 1993, it received an additional 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 move than 800,000 beneficiaries, representing 16 percent of Arizona’s population. AHCCCS has also become a model as managed care is increasingly by being implemented in other states’ Medicaid programs.

MEDICAL PLANS AND ADMINISTRATORS AHCCCS Contracted Health Plans Arizona Physicians IPA, Inc. 3141 North 3rd Avenue Phoenix, AZ 85013 602/264-1232 CIGNA Community Choice 11001 North Black Canyon Highway Phoenix, AZ 85029 602/371-2621 DES/CMDP CMDP-942-C Century Plaza Building, 10th Floor 3225 North Central Avenue Phoenix, AZ 85012 602/351-2245 Family Health Plan of NE Arizona 258 Justin Drive P.O. Box 2069 Cottonwood, AZ 86326

928/448-3585 Health Choice Arizona Suite 260 1600 West Broadway Tempe, AZ 85282-1136 480/968-6866 Maricopa Health Plan 2502 East University Drive Phoenix, AZ 85034 602/344-8700 Mercy Care Plan Suite 400 2800 North Central Phoenix, AZ 85004 602/263-3000 Phoenix Health Plan/Community Connection 1209 South 7th Avenue Phoenix, AZ 85004 602/824-3700 Pima Health System Suite A-200 5055 East Broadway Tucson, AZ 85711 602/512-5500 University Family Care 575 East River Road Tucson, AZ 85704 888/708-2930 Phoenix Arizona Indian Health Services (IHS) Two Renaissance Square 40 N. Central Avenue Phoenix, AZ 85004-5036 602/364-5038 Phoenix Indian Medical Center 4212 North 16th Street Phoenix, AZ 85016 602/263-1200 Indian Health Services (IHS) Southern Region 7900 J.J. Stock Road Tucson, AZ 85746 520/295-2406 Navajo Area Indian Health Services (IHS) P.O. Box 9020 Window Rock, AZ 86515-9020 928/871-5811



ALTCS Contractor List Cochise Health Systems Cochise County Health & Social Services 1415 West Melody Lane, Building A Bisbee, AZ 85603 520/432-9481 DES/DDD 1789 West Jefferson, 4th Floor Phoenix, AZ 85034 602/542-6866 Evercare Select Maricopa Managed Care Systems 2502 East University Drive Phoenix, AZ 85034 602/344-8700 Mercy Care Plan Suite 400 2800 North Central Phoenix, AZ 85004 602/263-3000 Pima County LTC Pima Health System Suite A-200, 5055 East Broadway Tucson, AZ 85711 520/512-5500 Pinal/Gila County-LTC P.O. Box 2140 574 South Central Avenue Florence, AZ 85232-2140 520/868-6775 Yavapai County LTC Yavapai County Department of Medical Assistance 255 East Gurley Street, First Floor Prescott, AZ 86301 520/771-3560 AHCCCS FFS (ALTCS) Ventilator Dependent Office of Medical Management 602/417-4283

STATE CONTACTS AHCCCS Officials Phyllis Biedess, Director AHCCCS 801 E. Jefferson Street

Phoenix, AZ 85034 T: 602/417-4680 F: 602/252-6536 E-mail: [email protected] C.J. Hindman, M.D. Medical Director (Additional information about AHCCCS can be found on the agency’s website at www.ahcccs.state.az.us)

Executive Officers of State Medical and Pharmaceutical Societies Arizona Medical Association, Inc. Chic Older Executive Vice President 810 West Bethany Home Road Phoenix, AZ 85013 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 852-82-5831 T: 480/838-3385 F: 480/838-3557 E-mail: [email protected] 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 Board of Pharmacy Llyn. A. Lloyd 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




National Pharmaceutical Council Arkansas-1

ARKANSAS 1





Child Adult SFO

Prescribed Drugs � � � � � � � �

Inpatient Hospital Care � � � � � � � �

Outpatient Hospital Care � � � � � � � �

Laboratory & X-ray Service � � � � � � � �

Nursing Facility Services � � � � � � � �

Physician Services � � � � � � � �

Dental Services � � � � � � � �

B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients TOTAL $209,933,612 290,749 $248,392,084 321,920 RECEIVING CASH ASSISTANCE, TOTAL $125,221,968 111,942 $142,811,387 111,016 Aged $17,273,356 14,363 $18,083,097 13,278 Blind/Disabled $101,382,563 67,787 $117,036,376 68,665 Child $3,571,657 20,226 $4,248,875 19,495 Adult $2,994,392 9,566 $3,443,039 9,578 MEDICALLY NEEDY, TOTAL $7,336,056 16,317 $7,660,175 13,964 Aged $122,924 214 $130,249 203 Blind/Disabled $2,751,009 1,993 $2,721,983 2,036 Child $1,837,114 8,028 $1,664,186 5,912 Adult $2,625,009 6,082 $3,143,757 5,813 POVERTY RELATED, TOTAL $13,636,604 74,453 $21,594,533 100,643 Aged $511,191 470 $370,667 367 Blind/Disabled $887,917 582 $917,628 673 Child $11,290,143 63,157 $18,932,809 88,224 Adult $947,353 10,244 $1,373,429 11,379 TOTAL OTHER EXPENDITURES/RECIPIENTS* $63,738,984 88,037 $76,325,989 96,297

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.

1 The State of Arkansas did not respond to the 2002 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 Arkansas Medicaid program to assess the accuracy and currency of the information included.


2-Arkansas National Pharmaceutical Council

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


Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin. Products not covered: blood glucose test strips; urine ketone test strips; total parenteral nutrition, interdialytic parenteral nutrition; cosmetics; fertility drugs; and experimental drugs. Prior authorization required for: nitroglycerin patches; agents for impotence; Synagis; Respigam; and Xenical-hyper lipidemia.

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; and selected smoking deterrent products (Zyban PA only).

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

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

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program.



Formulary: Closed formulary. General exclusions include:

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.

Prior Authorization: State currently has a prior authorization procedure.


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 in certified LTC recipients and recipients under 21 years old. Others can receive extension of three more per month.


PRODUR system implemented in March 1997. State currently has a DUR Board with a quarterly review.


Dispensing Fee: $5.51 effective 7/1/99.

Ingredient Reimbursement Basis: EAC = AWP–10.5%.

Prescription Charge Formula: Legend drugs: lower of the EAC plus a dispensing fee or CFA/state upper limit plus a dispensing fee. Total charge may not exceed provider’s charge to the self-paying public.

Maximum Allowable Costs: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. State-specific MAC list contains 800 drugs. Override requires “Brand Medically Necessary.” PA must be obtained once the pharmacy obtains the BNM Rx.



National Pharmaceutical Council Arkansas-3

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

$25.01 to $50.00 $2.00

$50.01 or more

ArKids

$3.00

$5.00

Services to individuals under 18, pregnant women, nursing home residents, emergency services, family planning services, and services provided by an HMO to its enrollees are excluded from the Medicaid copay policy.



An estimated 400,000 Medicaid recipients are enrolled with Primary Care Physicians and ArKids. Pharmaceutical benefits are provided through the State.

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

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

DUR Board Steve Bryant, P.D. Bryant’s Pharmacy 2000 Harrison Street Batesville, AR 72501 501/793-3999 Jason B. Hawkins, P.D. Benji Post, P.D. Debbie Hayes Ann Blaylock, A.P.N. Thomas Lewellen, D.O. 105 West Waterman Dumas, AR 71639 870/382-1188 Michael N. Moody, M.D. P.O. Box 829 Salem, AR 72576 501/895-2541 Laurence Miller, M.D. Prescription Price Updating First DataBank 1111 Bay Hill Drive San Bruno, CA 74066 650/588-5454

Medicaid Drug Rebate Contacts Audits: Suzette Bridges, P.D., 501/683-4120 Dispute Resolution: Mary Alice Easterling EDS 500 President Clinton Ave, Suite 400 Little Rock, AR 72201 T: 501/374-6608 F: 501/372-2971 E-mail: [email protected]

Claims Submission Contact John Herzog, Account Manager EDS


4-Arkansas National Pharmaceutical Council

500 President Clinton Ave, Suite 400 Little Rock, AR 72201 T: 501/374-8650 F: 501/372-2971 E-mail: [email protected]

Medicaid Managed Care Contact Bob Paladino Division of Medicaid Services Dept. of Human Services P.O. Box 1437 Little Rock, AR 72203 T: 501/682-8334 F: 501/683-4124 E-mail: [email protected]

Mail Order Pharmacy Benefit None

Department of Human Services Officials Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 329 Little Rock, AR 72203-1437 T: 501/682-8292 F: 501/682-6836 E-mail: [email protected] Ray Hanley, Director Division of Medical Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 T: 501/682-8292 F: 501/682-1197 E-mail: [email protected] Executive Officers of State Medical and Pharmaceutical Societies Arkansas Hospital Association James R. Teeter 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 Arkansas Pharmacists Association Richard E. Beck, P.D., C.A.E. Executive Vice President and CEO 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 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


National Pharmaceutical Council California-1

CALIFORNIA



Aged Blind/

Disabled

Child Adult Aged Blind/

Disabled

Child Adult SFO







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

B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $2,316,135,493 2,487,875 $2,808,298,437 2,486,910 RECEIVING ASSISTANCE, TOTAL $1,770,765,371 1,301,543 $2,143,413,178 1,334,480 Aged $389,560,223 260,790 $479,791,420 266,911 Blind/Disabled $1,284,923,008 572,336 $1,547,024,854 579,572 Children $32,410,720 288,397 $39,100,804 299,830 Adult $63,871,420 180,020 $77,496,100 188,167 MEDICALLY NEEDY, TOTAL $373,918,597 320,922 $423,154,155 279,326 Aged $156,177,417 112,375 $198,544,758 120,346 Blind/Disabled $187,650,486 58,626 $198,371,267 53,459 Children $12,528,551 99,463 $11,503,750 68,297 Adults $17,562,143 50,458 $14,734,380 37,224 POVERTY RELATED, TOTAL $20,626,801 157,404 $54,387,618 103,247 Aged $3,087,289 3,281 $14,257,426 11,923 Disabled $3,156,657 1,617 $32,358,484 10,485 Children $12,175,851 119,040 $5,572,729 51,243 Adults $2,207,004 33,466 $2,198,979 29,596 TOTAL OTHER EXPENDITURES/RECIPIENTS* $150,824,724 708,006 $187,343,486 769,857 *Total Other Expenditures/ Recipients include foster care children, demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-California National Pharmaceutical Council

C. ADMINISTRATION

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

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.


Drug Benefit Product Coverage: The Medi-Cal pharmacy benefit covers practically all FDA-approved drugs, including both legend and over-the-counter 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 requires 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 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 by schedule as part of the Vaccines for Children Program. Vaccines for adults covered through the prescription drug program, or as administered in a physician's office.



Formulary: Modified closed formulary. Medi-Cal List of Contract Drugs: 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 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 on contractual agreement by the manufacturer to provide the State a negotiated rebate. The Medi-Cal website at: http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/html/faqpage.htm has details of how the drug contracting process works.

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

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

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

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

4. Many antibiotics have diagnostic and/or age restrictions.

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

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 less-than-effective by FDA are not covered.

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

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.


Prescription Refill Limit: A prescription refill can be dispensed as authorized by prescriber. Exception is allowed for refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is to be pro-rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted) does not exceed fee for same prescription when refilled as routine service.

Monthly Quantity Limit: This is flexible, but should be consistent with the medical needs of the patient. Limited to 100 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.


Prospective DUR system implemented in August 1995. State currently has a DUR Board with a quarterly review.


Dispensing Fee: $4.05, effective 8/85.

Ingredient Reimbursement Basis: EAC = AWP-10%

Prescription Charge Formula: Reimbursement is based on the lowest of:

1. Estimated Acquisition Cost (EAC) + dispensing fee,

less $0.50. 2. Federal Upper Limit (FUL) + dispensing fee, less

$0.50. 3. State Maximum Allowable Ingredient Cost (MAIC) +

dispensing fee, less $0.50. 4. Pharmacy’s usual price to general public, less $0.50.

Maximum Allowable Cost: State 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.


Patient Cost Sharing: $1.00 copayment for branded and generic products.

Cognitive Services: Does not pay for cognitive services, but this is under consideration.


Approximately 3,000,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through the State and managed care plans.

Access Dental Plan, Inc. 555 University Ave, Suite 182 Sacramento, CA 95825 AIDS Healthcare Foundation 6255 W. Sunset Blvd., 16th Floor Los Angeles, CA 90028-7403 Alameda Alliance for Health 1850 Fairway Drive San Leandro, CA 94557-0187 Altamed Health Services Corp. 512 South Indiana Street Los Angeles, CA 90063 American Health Guard 30 East Santa Clara, Suite D Arcadia, CA 91006 Blue Cross of California 5151-A Camino Ruiz Camarillo, CA 93012



Care 1st Health Plan 1000 South Freemont Ave, Bldg. A-11, Unit 22 Alhambra, CA 91803 Center for Elders Independence 1955 San Pablo Ave Oakland, CA 94612 Cohen Medical Corp Tower Health Services 200 Oceangate, 6th Floor Long Beach, CA 90802 Community Health Group 740 Bay Blvd. Chula Vista, CA 91910 County of Contra Costa Contra Costa Health Plan 595 Center Avenue, Suite 100 Martinez, CA 94553 Denticare of California 3400 Data Dr. 3 West Rancho Cordova, CA 95670 Delta Dental Plan of CA 1115 International Drive, Bldg. C Rancho Cordova, CA 95670 Health Net Dental, Inc. 125 Technology Drive, Suite 100 Irvine, CA 92618 Health Plan of San Joaquin 1550 W. Fremont Street, Suite 200 Stockton, CA 95203-2643 Inland Empire Health Plan 303 E. Vanderbilt Way, Suite 400 San Bernardino, CA 92408 Kern Health Systems Kern Family Health care 1600 Norris Road Bakersfield, CA 93308 Kaiser Foundation Health Plan, Inc. 393 E. Walnut, 5th Floor Pasadena, CA 91188-8324 Kaiser Foundation Health Plan, Inc. Northern California Region 1800 Harrison Street, 9th Floor P.O. Box 12916 Oakland, CA 94612-2998

LA Care Health Plan 3530 Wilshire Boulevard, 9th Floor Los Angeles, CA 90100 Maxicare 1149 South Broadway, Suite 819 Los Angeles, CA 90015 Molina Medical Centers One Golden Shore Drive Long Beach, CA 90802 OnLok Senior Health Services 1333 Bush Street San Francisco, CA 94109 Orange County Organized Health System Cal Optima 1120 West La Veta Ave., 5th Floor Orange, CA 92668-4220 Placer County Managed Care Network 379 Nevada Street Auburn, CA 95603 San Francisco Health Authority San Francisco Health Plan 568 Howard Street, Fifth Floor San Francisco, CA 94105 San Francisco City & County Public Health Family Mosaic Project 1309 Evans Avenue San Francisco, CA 94124 San Mateo Health Commission Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA 94080 Santa Barbara County Regional Health Authority Santa Barbara Health Initiative 110 Castilian Dr. Goleta, CA 93117-3028 Santa Clara Family Health Plan 4050 Moopark Avenue San Jose, CA 95117 Santa Cruz County -Monterey Managed Care Commission Santa Cruz County Health Options 375 Encinal Street, Suite A Santa Cruz, CA 95060



Scan Health Plan Senior Care Action Network 3780 Kilroy Airport Way, Suite 600 Long Beach, CA 90806-2460 Sharp Health Plan 9325 Sky Part Ct., Suite 300 San Diego, CA 92123 Solano County Medical Care Commission Solano Partnership Health Plan 360 Campus Lane, Suite 100 Suisun City, CA 94585 Sonoma County Medi-Cal Managed care Network 1221 Farmers Lane, Suite 200 Santa Rosa, CA 95404-1705 Sutter Senior Care 1234 U Street Sacramento, CA 95818 UCSD Healthcare 200 West Arbor Dr. San Diego, CA 92103-8501 Universal Care 1600 E. Signal Hill Street Signal Hill, CA 90806-3682 Watts Health Foundation, Inc. United Health Plan 3405 West Imperial Highway, Suite 628 Inglewood, CA 90303 Western Dental Services 530 South Main Street, 6th Floor Orange, CA 92863 Western Health Advantage 1331 Garden Highway Suite 100 Sacramento, CA 95833-9754

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

Prior Authorization Contact J. Kevin Gorospe, Pharm.D. 916/657-4213

DUR Contact Vic Walker, R.Ph. B.C.P.P Senior Consulting Pharmacist Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/657-0785 F: 916/654-0513 E-mail: [email protected]

Medi-Cal Drug Utilization Review Board (DUR Board) Timothy E. Albertson, M.D., Ph.D. University of California-Davis Pulmonary/Critical Care Medicine 4301 X Street, Professional Bldg., Room 2120 Sacramento, CA 95817 Craig Jones, M.D. Director, Division of Allergy/Immunology Department of Pediatrics LA County/USC Medical Center 24725 Avenida Asoleada Calabasas, CA 91302 Janeen G. McBride, R.Ph. Rx America 1500 South Anaheim Blvd. Anaheim, CA 92815-0017 Gary M. McCart, Pharm.D. University of California, San Francisco 400 Parnassus Ave., Box 312 San Francisco, CA 94143 Kenneth Schell, Pharm.D. Pharmacy Services Clinical Operations Manager Kaiser Permanente 10990 San Diego Mission Road San Diego, CA 92108 Stephen M. Stahl, M.D., Ph.D. Clinical Neuroscience Research Center 8899 University Center Lane, Ste. 130 San Diego, CA 92122

Andrew L. Wong, M.D. Chief of Rheumatology University of California - Los Angeles 14445 Olive View - UCLA Medical Center Sylmar, CA 91342



Prescription Price Updating EDS Federal Corp. P. O. Box 13029 Sacramento, CA 95813-4029 916/636-1000

Medicaid Drug Rebate Contact Craig Miller Chief, Medi-Cal Rebate and Vision Section Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/654-0532 F: 916/654-0513 E-mail: [email protected]

Claims Submission Contact EDS Federal Corp. P.O. Box 31029 Sacramento, CA 95813-4029 916/636-1000 Internet Address: www.medi-cal.ca.gov

Medicaid Managed Care Contact Ronald Sanui, Pharm D. Pharmaceutical Consultant II Medi-Cal Managed Care Division 714 P Street, Room 950 Sacramento, CA 95814 916/653-1259 E-mail: [email protected]

Disease Management Program/Initiative Contact

Vic Walker, R.Ph., B.C.P.P., 916/657-0785

Mail Order Drug Benefit State currently has no formal mail order pharmacy program for in-state mail order pharmacies.

Physician-Administered Drug Program Contact Fulton Lipscomb, M.D. Chief, Medical Policy Unit Medi-Cal Benefits Branch 714 P Street, Room 1640 Sacramento, CA 95814 T: 916/657-1460 F: 916/657-3457

Health and Welfare Agency Officials Grantland Johnson Secretary California Health and Human Services Agency 1600 9th Street, Suite 460 Sacramento, CA 95814 T: 916/654-3454 F: 916/654-3343

E-mail address: www.chhs.ca.gov Diana M. Bontá, R.N., Dr.P.H., Director Medical Care Services Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814 T: 916/657-1425 F: 916/657-5183 E-mail: dbonta@@dhs.ca.gov Stan Rosenstein Deputy Director Medical Care Services Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814 T: 916/654-0391 F: 916/657-1156 E-mail: srosenst.dhs.ca.gov

Medi-Cal Contract Drug Advisory Committee Michael B. Huff, M.D. 314 West Fourth St. Oxnard, CA 93030 William B. Ness, M.D. 65 North 14th Street San Jose, CA 95112 Gary M. McCart, Pharm.D. University of California School of Pharmacy Division of Clinical Pharmacy Box 0622 San Francisco, CA 94143-0622 Bruce K. Uyeda, Pharm.D. 1076 Mercy Street Mountain View, CA 94041-1915 Adrian M. Wong, Pharm.D. 17 Warren Drive San Francisco, CA 94131 415/731-6239 Richard H. White, M.D. U.C. California, Davis Division of General Medicine Primary Care Center, Room 3107 2221 Stockton Blvd. Sacramento, CA 95817 Shirley Ann Floyd Blue Cross of California 131 Chester Ave., Suite A Bakersfield, CA 93301



Executive Officers of State Medical and Pharmaceutical Associations/Boards California Medical Association Jack C. Lewin, M.D. Executive Vice-President 221 Main Street, 3rd Floor San Francisco, CA 94105 T: 415/541-0900 F: 415/882-3349 Internet Address: www.cmanet.org Osteopathic Physicians & Surgeons of California Gary A. Gramm. D.O. Executive Director 1900 Point West Way, Suite 188 Sacramento, CA 95815-4703 T: 916/561-0724 F: 916/561-0728 E-mail: [email protected] California Pharmacists’ Association Carlo Michelotti, R.Ph., M.P.H. Chief Executive Officer 1112 I Street, Suite 300 Sacramento, CA 95814-2865 T: 916/444-7811 F: 916/444-7929 E-mail: [email protected] Internet Address: www.calpharm.com State Board of Pharmacy Patricia F. Harris Executive Officer 400 R Street, Suite 4070 Sacramento, CA 95814 T: 916/445-5014 F: 916/327-6308 Internet Address: www.pharmacy.ca.gov 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


National Pharmaceutical Council Colorado-1

COLORADO





Child Adult

SFO








B. EXPENDITURES FOR DRUGS 2000 2001 Expended Recipients Expended Recipients TOTAL $152,478,786 160,264 $177,115,553 143,169 RECEIVING CASH ASSISTANCE, TOTAL $104,010,530 82,036 $117,978,722 76,243 Aged $34,359,318 19,659 $38,858,494 18,862 Blind/Disabled $63,174,183 29,983 $71,297,760 26,703 Child $2,037,288 17,445 $2,406,437 15,586 Adult $4,439,741 14,949 $5,416,031 15,092

MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $16,837,337 45,302 $20,438,343 41,156 Aged $107,937 204 $101,358 129 Blind/Disabled $12,444,445 3,647 $15,354,288 3,802 Child $3,120,175 30,392 $3,695,461 27,041 Adults $1,164,780 11,059 $1,287,236 10,184 TOTAL OTHER EXPENDITURES/RECIPIENTS* $31,630,919 32,926 $38,698,488 25,770

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. Source: CMS, MSIS Report, FY 2000 and Colorado Medicaid Statistical Information System, FY 2001.


2-Colorado National Pharmaceutical Council

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.


Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered with restriction: total parenteral nutrition (prior authorization). Products not covered: cosmetics; DESI drugs; fertility drugs; prescribed vitamins (except prenatal); interdialytic parental nutrition products; 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 with restriction (i.e., must be deemed medically necessary): allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products (prior authorization).

Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents (given in home); ENT anti-inflammatory agents; estrogens; hypotensive agents; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; antihistamine drugs; anti-psychotics (prior authorization required for clozoril); prescribed cough and cold medications; contraceptives; growth hormones; misc. GI drugs; sympathominetics (adrenergic); vitamins; acne products; leukocyte stimulants; LHRH/GnRH; injectables; plasma products; Epoetin; fluoride preparations; antisera; oxycontin; erectile dysfunction 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.

Vaccines: Vaccines reimbursable as part of the EPSDT Program.

Unit Dose: Unit dose packaging not reimbursable.



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.


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 100 days for maintenance medication.

Other Limits: Stadol: limit of 4 bottles per month. Oxycontin: 2 tablet (any strength) per day limit without prior authorization.


PRODUR system implemented in December 1998. DUR Board meets semiannually.

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.


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 = AWP-13.5% or WAC (wholesaler acquisition cost) + 18%. AWP-35% for generics. Other: FUL, State Mac, usual and customary.

Prescription Charge Formula: Benefit drugs shall be reimbursed at the lesser of the Medicaid allowable reimbursement charge, or the provider’s usual and customary charge or whatever is accepted from any third party, discounts, rebates, etc.

The Medicaid allowable reimbursement charge is the sum of the ingredient cost of the drug dispensed and the provider’s dispensing fee.

Ingredient cost for retail pharmacies (estimated acquisition cost) is the price of the drug actually dispensed



as defined below or the MAC or the high volume EAC, whichever is less.

The ingredient cost for institutional and government pharmacies is defined as the actual cost of acquisition for the drug dispensed or the MAC, or the high volume EAC, whichever is less.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires prior authorization(Med Watch form).

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

(1) Multiple manufacturers;

(2) Broad wholesale price span;

(3) Availability of drugs to retailers at the selected cost;

(4) High volume of Medicaid recipient utilization;

(5) Bioequivalence or interchangeability.

When federal MAC limits for multiple source drugs are announced, they will be adopted if they are less than State MACs or if no State MACs exist.

The ingredient cost of any drug subject to MAC shall be limited to MAC or wholesale price as determined by the Department, whichever is less. Exceptions that will allow reimbursement greater than MAC for a drug entity are obtained through a prior authorization mechanism. An exception will be granted if the patient’s response to the generic drug is not therapeutic, an allergic reaction is involved, or any similar situation exists.

If a recipient requests a brand name for a prescription that is subject to MAC, then he/she may pay the ingredient cost difference between the MAC and brand name drug. The recipient must sign the prescription stating that he/she is willing to pay the difference in ingredient cost to the pharmacy. The pharmacy will be paid MAC plus a dispensing fee or reimbursement charges, whichever is lower.

High volume Estimated Acquisition Cost (EAC): Reimbursement for single source drugs or certain multiple source drugs which are most frequently prescribed will be based upon average wholesale prices (AWP) minus 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;

(4) Package sizes in excess of 100.

Drug Pricing: The Department will maintain a drug-pricing file that will be updated at least monthly. The average wholesale price of a drug as determined by the Department, MAC, and high volume EAC, will be the basis for setting the prices in the drug pricing file.

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

(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.

(3) If the prices or changes do not appear in the publications or the wholesalers’ records, then the distributors’ or manufacturers’ prices will be adjusted to the wholesale pricing level and used in the drug pricing file as the price of the drug.

If the difference between the pharmacist’s invoice purchase price and the average wholesale price which appears in the Red Book, its supplements, or Medi-Span exceeds 18%, then the Department may adopt a lower price after a survey is conducted to determine the validity of the published prices. The price from the distributor or manufacturer will be adjusted the same as in 3 above.

Special Note: The Maximum Allowable Cost shall be determined by the Division of Medical Assistance, based upon professional determination of a quality product available at the least expense possible.



Exceptions to the above are: - Shelf package size oral liquid medications, in pint size only, or smaller package size when not packaged in pint size.

- Shelf package size oral tablet and capsule medications in quantities of 100 only or smaller when not available in package size of 100.

- Prescriptions for less than minimum amounts will be denied reimbursement of the professional fee unless the physician notified the Department in writing of the medical need for amounts less than a 30-day supply. Medical consultation determines the decision.


Patient Cost Sharing: Co-pay is $3.00 for brand name products and $0.75 for generic.



Over 260,000 Medicaid recipients were enrolled in managed care in FY 2001. Recipients receive pharmaceutical benefits through the State.

Managed Care Organizations Total Long-term Care 303 East 17th Avenue Suite 650 Denver, Colorado 80203 303/896-4664 HMO Colorado 700 Broadway Denver, Colorado 80273 303/831-2374 Kaiser Permanente 10350 East Dakota Avenue Denver, Colorado 80905 303/344-7250 Rocky Mountain HMO 2775 Crossroads boulevard Grand Junction, Colorado 81506 800/843-0719 Colorado Access 600 South Cherry STREET Suite 800 Denver, Colorado 80222 303/355-6707

Community Health Plan of the Rockies 400 South Colorado Boulevard Suite 300 Denver, Colorado 80222 303/355-3220 United Healthcare 6251 Greenwood Plaza Blvd, Suite 200 Englewood, Colorado 80111-4910 303/267/3594

F. STATE CONTACTS Medicaid Drug Program Administrator Dima Ahram, Pharm.D. Department of Health Care Policy and Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: [email protected]

DUR Contact Dima Ahram, Pharm.D., 303/866-2468

Prescription Price Updating First Data Bank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

Medicaid Drug Rebate Contacts Vince Sherry Drug Rebate Manager Department of Health Care Policy and Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 T: 303/866-5408 F: 303/866-2573

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



Medicaid Managed Care Contact Lynn Barnard Director of Health Care Programs Department of Health Care Policy and Financing 1575 Sherman Street, 4th Floor Denver, CO 80203 T: 303/866-2445 F: 303/866-2803

Disease Management/Patient Education Programs Disease/Medical State: Schizophrenia Program Name: Clients with schizophrenia and comorbidities Program Manager: Specialty Disease Management Sponsor: Eli Lilly and Company Disease/Medical State: Asthma Program Name: Clients with asthma Program Manager: National Jewish Hospital Sponsor: Novartis and Astra Zeneca Disease/Medical State: Diabetes Program Name: Clients with diabetes Program Manager: McKesson Sponsor: Eli Lilly and Company Disease/Medical State: Neonatal Intensive Care Program Name: High Risk Infants Program Manager: Clinician Support Technology Sponsor: Johnson & Johnson Disease/Medical State: Breast and Cervical Cancer Program Name: Breast and Cervical Cancer Longitudinal Study Sponsor: Astra Zeneca Disease/Medical State: Case Management Sponsor: Pfizer, Abbott, and Astra Zeneca Disease/Medical State: Telemedicine Sponsor: GlaxoSmithKline

Disease Management/Patient Education Contact

Lynn Barnard, 303/866-2445

Mail Order Pharmacy Program None

Physician-Administered Drug Program Contact Patti Campbell, 303/866-5459 Health Care Policy & Financing Department Officials Richard Allen, Executive Director Vivianne Chavmont, Director Health Plan & Medical Services

Office of Medical Assistance Colorado Department of Health Care Policy & Financing 1575 Sherman Street Denver, Colorado 80203

Medical Advisory Council Donald W. Schiff, M.D. 600 Front Range Road Littleton, CO 80120 303/837-2745 Molly A. Markert 11060 E. Wesley Pl. Aurora, CO 80014 303/756-7234 Mary Jo Jacobs, M.D. 7425 E. Kenyon Ave. Denver, CO 80237 303/694-2878 Walter Daniels, D.D.S. 1633 Filmore Street Denver, CO 80206 303/388-0989 Rodney Fair, O.D. 105 Bridge Street Brighton, CO 80601 303/659-3036 Douglas Clinkscales Denver Health and Hospitals 777 Bannock Street Denver, CO 80204 303/426-7253 Cathy Corcoran 15920 W. 66th Place Golden, CO 80403 303/861-6256 Ernestine Kotthoff-Burrell 6098 S. Iola Ct. Englewood, CO 80111 303/270-8974



Carol Bartley Denver VNA 3801 E. Florida Ave., Suite 800 Denver, CO 80201 303/753-7312 Mary Ellen Kuhlman, MSW St. Mary’s Hospital & Medical Center P.O. Box 1628 Grand Junction, CO 81502 970/244-2273 Dan Stenerson Shalom Park 14800 E. Belleview Aurora, CO 80015 303/680-5000 Mark Kunart, D.O. 17200 E. Iliff Avenue Aurora, CO 80013 303/755-4111 Robert Slay Jefferson Co. CCB 7456 W. 5th Avenue Lakewood, CO 80226 303/233-3363 x366 Department Contact Richard Allen, Director Health Plans and Medical Services 303/866-6092 Legislative Liaison Dean Woodward Department of Health Care Policy and Financing 303/866-2708

Executive Officers of State Medical and Pharmaceutical Societies Colorado Medical Society Sandra L. Maloney Executive Director 7351 Lowry Boulevard. Denver, CO 80230 T: 720/859-10013 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 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 Kathleen Brennan Executive Director 650 South Cherry Street, Suite 440 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 Administration 1560 Broadway, Suite 1310 Denver, CO 80202-5146 T: 303/894-7750 F: 303/894-7750 E-mail: [email protected]/pharmacy Internet address: www.coloradodo.org Colorado Health and Hospital Association Larry H. Wall President 7335 East Orchard Road, Suite 100 Greenwood Village, CO 80111-2512 T: 720/489-4630 F: 720/489-9400 Internet address: www.cha.com


National Pharmaceutical Council Connecticut-1

CONNECTICUT



Aged Blind/

Disabled


Disabled

Child Adult SFO

Prescribed Drugs � � � � � � � � �

Inpatient Hospital Care � � � � � � � � �

Outpatient Hospital Care � � � � � � � � �

Laboratory & X-ray Service � � � � � � � � �

Nursing Facility Services � � � � � � � � �

Physician Services � � � � � � � � �

Dental Services � � � � � � � � �

B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients TOTAL $264,641,409 113,089 $304,470,534 116,755 RECEIVING CASH ASSISTANCE, TOTAL $77,985,386 29,535 $85,509,574 29,004 Aged $13,736,629 6,606 $14,661,696 6,146 Blind/Disabled $63,581,603 17,784 $70,113,706 17,814 Child $158,664 2,592 $176,052 2,598 Adult $508,490 2,553 $558,120 2,446 MEDICALLY NEEDY, TOTAL $79,159,403 29,860 $89,643,018 29,417 Aged $19,167,645 10,198 $21,970,885 10,353 Blind/Disabled $59,237,780 18,385 $67,436,637 18,548 Child $123,249 399 $91,458 283 Adult $630,729 878 $144,038 233 POVERTY RELATED, TOTAL $2,122,228 5,968 $3,750,393 5,721 Aged $221,813 250 $644,493 700 Blind/Disabled $818,286 475 $2,152,958 1,089 Child $1,005,370 3,966 $877,998 2,974 Adult $76,759 1,277 $74,944 958 TOTAL OTHER EXPENDITURES/RECIPIENTS* $105,374,392 47,726 $125,567,549 52,613

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 Data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Connecticut National Pharmaceutical Council

C. ADMINISTRATION

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

D. PROVISIONS RELATING TO DRUGS

Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin, disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition (except in NH); and interdialytic parenteral nutrition (except in NH). Products not covered: cosmetics; fertility drugs; experimental drugs; and weight loss products.

Over-the-Counter Product Coverage: Products covered: cough and cold preparations (children < 19 years) and topical products. Products covered with restrictions: digestive products (non H2 antagonists) – liquid generics only; and digestive products (H2 antagonists) – legend drugs not covered; birth control products; antihistamines; and decongestants. Products not covered: smoking deterrent products; allergy, asthma and sinus 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; 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); thyroid agents; and growth hormones. Therapeutic categories not covered: anorectics and prescribed smoking deterrents.

Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in home health care, extended care facilities, and in physicians offices.

Vaccines: Vaccines reimbursable as part of the Children Health Insurance Program.



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

Prior Authorization: State does not currently have a prior authorization procedure.

Prescribing or Dispensing Limitations Prescription Refill Limit: 5 refills per prescription except for oral contraceptives, which have a 12-month 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 PRODUR system implemented September 1996. Retro DUR since September 1991; the state currently has a 9 member DUR Board with a quarterly review.


Dispensing Fee: $3.85, effective 9/1/02.

Ingredient Reimbursement Basis: EAC = AWP-12%. Special rules for Factor VIII (AAC + 8%), OTCs (AWP x # units x 1.15), and neutral 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 Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary.”

Incentive Fee: The Department will pay an incentive professional dispensing fee of $0.50 per prescription, in addition to any other dispensing fee, for substituting a generically equivalent drug product.

Patient Cost Sharing: None.





Connecticut has approximately 290,000 Medicaid recipients enrolled in managed care. Pharmaceutical benefits received through the managed care plan.

Managed Care Organizations Anthem Blue Cross/Blue Shield of CT Blue Care Family Plan Deborah Hine, Director Medicaid Managed Care 370 Bassett Road North Haven, CT 06473-4201 203/985-6130 Community Health Network of CT Sylvia Kelly, CEO 290 Pratt - 2nd Floor Meriden, CT 06450 203/237-4000 Health Net Healthy Options Janice Perkins, Vice President Government Relations and Programs One Far Mill Crossing, Box 904 Shelton, CT 06484-0944 203/225-8630 First Choice of CT Preferred One Tejas Patel, Director 23 Maiden Lane North Haven, CT 06473 203/239-7444 Ext. 664 F. STATE CONTACTS Medicaid Drug Program Administrator Evelyn A. Dudley Pharmacy Program Manager Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] Internet address: www.ctmedicalassistanceprogram.com Department of Social Services Administrative Officials Patricia A. Wilson-Coker

Commissioner Department of Social Services 25 Sigourney St. Hartford, CT 06016-5033 T: 860/424-5008 F: 860/566-2022 E-mail: [email protected] Rita Pacheco, Deputy Commissioner 860/424-5055 Michael Starkowski, Deputy Commissioner 860/424-5053 David Parrella, Director Medical Care Administration 860/424-5177 Rose Ciarcia Director Managed Care 860-424-5139 Michelle Parsons, Manager Alternate Care Unit 860/424-5177 Marcia Mains, Director Medical Operations 860/424-5219 Evelyn Dudley Pharmacy Program Manager 860/424-5654

DUR Contact James Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services 25 Sigourney Street Hartford, CT 06106 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

Connecticut DUR Board Kenneth Fisher, R.Ph. Brooks Pharmacy Arturo Morales, M.D. St. Francis Hospital Lori Jane Duntz Lord, R.Ph. Greenville Drug 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 Michael Moore, R.Ph. Hebrew Home Hospital

Prescription Price Updating Ellen Arce, R.Ph. Pharmacy Manager Electronic Data Systems 100 Stanley Street New Britain, CT 06053 860/832-5858

Medicaid Drug Rebate Contacts Mark Heushkel (Audits) Lead Planning Analyst - Pharmacy Department of Social Services Medical Operations 25 Sigourney Street Hartford, CT 06106 T: 860/424-5347 F: 860/424-5206 E-mail: [email protected] Ellen Arce, R.Ph. (Rebate & Disputes) 860/832-5858

Claims Submission Contact Kevin Walsh Electronic Data Systems 100 Stanley Street New Britain, CT 06053 860/832-5858

Medicaid Managed Care Contact Rose Ciarcia Department of Social Services 25 Sigourney St. Hartford, CT 06106 T: 860/424-5139 E-mail: [email protected]


Elderly Drug Coverage Program Contact Evelyn Dudley 860/424-5654

Physician-Administered Drug Program Contact Zanita McKinney, Medical Policy 25 Sigourney Street Hartford, CT 06106 860/424-535

State Pharmacy Commission William Summa, P.D., Chairman

Executive Officers of State Medical and Pharmaceutical Societies State Medical Society Timothy B. Norbeck, Executive Director 160 St. Ronan Street New Haven, CT 06511-2390 T: 203/865-0587 F: 203/865-4997 E-mail: [email protected] Internet address: www.csms.org Connecticut Pharmacists Association Margherita R. Guiliano, R.Ph. Executive V.P. 35 Cold Spring Road, Suite 124 Rocky Hill, CT 06067-3161 T: 860/563-4619 F: 860/257-8241 E-mail: [email protected] Internet address: www.ctpharmacists.org Connecticut Osteopathic Medical Society Donald Halpin, Executive Director P.O. Box 487 Winchester, MA 01800-0487 T: 781/721-9900 F: 781/721-4400 E-mail: [email protected] Internet address: www.northeastosteo.org Pharmacy Commission & Drug Control Division Michelle Sylvestre, R.Ph. Board Administrator State Office Building 165 Capitol Avenue, Room 147 Hartford, CT 06106 T: 860/713-6070 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 P.O. Box 90 Wallingford, CT 06492-0090 T: 203/265-7611 F: 203/284-9318



Internet address: www.chime.org




National Pharmaceutical Council Delaware-1

DELAWARE 1



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients TOTAL $66,263,771 78,167 $81,623,058 85,351 RECEIVING CASH ASSISTANCE, TOTAL $40,920,160 53,640 $52,023,939 62,035 Aged $4,873,491 2,464 $5,833,794 2,470 Blind/Disabled $22,570,175 9,405 $27,480,662 9,724 Child $4,927,265 26,644 $7,259,311 31,503 Adult $8,549,229 15,127 $11,450,172 18,338 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $1,369,908 4,901 $1,423,154 3,654 Aged $180,455 147 $145,083 132 Blind/Disabled $399,640 286 $533,696 282 Child $715,522 4,084 $718,597 3,103 Adults $74,291 384 $25,778 137 TOTAL OTHER EXPENDITURES/RECIPIENTS* $23,973,703 19,626 $28,175,965 19,662

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and FY 2001.

1 The State of Delaware did not respond to the 2002 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 Delaware Medicaid program to assess the accuracy and currency of the information included.


2-Delaware National Pharmaceutical Council

C. ADMINISTRATION

Division of Social Services, Department of Health and Social Services, through three county offices of the State agency.


Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); digestive products (H2 antagonists); and smoking deterrent products. Products covered with restriction: feminine products (antifungals) and topical products (anti-infectants).

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

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program and physician payment when used in physician offices. Reimbursable only through the Prescription Drug Program when used in home health care and extended care facilities.

Vaccines: Vaccines reimbursable under the Vaccines for Children program and the CHIP program.

Unit Dose: Unit dose packaging not reimbursable. No price based on AWP.

Formulary/Prior Authorization Formulary: Open formulary.


Prescribing or Dispensing Limitations Prescription Refills: Prescription blank has space for physician to authorize renewals.

Monthly Quantity Limit: Greater of 34-day supply or 100 dosing units.

Monthly Dollar Limits: None.

Drug Utilization Review PRODUR system implemented in August 1994.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.65.

Ingredient Reimbursement Basis: EAC = AWP-12.9%.

Prescription Charge Formula: Payment is based on AWP-12.9% or maximum allowable cost (MAC) plus a dispensing fee, or the usual and customary cost to the general public, whichever is lower.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as state-specific limits on generic drugs. Override requires completion of an FDA Med-Watch form.





Approximately 83,500 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through the State.

Managed Care Organizations DelawareCare 2751 Centerville Road, Suite 400 Wilmington, DE 19808 215/937-8285 First State Health Plan 1801 Rockland Road, Suite 300 Wilmington, DE 19803 302/576-7603



F. STATE CONTACTS State Drug Program Administrator Philip Soulé Deputy Director/Medicaid Dept. of Health and Social Services 1901 N. Dupont Highway New Castle, DE 19720 T: 302/255-9501 F: 302/255-4425 Internet address: http://www.state.de.us/govern/agencies/dhss

Prior Authorization Contact Cynthia Denemark, R.Ph. Pharmacist Consultant EDS 248 Chapman Road, Suite 100 Newark, DE 19702-9720 T: 302/453-8453 F: 302/454-7603 E-mail: [email protected]

DUR Contact Cynthia Denemark, 302/453-8453

DUR Board Calvin Freedman, R.Ph. 302 Lark Drive Newark, DE 19713-1216 Marvin H. Dorph, M.D. 614 Loveville Road Unit E4H Coffee Run Condo Hockessin, DE 19707 Daniel M. Hauser, Pharm.D. 325 W. Broadstair Dover, DE 19904 Micheal Glacken 500 West 10th Street Wilmington, DE 19801 Richard Steele 2617 Epping Rd. Wilmington, DE 19810 Teresa Corbo 114 Vincent Circle Middletown, DE 19709 Sharon Wisneski, R.N., M.S. 336 Pine Valley Road

Dover, DE 19901 Carl Mulveny 1941 Limestone Rd. Wilmington, DE 19808 John Barron 4735 Ogletown-Stanton Road Suite 3201 Newark, DE 19713

Prescription Price Updating Cynthia Denemark, 302/453-8453

Medicaid Drug Rebate Contacts Lynnessa Reynoso, Rebate Analyst EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-7603

Claims Submission Contact Robert Curnutt System Manager EDS 248 Chapman Rd Newark, DE 19702 T: 302/453-8453 F: 302/454-7603

Medicaid Managed Care Contact Glyne Williams Division of Social Services P.O. Box 906 New Castle, DE 19720 T: 302/577-4900 F: 302/577-4405

Physician-Administered Drug Program Contact Cynthia Denemark, 302/453-8453




Health and Social Services Department Officials Vincent P. Meconi Secretary Dept. of Health & Social Services 1901 N. Dupont Highway New Castle, DE 19720 T: 302/421-6705 F: 302/255-4429 E-mail: [email protected] Elaine Archangelo Director Division of Social Services Dept. of Health & Social Services 1901 N. Dupont Highway New Castle, DE 19720 T: 302/255-9668 F: 302/255-4433 E-mail: [email protected] Medical Advisory Committee Members Susan Ebner 2 Dove Place Wyoming, DE 19934 Anne Aldridge, M.D. 671 Clifton Dr. Bear, DE 19701 Caroline Vecchiolla Scott Levin Healthcare Consulting 60 Blacksmith Road Newtown, PA 18940 Neil McLaughlin, Director Fernhook Community Mental Health 14 Central Avenue New Castle, DE 19720 Richard Cherrin Visiting Nurses Association 205 N. Pembrey Drive Wilmington, DE 19806 Kevin Sheahan DuPont Pediatrics at Rodney 1726 S. Governors Avenue Dover, DE 19901 Bob Welch Bureau Health Planning & Resource Management Jesse Cooper Building, Suite 160 Dover, DE 19901

John A. Forrest, Jr., M.D. 195 Lynnhaven Drive Dover, DE 19904 Mark Meister Medical Society of Delaware 1925 Lovering Avenue Wilmington, DE 19806 Olga Ramirez Community Legal Aid Society, Inc. 100 W. 10th Street, Suite 801 Wilmington, DE 19801 Penny D. Chelucci Mental Health Consumer Coalition 100 W. 10th Street Community Service Bldg., Suite 303 Wilmington, DE 19801 Joseph Letnaunchyn Delaware Health Care Association 1280 S. Governor’s Avenue Dover, DE 19901 Al Pilong Vice President for Ambulatory Care Bayhealth Medical Center/Kent General Hospital 640 S. State Street Dover, DE 19901 George English Blue Cross Blue Shield of DE One Brandywine Plaza Wilmington, DE 19899 Michael Glacken, M.D. Medical Director Connections, CSP 500 West 10th St. Wilmington, DE 19801 Daniese McMullin-Powell A.D.A.P.T 24 S. Old Baltimore Pike Newark, DE 19702 Leonard Nitowski, M.D. Doctors for Emergency Services PO Box 3048 Wilmington, DE 19804 Julia M. Pillsbury, D.O. Center for Pediatric and Adolescent Medicine 125-1 Greentree Drive Dover, DE 19904



Ulder Jane Tillman, M.D. Director, DPH Jesse Cooper Building 417 Federal and Water Streets Dover, DE 19901 Yrene E. Waldron Executive Director DE Health Care Facilities Association Two Mill Rd., Suite 200 Wilmington, DE 19806 Anne M. Allen Medical Society of Delaware 1925 Lovering Avenue Wilmington, DE 19806 Theodore Gregory Mental Health Consumer Coalition 100 W. 10th Street Community Services Building, Suite 303 Wilmington, DE 19801 Ellen M. Steele 2863 Kenton Road Dover, DE 19904 Kim L. Carpenter, M.D. MSB Bldg, Level II 7th & Clayton Streets Wilmington, DE 19805

Executive Officers of State Medical and Pharmaceutical Societies Medical Society of Delaware Mark Meister, Sr. Executive Director 131 Continental Drive, Suite 405 Wilmington, DE 19713 T: 302/658-7596 F: 302/658-9669 E-mail: [email protected] Internet address: www.medsocdel.org Delaware Pharmacists Society Pat Carroll-Grant, R.Ph. Executive Director P.O. Box 454 Smyrna, DE 19977-0454 T: 302/659-3088 F: 302/659-3089 Internet address: www.depharmacy.org/index.htm

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 State Board of Pharmacy David W. Dryden, R.Ph., J.D. Executive Secretary P.O. Box 637 Dover, DE 19901 302/739-4798 E-mail: [email protected] Internet address: www.professionallicensing.state.de.us Delaware Healthcare Association Joseph M. Letnaunchyn President & 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




National Pharmaceutical Council District of Columbia-1

DISTRICT OF COLUMBIA1



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $55,092,178 38,129 $62,292,004 35,324 CATEGORICALLY NEEDY CASH TOTAL $38,607,849 24,754 $42,750,082 22,033 Aged $3,403,484 2,385 $3,745,744 2,262 Blind/Disabled $33,339,739 14,921 $37,256,814 14,440 Child $440,863 3,146 $358,540 2,063 Adult $1,423,763 4,302 $1,388,984 3,268 CATEGORICALLY NEEDY NON-CASH TOTAL $6,862,242 5,037 $7,930,965 4,980Aged $1,476,093 835 $1,637,536 819 Blind/Disabled $4,724,198 2,015 $5,639,520 2,399 Child $116,837 1,114 $128,355 853 Adult $545,114 1,073 $525,554 909 MEDICALLY NEEDY TOTAL $6,667,998 5,177 $8,495,578 5,135 Aged $2,199,308 1,344 $2,772,481 1,513 Blind/Disabled $4,237,256 1,626 $5,511,608 1,858 Child $199,741 2,015 $195,736 1,575 Adult $31,693 192 $15,753 189 TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,954,089 3,161 $3,115,379 3,176

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001. 1The District of Columbia did not respond to either the 2001 or 2002 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 District’s Medicaid program to assess the accuracy and the currency of the information included.


2-District of Columbia National Pharmaceutical Council

C. ADMINISTRATION

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


Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; and ferrous sulfate. Prior authorization required for: injectable drugs administered on an outpatient basis; anorexic drugs for treatment of narcolepsy and minimal brain dysfunction in children; acute anti-ulcer drugs, and brand NSAIDS. Products not covered: all other non-legend items.

Over-the-counter Product Coverage: Products covered: oral analgesics; oral antacids; contraceptive foams and jellies; prenatal vitamin formulations; geriatric vitamin formulations for recipients 65 and over; and multivitamin formulations for children 7 years of age and over.

Coverage of Injectables: Injectable medicines reimbursable when used in physicians offices, home health care, and extended care facilities.

Vaccines: Vaccines reimbursable at cost as part of the EPSDT service.

Unit Dose: Unit dose packaging not reimbursable


Formulary: Open formulary


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.

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


PRODUR system implemented in September 1996.


Dispensing Fee: $3.75.

Ingredient Reimbursement Basis: AWP-10%.

Prescription Charge Formula: The lesser of: Upper limit established by HCFA or the AWP-10% plus the dispensing fee or usual and customary to the public.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” with explanation.


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.



Recipients enrolled in managed care receive pharmaceutical benefits through managed care plans.

Managed Care Organizations Advantage Health Plan, Inc. P.O. Box 9596 Washington, DC 20016 202/686-8555 American Preferred Provider Plan Mid-Atlantic, Inc. 1501 M Street, NW, Suite 500 Washington, DC 20002 202/408-0460 D.C. Chartered Health Plan 820 First Street, NE, Suite LL100 Washington, DC 20002 202/408-4710 Capitol Community Health Plan 750 First Street, NE, Suite 1120 Washington, DC 20002 202/408-0460


National Pharmaceutical Council District of Columbia-3

George Washington University Health Plan 4550 Montgomery Avenue Bethesda, MD 20814 301/941-2044 Health Right, Inc. 3020 14th Street, NW Washington, DC 20009 202/518-2370 Prudential Health Care Plan 2800 N. Charles Street Baltimore, MD 21218 410/554-7224

F. STATE CONTACTS State Drug Program Administrator Donna Bovell, R.Ph. Pharmacist Consultant 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]

District of Columbia DUR Board Christopher Keeyes, Pharm.D. (Chair) President, Clinical Pharmacy Associates 11710 Beltsville Drive, Suite 510 Calverton, MD 20705 301/572-1616 Martin Dillard, M.D. (Vice Chair) Assistant Dean for Clinical Affairs Chief, Division of Nephrology Howard University Hospital 2041 Georgia Avenue, NW, Suite 5C02 Washington, DC 20060 202/865-1191 Howard Robinson, R.Ph. Manager, Central Pharmacy Greater Community Hospital 1310 Southern Avenue, SE Washington, DC 20032 Dr. Kim Bullock Providence Hospital Emergency Room 1150 Varuum St., NE Washington, DC 20017 202/269-7863

Medicaid Drug Rebate Contacts Technical: Ken Boni, 202/965-7400 Policy: Donna Bovell, R.Ph., 202/442-5988 DUR: Donna Bovell, R.Ph., 202/442-5988

Physician-Administered Drug Program Contact Donna Bovell, R.Ph., 202/442-5988

Department of Human Services Officials James A. Buford Director Department of Health 825 North Capitol Street, NE Fourth Floor Washington, DC 20002 T: 202/442-5999 F: 202/442-4788 E-mail: [email protected] Wanda Tucker Interim 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

Executive Officers of District Medical and Pharmaceutical Societies Medical Society of the District of Columbia K. Edward Shanbacker 2215 M St., NW, Suite 200 Washington, DC 20037-2059 T: 202/466-1800 F: 202/452-1542 E-mail: [email protected] Internet address: www.msdc.org Washington D.C. Pharmacy Association Herbert Kwash, R.Ph., President 6406 Georgia Ave, NW Washington, DC 20012-2960 T: 202/829-1515 F: 202/829-1515 Osteopathic Association of the District of Columbia


4-District of Columbia National Pharmaceutical Council

Roy Heaton, D.O., President 2517 North Glebe Road Arlington, VA 22207 T: 703/522-8404 F: 703/522-2692 DC Board of Pharmacy Graphelia Ramseur Health Licensing Specialist 825 North Capitol Street, NE, Room 224 Washington, DC 20002 T: 202/442-4776 F: 202/442-9431 E-mail: gramseur@dchealth .com Internet address: www.dchealth.dc.gov District of Columbia Hospital Association Robert Malson, President 1250 Eye Street, NW, Suite 700 Washington, DC 20005-3980 T: 202/682-1581 F: 202/371-8151 E-mail: [email protected] Internet address: www.dcha.org


National Pharmaceutical Council Florida-1

FLORIDA



Aged Blind/

Disabled


Disabled

Child Adult SFO







Dental Services � �

B. EXPENDITURES FOR DRUGS 2001 2002 Expenditures Recipients Expenditures Recipients TOTAL $1,474,041,051 1,109,511 $1,714,883,612 1,179,944 RECEIVING CASH ASSISTANCE TOTAL $902,864,131 501,647 $1,026,862,696 576,092 Aged $151,665,321 77,328 $170,850,446 79,748 Blind/Disabled $655,894,629 226,562 $750,274,442 235,685 Child $40,614,696 168,664 $46,013,540 170,004 Adult $54,689,485 89,093 $59,724,268 90,655 MEDICALLY NEEDY, TOTAL $83,614,245 28,388 $118,805,473 33,216 Aged $52,764 16 $31,545 21 Blind/Disabled $69,638,383 13,733 $120,427,359 16,970 Child $2,869,193 3,007 $2,360,440 2,997 Adult $11,053,905 11,632 $15,986,129 13,228 POVERTY RELATED, TOTAL $288,039,981 359,849 $336,992,042 397,152 Aged $100,027,087 50,977 $100,463,428 56,777 Blind/Disabled $132,695,788 42,558 $145,453,276 41,099 Child $46,875,856 203,778 $60,847,477 230,119 Adult $8,441,250 62,536 $10,227,861 69,157 TOTAL OTHER EXPENDITURE/RECIPIENTS $199,522,694 159,627 $232,223,401 173,484

Source: Florida Medicaid Statistical Information System, FY 2001 and FY 2002.


2-Florida National Pharmaceutical Council

C. ADMINISTRATION

Agency for Health Care Administration. Claims processing and payment by contract with fiscal agent.


Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; total parenteral nutrition; and urine ketone test strips for children under age 21. Prior authorization required for: Cytogam; Proleukin; Serostim; Albumin; Neutrexin; Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; Regranex (long term care); Botox; and nutritional supplements. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered: smoking deterrent products (8-12 weeks/yr); iron supplements; Guaifenesin; and vaginal antifungals. Products covered with restriction: analgesics (asprin/Tylenol for anti-inflammatory use); feminine products (prior Rx products only). Products not covered: allergy, asthma, and sinus products; cough and cold preparations; digestive products (including H2 antagonists); and topical products.

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; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents (only children under 21 years); sympathominetics (adrenergic); and thyroid agents. Partial coverage for: anoretics; prescribed cold medications. Prior authorization required for: growth hormones; drugs not included on the Medicaid preferred drug list; and brand name prescriptions beyond the four brand cap unless exempted.

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.




Formulary: Preferred Drug List (PDL) with mandatory limits and exclusions. All covered drugs are available through the preferred drug process. General exclusions include restrictions on use, prior authorization and physician profiling. Specific limits and exclusions include:

1. Vitamins and phosphate binders only for dialysis patients.

2. Prostheses; appliances; devices; and personal care items.

3. 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).

4. Anorexants unless the drug is prescribed for an indication other than obesity (i.e. narcolepsy, hyperkinesis).

5. Drugs with questionable efficacy as rated by FDA (DESI).

6. Investigational and experimental items. 7. Oral vitamins with exception of fluorinated pediatric

vitamins prescribed for pediatric patients, vitamins for dialysis patients, prenatal vitamins.

8. Nursing home floor stock drugs.

Prior Authorization: State currently has a formal prior authorization procedure. An appeal hearing request is required to appeal prior authorization decisions.


Prescription Refill Limit:

1. Limited to four brand name RX’s per month. Exemptions are: Anti-Retrovirals for HIV, Anti-Psychotics, Depressants and Convulsants, Family Planning, and Diabetic supplies and insulin, unlimited generic prescriptions.

2. Drugs not included in the Preferred Drug list (PDL) require PA. Anti-retrovirals and mental health are exempted. 3. Maintenance medication should be dispensed and billed for at least a one-month supply. 4. Refills must be authorized by the prescriber and can

be made for up to one year, except that controlled substances can be refilled only in accordance with Federal and State regulations.

5. Nutritional supplements are covered with prior authorization when the patient is otherwise at risk of hospitalization.

6. Other third parties, including Medicare, must be billed first.


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.



Nursing Home Fee $4.73, effective 7/1/01

Ingredient Reimbursement Basis: AWP-13.25 % or WAC + 7%.

Prescription Charge Formula: Lower of:

1. FUL (Federal Upper Limits or State MAC) plus dispensing fee.

2. EAC plus dispensing fee. 3. Usual and customary charge. 4. In-house unit dose diff. + 0.015/dose.

Maximum Allowable Cost: State imposes Federal Upper Limits and State-specific limits on generic drugs. Provisions for MAC override by physicians only if listed on negative formulary.

Incentive Fee: No incentive fee.

Patient Cost Sharing: No copayment



Approximately 600,000 Medicaid recipients (30% of all recipients) received pharmaceutical benefits through managed care plans (inclusion of such benefits is mandated under State law) in 2001.

Managed Care Organizations Alpha Health Plan, Inc. Beacon Health Plans, Inc. Contact: Ana M. Berenguer 2511 Ponce de Leon Blvd., 5th Floor Coral Gables, FL 33134 305/774-2599

Discovery Plan Contact: Robert Wychulis 3520 Thomasville Road, Suite 200 Tallahassee, FL 32308 850/894-0100 ext. 801 Florida 1st Health Plans, Inc. Contact: Frank Willis 3425 Lake Alfred Road Winter Haven, FL 33881 941/293-0785 Foundation Health, A Florida Health Plan, Inc. Contact: Michael Comerford 1340 Concord Terrace Sunrise, FL 33323 800/422-7335 Healthease Contact: Christopher O’Connor 6800 N. Dale Mabry Hwy., Suite 168 Tampa, FL 33614-3988 813/290-6358 Healthy Palm Beaches, Inc. Humana Family Contact: Patricia L. Hubrig c/o Humana Medical Plan, Inc. 3400 Lakeside Drive, 5th Floor Miramar, FL 33027 305/626-5616 Jackson Memorial Health Plan Contact: Taryn Davis 1801 NW 9th Ave., Suite 700 Miami, FL 33136 305/575-3700 MedChoice Health Plan Contact: Jeffery G. Keiser 5300 West Atlantic Avenue Delray Beach, FL 33484-8190 561/496-0505 Neighborhood Health Partnership, Inc. Contact: Heidi Etzold 7600 Corporate Center Dr., Suite 300 Miami, Fl 33126-1216 305/715-4318



Personal Health Plan Contact: Debi L. Gavras Dr. Jeff Davis, D.O. (Interim) 324 Datura Street, Suite 401 West Palm Beach, FL 33401 561/659-1270 ext. 5885 Physicians Healthcare Plans, Inc. Contact: Peter Jimenez 2333 Ponce de Leon Blvd. Ste 303 Coral Gables, FL 33134 305/441-9400 ext. 125 Preferred Medical Plan, Inc. Contact: Tamara Meyerson 4950 SW 8th Street Coral Gables, FL 33134 305/445-8373 St. Augustine Health Care, Inc. Contact: Mary Lynn Leach Mail: P.O. Box 23160 Location: 4300 NW 89th Blvd. Gainesville, FL 32606 352/337-8650 Stay Well Health Plan Contact: Nancy Gareau 6800 N. Dale Mabry Hwy., Ste. 209-211 Tampa, FL 33614 813/290-6283 United Healthcare of Florida, Inc. Contact: Linna Van Nette 800 North Magnolia Ave., Suite 600 Orlando, FL 32803 407/872-1000 United ElderCare Plan 800 North Magnolia Ave., Suite 600 Orlando, FL 32803 800/643-5337

F. STATE CONTACTS State Drug Program Administrator George Kitchens Chief, Pharmacy Bureau 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: www.fdhc.state.fl.us

Agency for Health Care Administration Officials Rhonda Meadows, M.D. Secretary Agency for Health Care Administration 2727 MahanDrive, MS 1 Tallahassee, FL 32308 T: 850/922-3809 F: 850/488-0043 E-mail: [email protected] Bob Sharpe Deputy Secretary 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]

Prior Authorization Contact Jerry F. Wells Pharmacy Program Manager Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected]

DUR Contact Jerry F. Wells Pharmacy Program Manager 850/487-4441

Medicaid DUR Board Bryan Bognar, M.D. 17515 Mallard Court Lutz, FL 33549 Leanne Lai, Ph.D. 3200 South University Drive Ft. Lauderdale, FL 33328 David Levine, DPM, D.O. 111 West Broward Blvd Ft. Lauderdale, FL 33312 Earlene Lipowski, Ph.D. JHMHC Box 100496 Gainesville, FL 32610 Larry Mattingly, D.O. 2233 Park Ave, Suite 303 Orange Park, FL 32073 Jeane McCarthy, M.D., Ph.D.



880-6th Street South St. Petersburg, FL 33701 Richard Roberts, Pharm.D. 5219 Magnolia Oaks Lane Jacksonville, FL 32210

Prescribing Pattern Review Panel Cynthia Griffin, Pharm.D. C/o Humana 76 S. Laura Street Jacksonville, FL 32209 Mary Stelnicki, R.Ph. 5320 N.E. 31st Avenue Ft. Lauderdale, FL 33308 Stephen Clark, M.D. 3901 University Blvd. S. Suite 215 Jacksonville, FL 32216 James D. Ruskiv, D.M.D., M.D., FACC P.O. Box 100416 Gainesville, FL 32610 Walter Flesner, D.O. 20537 N.E. Sixth Court Miami, FL 33179 Daryl D. Wier, M.D. 1181 Orange Avenue Winter Park, FL 32789 George Thomas, M.D. 316 Manatee Ave. West Bradenton, FL 34205 Bob Windom, M.D. 5450 Eagle Point Circle Sarasota, FL 34231


First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

Medicaid Drug Rebate Contacts Jason Ottinger Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 T: 850/922-7794 F: 850/922-0685 E-mail: [email protected]

Claims Submission Contact Kevin Whittington Clinical Program Coordinator ACS 2308 Killearn Center Blvd. Tallahassee, FL 32308 850/201-1418

Medicaid Managed Care Contact Elizabeth Dudek Agency for Health Care Administration 2727 Mahan Drive, BLD 1, Rm 323 Tallahassee, FL 32308 T: 850/922-6830 F: 850/414-5418

Mail Order Pharmacy Program State has a mail order pharmacy benefit under its diabetes demonstration waiver.

Disease Management Program/Initiative Contact Hemophilia:

Michael L. Ansel Accordant Health Services 5509-A West Friendly Avenue, Ste 101 Greensboro, NC 27410 T: 336/855-5870 ext.134 F: 336/852-7413 E-mail: [email protected] George E. Hurrell, Jr. Director, Disease Management Caremark Inc. 1127 Bryn Mawr Avenue Redlands, CA 92374 T: 909/799-4160 F: 909/7998-4335 E-mail: [email protected]



AIDS:

Peter D. Reis Director of Business Development AIDS Healthcare Foundation 6255 West Sunset Blvd, 16th Fl. Los Angeles, CA 90028 T: 213/860-5200 F: 213/860-5235 E-mail: [email protected] S. Shai Gold, Director, Business and Proposal Development Center The South Florida Community Care Network 1801 NW 9th Avenue, Ste 700 Miami, FL 33136 T: 305/585-5187 F: 305/585-3815 E-mail: [email protected] Plans exist for disease management programs for End-Stage Renal Disease (ESRD) and congestive heart failure. Contact: David Rogers Program Administrator Agency for Health Care Administration 2727 Mahan Drive Tallahassee, FL 32308 T: 850/487-4642 F: 850/410-1676

Physician-Administered Drug Program Laura Rutledge 850/488-4481

Executive Officers of State Medical and Pharmaceutical Societies Florida Medical Association, Inc. Robert E. Cline, M.D. President 113 East College Avenue P.O. Box 10269 Tallahassee, FL 32302 T: 850/224-6496 F: 850/222-8030 Internet address: www.fmaonline.org

Florida Pharmacy Association Michael Jackson, R.Ph. Executive Direct 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 Joel B. Rose, D.O. President 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 State Board of Pharmacy Vacant Executive Director 4052 Bald Cypress Way Tallahassee, FL 32399-3254 T: 850/245-4292 F: 850/413-6982 E-mail: [email protected] Internet address: www.doh.state.fl.us/mga Florida Hospital Association Wayne N. Smith 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


National Pharmaceutical Council Georgia-1

GEORGIA





Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients TOTAL $580,612,920 847,730 $655,515,772 856,797 RECEIVING CASH ASSISTANCE, TOTAL $366,686,830 298,096 $422,797,389 368,161 Aged $48,636,401 33,486 $49,961,732 31,775 Blind/Disabled $291,064,893 157,467 $323,103,058 156,568 Child $13,292,609 72,236 $22,633,229 112,507 Adults $13,692,927 34,907 $27,099,370 67,311 MEDICALLY NEEDY, TOTAL $14,032,902 8,110 $15,484,179 8,446 Aged $5,217,528 3,517 $5,802,403 3,606 Blind/Disabled $8,802,364 4,565 $9,681,639 4,837 Child $12,940 27 $137 3 Adults $70 1 $0 0 POVERTY RELATED, TOTAL $57,728,991 325,482 $63,048,028 309,147 Aged $3,340,565 2,468 $3,524,685 2,335 Blind/Disabled $2,999,264 2,015 $3,102,251 2,047 Child $40,209,249 244,977 $44,949,926 230,198 Adults $11,179,913 76,022 $11,471,166 74,567 TOTAL OTHER EXPENDITURES/RECIPIENTS* $142,164,197 216,042 $154,186,176 171,043

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change.

Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Georgia National Pharmaceutical Council

C. ADMINISTRATION

Department of Community Health, Division of Medicaid

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin and disposable needles and syringe combinations used for insulin. Products covered with restrictions: blood glucose test strips (Roche products only); urine ketone test strips (Roche products only); total parenteral nutrition (21 and younger) and interdialytic parenteral nutrition (21 and younger). Products requiring prior authorization: Marinol; Epoetin; interferons; lactulose; neupogen; top.vit.A derivatives; toradol; Regranex; Viagra; PPIs; Lamisil; Sporanox; Botox; Oxycontin; brand-names and multi-source. Products not covered: cosmetics; fertility drugs; experimental drugs; prescription vitamins and minerals (except for prenatal and fluorides not in combination with other vitamins); barbituates (except Seconal); DESI drugs; and Miralax; and smoking cessation products.

Over-the-Counter Product Coverage: Products covered: analgesics (Ibuprofen suspension) covered with restriction for ages less than 21; cough and cold preparations; topical products; PIN-X; NIX; OTC iron and multivitamins; klout; and meclizine. Products not covered: allergy, asthma, and sinus products; digestive products; feminine products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamines; antilipemic 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; and immunoglobulins. Therapeutic categories not covered: anoretics and prescribed smoking deterrents.

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 and as part of the Vaccines for Children Program.


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

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: Physicians are encouraged to prescribe a 31-day supply. Some exceptions exist.

Monthly Dollar Limit: $2,999.99 requires an override; >$9,999.99 requires paper claim and a copy of the prescription.


On-line PRODUR system implemented in October 2000. State has a 20 member DUR Board (4 meetings per year).

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.63, effective 7/1/98.

Ingredient Reimbursement Basis: EAC = AWP - 10% or MFN price.

Prescription Charge Formula: Lower of average wholesale price (AWP) minus 10% plus dispensing fee, MAC plus fee, or usual and customary.

Maximum Allowable Cost: State imposes a combination of Federal Upper Limits and State- Specific Limits on generic drugs. Override requires Prior Approval. Approximately 800 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 non-preferred and brand drugs, dependent on the cost of the drug.






F. STATE CONTACTS State Drug Program Administrator Lori S. Garner, R.Ph., M.B.A., M.H.S. Director, Pharmacy Services Department of Community Health-Medicaid Division 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303-3159 T: 404/656-4044 F: 404/656-8366 E-mail: [email protected] Internet Address: http://www.dch.state.ga.us

Department of Community Health Gary Redding, 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] Mark Trail, Medicaid Director Department of Community Health 2 Peachtree Street, NW, Suite 4043 Atlanta, GA 30303-3159 T: 404/656-4496 F: 404/651-6880 E-mail: [email protected]

Prior Authorization Contact Jean Cox, R.Ph. Drug Utilization Review/Prior Approval DCH/Division of Medical Assistance 2 Peachtree Street, 37th floor Atlanta, GA 30303-3159 T: 404/657-7241 F: 404/656-8366 E-mail: [email protected]

DUR Contact Jean Cox, 404/657-7241

Medicaid DUR Board John Stephen Antalis, M.D. Dalton Family Practice, P.C. 1114 Professional Blvd. Dalton, GA 30720 Frank W. Brown, M.D., M.B.A. Wesley Woods Center 1841 Clifton Road, NE Atlanta, GA 30329 Catherine E. Burley, M.D. 7365 Old National Hwy, Suite A

Riverdale, GA 30296 J. Russell May, Pharm.D. , Chairperson Director of Pharmacy Services Department of Pharmacy Medical College of Georgia Hospital and Clinics 1120 15th Street Augusta, GA 30912-5600 Harry Strothers III, M.D., M.M.M. Professor, Family Medicine Morehouse School of Medicine Department of Family Medicine 505 Fairburn Rd. S.W. Atlanta, GA 30331 Ronald M. Barnes, M.S., R.Ph. 6025 Coventry Circle Alpharetta, GA 30004 L. Dianne Bradford, Ph.D. Morehouse School of Medicine Departments of Psychiatry and Medicine 720 Westview Drive, SW Atlanta, GA 30310-1495 Stacy Ivin Burke, Pharm.D. Publix Pharmacy 2095 Highway 211 Braselton, GA 30517 Daniel Gallina, M.D. Emory University School of Medicine Grady Health System Diabetes Unit 69 Butler Street Atlanta, GA 30303-3033 Louis Wayne Goolsby, M.D. Senior Vice President for Medical Affairs Medical Center of Central Georgia 777 Hemlock Street #146 Macon, GA 31201 Phyllis A. Johnson, R.N., Ph.D. 1010 Forest Overlook Trail, SW Atlanta, GA 30331



Robyn Anderson Lorys, Pharm.D. 2430 Laurelwood Road Atlanta, GA 30360 Calvin W. McLarin, M.D. Metropolitan Atlanta Cardiology Consultants 999 Peachtree Street, NE Suite 850 Atlanta, GA 30309 Mathew Perri III, R.Ph., Ph.D. Department of Clinical and Administrative Sciences University of Georgia College of Pharmacy DW Brooks Drive, Room 250G Athens Georgia 30602 Cynthia O’Steen-Piela, R.Ph. District Manager Wal-Mart Pharmacy 1350 Arborwood Ridge Bishop, Georgia 30621 Kimberly Rogan, R.Ph. District Manager, South Region Ekcerd Drugs 3549 Chamblee Tucker Road Tucker, GA 30341 Joseph Rosenfeld, M.D. Snapfinger Woods Pediatric 5008 Snapfinger Woods Drive Decatur, GA 30035 William Dennis Taylor, M.D. Green Acres Nursing Home 313 Allen Memorial Drive Milledgeville, GA 31061 Cynthia Wainscott 2274 Camden Drive Marietta, GA 30064 Andrew D. Weinberg, M.D., FACP 1647 Brookhaven Close, NE Atlanta, GA 30319 Prescription Price Updating Andrew Shim, Pharm.D. Clinical Program Manager Express Scripts, Inc. 6625 W. 78th Street, BL0420 Bloomington, MN 55439 T: 952/837-5326 F: 952/837-7184 E-mail: [email protected]

Medicaid Drug Rebate Contact Patricia Zeigler Jeter, M.P.A., R.Ph. Pharmacist Pharmacy Services Unit, Program Policy Section Division of Medical Assistance 2 Peachtree Street, NW 37th Floor Atlanta, GA 30303 T: 404/657-9181 F: 404/656-8366 E-mail: [email protected]

Claims Submission Contact Dustin Gruhlke Account Manager Express Scripts, Inc. 6625 W. 78th St., BL-0420 Bllomington, MN 55439 T: 952/837-7741 F: 952/837-7741 E-mail: [email protected]

Medicaid Managed Care Contact Kathy Driggers Director, Managed Care Department of Community Health 2 Peachtree Street, NW Atlanta, Georgia 30303 T: 404/657-7793 F: 404/656-8366 E-mail: [email protected]

Disease Management Program/Initiative Contact Charmaine Heard, M.D. Medical Director Department of Community Health 2 Peachtree Street, NW, 37th Floor Atlanta, Georgia 30303 T: 404/463-7638 F: 404/656-8366 E-mail: [email protected]

Mail Order Pharmacy Benefits None

Physician-Administered Drug Program Contact Margie Preston, R.N. 2 Peachtree Street, N.E. Atlanta, Georgia 30303 404/656-3961



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

Pharmacy Advisory Committee Ifeanyi J. Anikpe, Pharm.D. Washington Road Pharmacy 3518 Washington Road East Point, GA 30344 Anthony Compton, Pharm.D. Pharmacy Manager Saint Joseph’s Hospital of Atlanta 2783 Harvest Drive Conyers, GA 30013 Amanda R. Gaddy, R.Ph. Kroger 131 Windsong Drive Stockbridge, GA 30281 Ted M. Hunt, R.Ph. General Manger PharMerica 1100 Wilson Way, Suite 500 Smyrna, GA 30082 Leslie M. Litton Executive Director Kaiser Permanente 9 Piedmont Center 3495 Piedmont Rd. NE Atlanta, GA 30082 Scott Moody, Pharm.D. Regional Manager, Pro Glaxo Wellcome, Inc. 9306 Fall Court West Brentwood, TN 37027 Malcolm “Mickey” Tatum, R.Ph. Dinglewood Pharmacy 1819 Wynnton Road Columbus, GA 31902 Homer L. Whelchel, R.Ph. President, CEO Berrien Health Center P.O. Box 866 Nashville, GA 31639-0866 Julie M. Wickman, Pharm.D.

Mercer University 593 Cantebury Lane Winder, GA 30680 Ellen Whipple Guthrie, Pharm.D. Pharmacy Manager The Shepard Center 2020 Peachtree Rd., NW Atlanta, GA 30309 Timara Faulkner Rembert, Pharm.D. 87 Buckeye Loop Midland, GA 31820

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 Internet address: www.mag.org Georgia Pharmaceutical Association Oren “Buddy” Harden, Jr. Chief Executive Officer 50 Lenox Pointe, NE Atlanta, GA 30324-3170 T: 404/231-5074 F: 404/237-8435 Internet address: www.gpha.org Osteopathic Medical Association Sheila J. Smith, D.O. President 2037 Grayson Highway, Suite 200 Grayson, GA 30017 T: 770/493-9278 F: 770/908-3210 E-mail: www.goma.org State Board of Pharmacy Anita O. Martin Executive Director 237 Coliseum Drive Macon, GA 31217-3858 T: 478/207-1686 F: 404/656-0513 Internet address: www.sos.state.ga.us/plb, pharmacy Georgia State Medical Association



Katherine Daniels Executive Director Morehouse School of Medicine 720 Westview Drive, SW Atlanta, GA 30310-1495 T: 404/752-1564 F: 404/752-1024 Internet address: www.gastatemedicalassoc.org Georgia Hospital Association Joseph A. Parker President 1675 Terrell Mill Road Marietta, GA 30067 T: 770/249-4522 F: 770/955-5801 Internet address: www.gha.org


National Pharmaceutical Council Hawaii-1

HAWAII



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $44,849,669 35,687 $74,869,859 RECEIVING CASH ASSISTANCE TOTAL $26,683,919 19,797 Aged $7,181,063 7,581 Blind/Disabled $19,457,302 11,436 Child $10,145 364 Adult $35,409 416 MEDICALLY NEEDY, TOTAL $2,533,810 1,915 Aged $1,799,925 1,555 Blind/Disabled $733,885 360 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $15,209,816 12,118 Aged $6,660,312 6,911 Blind/Disabled $8,481,521 4,460 Child $9,495 192 Adult $58,488 555 TOTAL OTHER EXPENDITURES/RECIPIENTS* $422,119 1,857

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Note: Hawaii estimates 2002 drug expenditures to be $80 million. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Hawaii National Pharmaceutical Council

C. ADMINISTRATION

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

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 requiring prior authorization: total parenteral nutrition (for home infusion); interdialytic parenteral nutrition (for home infusion); Clorazil; Procardia XL; Norvasc; brand products on FUL price list; and Betaseron. Products not covered: cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Limited coverage for allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; and topical products. Products not covered: smoking deterrent products.

Therapeutic Category Coverage: Products covered: antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anxiolytics; sedatives; and hypnotics; cardiac drugs; contraceptives; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents Prior authorization required for: anabolic steroids; analgesics, antysyretics, and single source NSAIDs; anorectics; non-sedating antihistamine drugs; atypical anti-psychotics; chemotherapy agents; prescribed cold medications; proton pump inhibitors; and growth hormones. Products not covered: prescribed smoking deterrents.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, extended care facilities, and physicians offices.

Vaccines: Vaccines reimbursable as part of EPSDT service, CHIP, and covered by the Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable



Prior Authorization: State currently has a formal prior authorization procedure. A fair hearing may be requested for appeal of prior authorization decisions.

Prescribing or Dispensing Limitations Monthly Quantity Limit: Physicians are encouraged to prescribe a 30-day supply or 100 units.


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 = AWP-10.5%.

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 AWP-10.5% when equal to average selling price plus dispensing fee, or billed amount, whichever is lowest.

Maximum Allowable Cost: State imposed Federal Upper Limits and State-specific limits on generic drugs. Override requires “Medically Necessary” as “Brand Medically Necessary”.


Patient Cost Sharing: No copayment.



Approximately 135,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through State/managed care plans or both. State has specific guidelines for the pharmacy benefit for Medicaid recipients enrolled in managed care plans.

Managed Care Organizations AlohaCare, Inc. Mr. John McComas 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814 808/973-1650 Hawaii Medical Service Association (HMSA) Andreas Carvalho, Director QUEST Administration 818 Keeaumoku Street Honolulu, HI 96808 808/948-5250 Kaiser Foundation Health Plan, Inc.


National Pharmaceutical Council Hawaii-3

Ms. Virginia Vierra 1441 Kapliolani Blvd, Suite 1600 Honolulu, HI 96814 808/944-0261 Behavioral Health Services Community Care Services (CCS) Sharon Yoshiura or Carolyn Gire 810 N. Vineyard Blvd. Honolulu, HI 96817 T: 808/948-5379 F: 808/948-6588

F. STATE CONTACTS Medicaid Drug Program Administrator Lynn Donovan, R.Ph. Pharmacy Consultant Med-Quest Division P.O. Box 700190 Kapolei, HI 96709-0190 T: 808/692-8116 F: 808/692-8131

Prior Authorization Contact Lynn S. Donovan, R.Ph. 808/692-8116 DUR Contact Kathleen Kang-Kaulupali DUR Coordinator Med-Quest Division P.O. Box 700190 601 Kamokila Blvd., Room 506 B Kapolei, HI 96709-0190 T: 808/692-8065 F: 808/692-8131

Medicaid DUR Board Myron Shirasu, M.D. (Internal Medicine) 321 North Kuakini Street #200 Honolulu, HI 96817 808/523-8611

Gregory E.M. Yuen, M.D. (Psychiatry) 1188 Bishop Street, Suite 806 Honolulu, HI 96813 808/599-5050

Linda Tom MD (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, R.Ph. (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 201 Hamakua Drive, Building B Kailua, HI 96734 808/432-3454

Kerry Kitsu, R.Ph. (Community, chain) DHS/MQD/MSB P.O. Box 700190 Kapolei, HI 96709-0190 808/692-8065

Carl Mudrick, R.Ph. (Community, independent) 750 Palani Avenue Honolulu. HI 96816 808/739-1188

Prescription Price Updating First Data Bank 111 Bayhill Dr. San Bruno, CA 94066 800/633-3453

Medicaid Drug Rebate Contacts Technical: Lynn Donovan, 808/692-8116 Policy: Lynn Donovan, 808/692-8116 Audits: Lynn Donovan, 808/692-8116 DUR: Kathleen Kang-Kaulupali, 808/692-8065

Claims Submission Contact Med. - Supplies: ACS P.O. Box 1220 Honolulu, HI 96807-1220 808/952-5570 Drugs:

ACS Heather Bodiford Attn: Hawaii Medicaid 9040 Roswell, Road, Suite 700 Atlanta, Georgia 30350


4-Hawaii National Pharmaceutical Council

T: 800/358-2381 F: 770/730-5198 E-mail: [email protected]

Disease Management/Patient Education Contact Susan Oh Clinical Services Manager ACS T: 800/358-2381 E-mail: [email protected]


Department of Human Services Officials Lillian Koller Director Department of Human Services P.O. Box 339 Honolulu, HI 96809-0339 T: 808/586-4997 F: 808/586-4890 E-mail: [email protected] Aileen Hiramatsu Administrator, Med-Quest Division Department of Human Services P.O. Box 700190 Kapolei, HI 96809-0339 T: 808/692-8050 F: 808/586-4890 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Hawaii Medical Association Paula Arcena Executive Director 1360 S. Beretania Street, Suite 100 Honolulu, HI 96814-1520 T: 808/536-7702 F: 808/528-2376 E-mail: [email protected] Internet address: www.hmaonline.net Hawaii Pharmacist Association Les Krenk President P. O. Box 1198 Honolulu, HI 96807-1198 T: 808/877-6222 F: 808/432-5535 E-mail: [email protected] Association of Osteopathic Physicians and Surgeons Brenda Dela Cruz 545 Ohohia Street Honolulu, HI 96819 T: 808/831-3000 F: 808/834-5763

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/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


National Pharmaceutical Council Idaho-1

IDAHO



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $83,525,730 92,776 $105,473,425 112,357 RECEIVING CASH ASSISTANCE, TOTAL $52,792,616 20,936 $64,871,126 22,489 Aged $4,481,474 2,040 $4,947,969 2,016 Blind/Disabled $48,041,510 17,913 $59,411,640 19,271 Child $164,562 799 $280,234 963 Adult $105,070 184 $231,283 239 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $6,389,472 42,534 $10,152,018 55,312 Aged $44,337 52 $139,939 93 Blind/Disabled $190,496 126 $160,823 132 Child $5,335,356 36,583 $8,806,102 48,702 Adult $819,283 5,773 $1,045,154 6,385 TOTAL OTHER EXPENDITURES/RECIPIENTS* $24,343,642 29,306 $30,450,281 34,556

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Idaho National Pharmaceutical Council

C. ADMINISTRATION Division of Medicaid Idaho Department of Health & Welfare

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

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition. Note: blood glucose test strips; urine ketone test strips; and total parenteral nutrition are DME items and do not fall under the pharmacy program.

OTC Coverage: Products covered: permethrin; oral iron salts; insulin and insulin syringes. Products not covered: allergy, asthma, and sinus; analgesics, cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; 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; misc. sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics; antipyretics, and NSAIDs; antihistamines; misc. GI drugs; amphetamines; provigil; aldara; synagis; regranex; retinoids; andragel; prolastin; and brand names of FUL and SMAC drugs. Therapeutic categories not covered: anorectics and prescribed smoking deterrents.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians offices.

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

Unit Dose: Unit dose packaging reimbursable when used in unit dose systems.

Formulary Authorization Formulary: Open formulary.

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

committee. Written “notice of appeal” required for fair hearing.

Prescribing or Dispensing Limitations Monthly Quantity Limit: Prescription drugs are limited to a 34-day supply. The following drugs are limited to a 100-day supply: Digoxin, thyroids, prenatal vitamins, nitroglycerin, fluoride, fluoride and vitamin combinations, non-legend oral iron salts and 3 cycles of birth control.


Contracted DUR through Idaho State University. PRODUR system implemented January 1998. State currently has a DUR board with a quarterly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.94 ($5.54 for unit dose), effective March 1999.

Ingredient Reimbursement Basis: EAC = AWP-12% as determined by First DataBank Data File Service or manufacturer direct price for selected manufacturers.

Prescription Charge Formula: Lower of FUL, SMAC or EAC plus a dispensing fee or provider’s usual and customary price to the general public.

Maximum Allowable Cost: State imposes Federal Upper Limits and State-specific limits on generic drugs. Override requires prior authorization. Pharmacy must provide invoice or pharmacy showing that they are charging below cost.





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


National Pharmaceutical Council Idaho-3

F. STATE CONTACTS Medicaid Drug Program Administrator Shawna Kittridge, R.Ph., M.H.S. Medicaid Drug Program Supervisor Department of Health and Welfare Division of Medicaid Bureau of Care Management HR 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 T: 208/364-1956 F: 208/364-1864 E-mail: [email protected] Internet Address: www.state.id.us/dhw/medicaid/providers/pharmacy.htm

Prior Authorization Contact Shawna Kittridge, R.Ph., M.H.S., 208/364-1956

DUR Contact Tamara Eide, Pharm.D., BCPS, FASHP Pharmacy Service Specialist Department of Health and Welfare Division of Medicaid Bureau of Care Management 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 208/364-1821 E-mail: [email protected]

Medicaid DUR Board Board Members: Gary Wilburn, R.Ph. Don Smith, R.Ph. Kent Jensen, R.Ph. Joseph Steiner, Pharm. D. Nancy Mann, M.D. E. Gregory Thompson, M.D. Robert Ting, M.D. Staff: Tamara Eide, Pharm. D., Dept. Contact Vaughn Culbertson, Pharm.D. Project Dir.

Prescription Price Updating Kaydeen Burkett, R.Ph. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid Bureau of Care Management 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 208/364-1826 E-mail: [email protected]

Medicaid Drug Rebate Contact Carl Jefferey, Pharm. D. Pharmacy Services Specialist Department of Health and Welfare

Division of Medicaid Bureau of Care Management 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 208/364-1832 E-mail: [email protected]

Claims Submission Contact EDS P.O. Box 23 Boise, ID 83707 T: 208/395-2000 F: 208/395-2030

Medicaid Managed Care Contact Robin Pewtress Alternate Care Coordinator P.O. Box 83720 Boise, ID 83720 T: 208/364-1892 F: 208/364-1911 E-mail: [email protected]

Mail Order Pharmacy Program State currently has a mail order pharmacy program. Pharmacy must be a registered Idaho Medicaid provider.

Physician-Administered Drug Program Contact Robbie Charlton Medicaid Policy PO Box 83720 Boise, ID 83720-0036

Health and Welfare Department Officials Karl Kurtz, Director Dept. of Health & Welfare 450 West State Street PO Box 83720 Boise, Idaho 83720-0036 T: 208/334-5500 F: 208/334-6558 E-mail: [email protected] Bureau of Medicaid Care Mgmt. Ike Gayfield, Bureau Chief Randy May, Interim Medicaid Administration Shawna Kittridge, R.Ph., Pharmacy Services Supervisor Tom Young, M.D., Medical Director

Title XIX Medical Care Advisory Committee JoAn Condie Idaho State Pharmacy Association Greg Dickerson Mental Health Providers Association


4-Idaho National Pharmaceutical Council

Bill Foxcroft Idaho Primary Care Association Bonnie Haines Idaho Hospital Association Linda Johnson (Individual) Deedra Kucera (Aged Community) Mark Leeper (Disabled Community) Marla Lewis Kootenai County Welfare Department Randy Robinson Legal Aid-Lewiston Robert VandeMerwe Idaho HealthCare Association Bob Seehusen Idaho Medical Association Mitzi Smith St. Luke’s Hospital Gene Wiggers (Chairperson) AARP Executive Officers of State Medical and Pharmaceutical Societies Idaho Medical Association Robert Seehusen, CEO 305 West Jefferson Boise, ID 83701 T: 208/344-7888 F: 208/344-7903 E-mail: [email protected] Internet address: www.imed.org 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

Idaho Osteopathic Medical Association -Inactive State Board of Pharmacy Richard K. Markuson Executive Director 3380 Americana Terrace, Suite 320 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


National Pharmaceutical Council Illinois-1

ILLINOIS1



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001**

Expenditures Recipients Expenditures Recipients TOTAL $847,001,431 1,013,254 $975,308,665 1,068,512 RECEIVING CASH ASSISTANCE TOTAL $331,464,185 314,029 $330,554,700 241,558 Aged $36,629,569 19,225 $39,705,433 19,211 Blind/Disabled $261,163,109 122,778 $270,172,401 120,775 Child $13,779,760 116,293 $9,671,068 71,477 Adult $19,891,747 55,733 $11,005,798 30,095 MEDICALLY NEEDY, TOTAL $402,152,932 254,191 $458,851,724 294,439 Aged $119,518,205 58,482 $128,714,145 61,241 Blind/Disabled $236,268,215 84,298 $270,986,820 93,060 Child $512,937 846 $620,921 783 Adult $45,853,575 110,565 $58,529,838 139,355 POVERTY RELATED, TOTAL $68,711,632 362,584 $84,313,807 456,812 Aged $5,525,333 3,869 $3,621,230 2,432 Blind/Disabled $11,633,989 5,521 $9,303,294 3,666 Child $46,879,148 313,744 $64,770,113 404,559 Adult $4,673,126 39,414 $6,619,170 46,155 OTHER EXPENDITURES/RECIPIENTS* $44,672,682 82,486 $101,588,434 75,703

1 The State of Illinois did not respond to either the 2001 or 2002 NPC Surveys. Using CMS data and other source materials, we have to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Illinois Medicaid program to assess the accuracy and currency of the information included.



2-Illinois National Pharmaceutical Council

C. ADMINISTRATION Illinois Department of Public Aid, Division of Medical Assistance.

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. Prior authorization required: syringe combinations used for insulin. Products covered with restrictions: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI-ineffectives; fertility drugs; and experimental drugs.

OTC Coverage: Products covered: analgesics and smoking deterrent products. Products requiring prior authorization: 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: analgesics, antipyretics, and NSAIDs; antibiotics; anticogulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Partial coverage: antihistamines; anxiolytics, sedatives, and hypnotics; and estrogens. Prior authorization required: ENT anti-inflammatory agents; growth hormones; and Cox II’s. Products not covered: anoretics and prescribed cold medications.

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 are reimbursable as part of the Vaccines for Children Program.



Prior Authorization: State currently has a formal prior authorization procedure and a Committee on Drugs and Therapeutics. Recipient must file an appeal with their local office in order to appeal prior authorization decisions. To appeal the coverage of an excluded product, the recipient can request the opportunity to appear before the Committee on Drugs and Therapeutics.

Prescribing or Dispensing Limitations Prescription Refill Limit: Maximum of eleven refills.

Monthly Quantity Limit: As medically appropriate. Also edit for maximum daily quantities.

Drug Utilization Review PRODUR system implemented in January 1993. State currently has a DUR board which meets as needed.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.00 for branded drugs; $5.10 for generics. Effective 7/1/00.

Ingredient Reimbursement Basis: EAC = B: AWP-11%; G: AWP-20%.

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. Generics priced at the lower of the NDC, FUL, state MAC, or AWP-20%. Override requires prior authorization.


Patient Cost Sharing: $1.00 for both branded drugs and generics.


E. USE OF MANAGED CARE Approximately 140,000 Medicaid recipients were voluntarily enrolled in MCOs in 2001. Recipients receive pharmaceutical benefits through managed care plans.



Managed Care Organizations Amerigroup Illinois 211 Wacker Drive Suite 1350 Chicago, IL 60606-3101 United Health Care of IL 233 N. Michigan Ave. 8th Fl-12th Fl. Chicago, IL 60601 Harmony Health Plan of Illinois 125 South Wacker Drive Suite 2900 Chicago, IL 60606-4402 Harmony Health Plan 23 Public Square Belleville, IL 62220 Humana Health Plan 30 South Wacker Drive Suite 3100 Chicago, IL 60606 Family Health Network 910 West Van Buren 6th Floor Chicago, IL 60607-3523

F. STATE CONTACTS State Drug Program Administrator Marvin L. Hazelwood, Manager Pharmacy and Ancillary Services Programs Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut St. Springfield, IL 62702 T: 217/524-5565 F: 217/524-7194 E-mail: [email protected] Internet address: http://www.state.il.us/dpa/

Prior Authorization Contact Pharmacy Unit Staff 217/782-5565

DUR Contact Marvin L. Hazelwood 217/524-5565

Prescription Price Updating First DataBank 111 Bayhill Dr. San Bruno, CA 94066

650/588-5454

Medicaid Drug Rebate Contact Brandley Wallner Manager Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62704 217/785-6114 E-mail: [email protected]

Medicaid Managed Care Contact Bureau of Managed Care Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, Illinois 62763 T: 217/524-7478 F: 217/524-7535 E-mail:[email protected]


Elderly Expanded Drug Coverage Program Susan Coombe, Supervisor Circuit Breaker Program Illinois Department of Revenue 101 W. Jefferson - Level 3- 250 Springfield, Illinois 62794 217/785-2097

Physician-Administered Drug Program Contact Cheryl Bechner 217/782-5565

Illinois Medicaid Agency Officials 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] A. George Hovanec, Administrator Division of Medicaid Programs Illinois Department of Public Aid 201 South Grand Avenue, East, Third Floor Springfield, IL 62763-0001 T: 217/782-2570 F: 217/524-7979



Title XIX Medical Care Advisory Committees State Medical Advisory Committee Arthur Traugott, M.D. 32207 Weisiger Way Urbana, IL 61801 Committee on Drugs and Therapeutics Marshall Blankenship, M.D., Chairman 1555 Astor Avenue Chicago, IL 60610 708/636-3757 Nicholas C. Bellios, M.D. 2504 Washington Waukegan, IL 60085 708/249-3660 Armand Littman, M.D. Medical Services Hines VA Hospital Hines, IL 60141 708/216-2006 Vincent A. Costanzo, Jr., M.D. 7501 South Stony Island Avenue Chicago, IL 60649 312/995-1075 Theodore M. Kanellakes, M.D. 229 N. Hammes Avenue Joliet, IL 60435 815/744-2300 Patrick R. Staunton, M.D. 156 N. Oak Park Avenue Oak Park, IL 60301 708/696-5887 Board of Trustees Phillip D. Boren, M.D. Doctor's Clinic S. Plum Street Carmi, IL 62821 618/382-4193 Joan E. Cummings, M.D. Extended Care 181 Hines VA Hospital Building 1, Room C-124D Hines, IL 60141 708/343-7200 ext. 5057 David B. Littman, M.D. 1030 Old Elm Road

Highland Park, IL 60035 708/433-3900 Richard P. Snodgrass, M.D. 550 30th Avenue Moline, IL 61265 309/764-1910 IDPA Representative Marvin Hazelwood Illinois Department of Public Aid 1001 N. Walnut St. Springfield, IL 62702 217/524-7112 Illinois State Medical Society Kenneth E. Ryan Director, Department of Economics 20 N. Michigan Avenue, Suite 700 Chicago, IL 60602 312/782-1654 IDPH Representative: Ron Gottrich, R.Ph Illinois Department of Public Health 525 W. Jefferson Springfield, IL 62761 217/782-7532

Executive Officers of State Medical and Pharmaceutical Societies Illinois State Medical Society William E. Kobler, 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 Terri McEntaffer, R.Ph., CAE Executive Director 204 West Cook 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 Gary Knepp President 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 State Board of Pharmacy Judy Cullen Pharmacy Coordinator Illinois Department of Professional Regulation Pharmacy Section 320 West Washington Street, 3rd Floor Springfield, IL 62786 T: 217/782-8556 F: 217/782-7645 Internet address: www.dpr.state.il.us Illinois Hospital and Health Systems Association Kenneth C. Robbins President Center for Health Affairs 1151 East Warrenville Road P.O. Box 3015 Naperville, IL 60566-7015 T: 630/505-7777 F: 630/505-9457 Internet address: www.ihatoday.org




National Pharmaceutical Council Indiana-1

INDIANA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE Type of Benefit Categorically Needy Medically Needy (MN) Other



Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients

TOTAL $464,982,829 420,041 $562,120,344 464,879 RECEIVING CASH ASSISTANCE, TOTAL $228,983,212 167,338 $277,174,243 188,399 Aged $41,456,711 16,201 $47,951,486 16,531 Blind/Disabled $161,118,015 53,734 $190,763,506 56,296 Child $10,263,863 58,420 $15,067,039 69,054 Adult $16,144,623 38,983 $23,392,212 46,518 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $35,072,606 130,043 $48,080,747 146,488 Aged $337,019 397 $304,966 378 Blind/Disabled $475,865 543 $535,916 566 Child $33,151,471 120,008 $46,038,486 136,278 Adult $1,108,251 9,095 $1,201,379 9,266 TOTAL OTHER EXPENDITURES/RECIPENTS* $200,927,011 122,660 $236,865,354 129,992



2-Indiana National Pharmaceutical Council

C. ADMINISTRATION

Office of Medicaid Policy and Planning


Benefit Design

Drug Benefit Product Coverage: Products covered: All FDA-approved legend drugs from rebating labelers, excluding those products specifically non-covered by state law (e.g., cosmetics; enhancement drugs; and experimental drugs).

Over-the-Counter Product Coverage: Indiana has a Medicaid OTC drug formulary. Listed drugs are reimbursed based on State MAC.

Therapeutic Category Coverage: All coverage in accordance with OBRA ’90 & ’93.

Coverage of Injectables: Covered.

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

Unit Dose: In accordance with OBRA 1990 Requirements. MCFA policy only.


Formulary: Preferred Drug List

Prior Authorization: State has a prior authorization program with formal appeal process.


Monthly Quantity Limit: 34-day supply for maintenance drugs.

Drug Utilization Review PRODUR system implemented in March 1996. State currently has a DUR Board with a monthly review.


Ingredient Reimbursement Basis:

EAC = Brand: AWP-13.5% Generic: AWP-20%

Legend Drug Reimbursement Methodology:

Lower/Lowest of:

1. Federal MAC, if applicable, plus a dispensing fee.

2. State MAC, if applicable, plus a dispensing fee.

3. EAC plus a dispensing fee.

4. 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. “Brand Medically Necessary” requires prior authorization as of September 2001.


Patient Cost Sharing: Copayment varies from $0.50 to $3.00 for branded drugs and is $0.50 for generic drugs.

Cognitive Services: None.


Approximately 105,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through managed care plans.

Managed Care Organizations Harmony Health Management, Inc. 504 Broadway, Suite 200 Gary, IN 46404-4300

Managed Health Services 1099 N. Meridian Street, Suite 400 Indianapolis, IN 46204

MDwise 1099 N. Meridian Street, Suite 320 Indianapolis, IN 46204

F. STATE CONTACTS State Drug Program* Marc Shirley, R.Ph. Pharmacy Program Director Office of Medicaid Policy and Planning Room W382 Indiana State Government Center South 402 W. Washington Street Indianapolis, IN 46204-2739 T: 317/232-4343 F: 317/232-7382 E-mail: [email protected] *Do not contact state staff with requests for survey information. All industry information requests and inquiries by or on behalf of pharmaceutical manufacturers must be directed via e-mail to: ACS



David George [email protected]

No Phone Surveys Will Be Accepted! DUR Contact Karen Clifton DUR Board Secretary Office of Medicaid Policy & Planning Room W382, Indiana Sate Government Center South, 402 West Washington St. Indianapolis, IN 46204 T: 317/232-4391 F: 317/232-7382 E-mail: [email protected]

Medicaid DUR Board Physicians Neil Irick, M.D. Patricia Treadwell, M.D. John J. Wernert, M.D. Philip N. Eskew, Jr., M.D. Pharmacists Paula Ceh, Pharm.D. Brian Musial, R.Ph. Thomas A. Smith, P.D., M.S. G. Thomas Wilson, B.S. Pharm., J.D. Health Care Economist Marko Mychaskiw, R.Ph., Ph.D. Pharmacologist Terry Lindstrom, Ph.D. Representative from HMO Vicki Perry

Prescription Pricing Updating First DataBank 1111 Bay Hill Drive San Bruno, CA 94066 650/588-5454

Medicaid Drug Rebate Contacts ACS [email protected]

Claims Submission Contact ACS [email protected]

Medicaid Managed Care Contact John Barth Managed Care Director Office of Medicaid Policy and Planning 402 W. Washington St Room W382, MS07 Indianapolis, IN 46204 T: 317/233-4697

F: 317/232-7382


Physician-Administered Drug Program Contact ACS [email protected]

Administration Officials Melanie Bella Assistant Secretary Medicaid Policy & Planning Indiana Family & Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN 46204 T: 317/233-4455 F: 317/232-7382 John Barth Managed Care Director 317/233-4697 Pat Nolting, Director Medicaid Program Operations – Acute Care 317/232-4318

Medicaid Advisory Committee John B. DeLap 2365 Chestnut Street Columbus, IN 47201 Deborah A. Freund 1327 East First Street Bloomington, IN 47402 Eleanor DeArman Kinney 5140 Reed Road Indianapolis, IN 46254



Kayla Templin West 1014 N. Arsenal Avenue Indianapolis, IN 46201 Edward A. White, D.O. 410 North Main Street Princeton, IN 47670-1516 Beverly Richards, D.N.S., R.N. Indiana St. Nurses Association 2915 North High School Road Indianapolis, IN 46224-2969 David Giles, M.D. 6934 Hillsdale Court Indianapolis, IN 46250 L. Richard Gohman One American Sq. - Suite 1100 Indianapolis, IN 46204 Polly E. Hendricks, O.D. 3222 Oceanline E. Drive Indianapolis, IN 46214 James F. Jones, M.S. 101 W. Ohio Street - Suite 610 Indianapolis, IN 46204 Mike Weber Indiana Health Care Association One N. Capital, Suite 1115 Indianapolis, IN 46204 Anna Schenk, Pres., ILPNA 1501 W. 500 North Marion, IN 47952 Paul C. Johnson, D.D.S. 8240 Naab Road Indianapolis, IN 46260 Robin Taylor, R.Ph., President Healthcare Prescription Svs, Inc. 3830 E. Southport Road, Suite C Indianapolis, IN 46237 Greg Wilson, M.D. Developmental Pediatrics 702 Barnhill Dr., Room 1601 Indianapolis, IN 46202 Sen. Marvin Riegsecker 801 S. 6th Street Goshen, IN 46526

Rep. William Crawford PO Box 18446 Indianapolis, IN 46218-0446 Rep. Jeffrey K. Espich 1250 W. Hancock Street, Box 158 Uniondale, IN 46791 Vickie Trout Division of Mental Health 402 W. Washington - W 353 Indianapolis, IN 46204 David Harris 125 East 48th Street Indianapolis, IN 46205 Donald Mulligan, Sr. 6185 Broughton Portage, IN 46368 Barry Delks 21 Peregrine Court West Lafayette, IN 47906 Lula E. Baxter 9710 East 38th Street Indianapolis, IN 46236 R. Stanley Wilson, M.D. 3 Hazelwood Drive Vinciennes, IN 47591 Paul Schneider, Ph.D. 6320 Latona Court Indianapolis, IN 46278 Robert S. Mandresh, D.P.M. 3351 N. Meridian #101 Indianapolis, IN 46208 Chip Garver 101 West Ohio, Suite 560 Indianapolis, IN 46204 Michael Sullivan Ind. Assn. For Home Care, Inc. 8888 Keystone Crossing Suite 1000 Indianapolis, IN 46202 Louis Cantor, M.D. 702 Rotary Circle Indianapolis, IN 46202



Joe D. Hunt, Director Bureau of Policy Development State Department of Health 1330 W. Michigan Street Indianapolis, IN 46202

Executive Officers of State Medical and Pharmaceutical Societies Indiana State Medical Association Richard R. King, J.D. Executive Director 322 Canal Walk, Canal Level 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 Terry Iwasko, D.O. President 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 State Board of Pharmacy Joshua Bolin Director 402 W. Washington Street, Room 041 Indianapolis, IN 46204-2739 T: 317/234-2067 F: 317/233-4236 Email: [email protected] Internet address: www.in.gov/hpb/boards/isbp Indiana Hospital and Health Association Kenneth G. Stella President One American Square P.O. Box 82063 Indianapolis, IN 46282 T: 317/633-4870 F: 317/633-4875 Internet address: www.inha.org




National Pharmaceutical Council Iowa-1

IOWA



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $193,832,443 212,178 $230,430,967 221,691 RECEIVING CASH ASSISTANCE TOTAL $100,555,605 103,217 $114,379,584 106,099 Aged $13,767,752 7,089 $14,750,173 6,734 Blind/Disabled $71,452,959 32,561 $81,135,611 32,484 Child $6,199,907 37,726 $7,586,771 39,126 Adult $9,134,987 25,841 $10,907,029 27,755 MEDICALLY NEEDY, TOTAL $11,931,960 6,673 $13,202,042 6,191 Aged $4,201,568 2,643 $3,922,542 2,287 Blind/Disabled $6,624,010 2,352 $7,976,548 2,034 Child $224,083 272 $154,791 278 Adult $882,299 1,406 $1,148,161 1,592 POVERTY RELATED, TOTAL $7,214,153 42,643 $8,996,176 46,728 Aged $586,638 1,037 $513,385 843 Blind/Disabled $791,858 896 $740,862 756 Child $4,928,129 33,469 $6,629,188 37,819 Adult $907,528 7,241 $1,112,741 7,310 TOTAL OTHER EXPENDITURES/RECIPIENTS* $74,130,725 59,645 $93,853,165 62,673 *Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Iowa National Pharmaceutical Council

C. ADMINISTRATION

State Department of Human Services, Bureau of Long Term Care.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered requiring prior authorization: PPIs; dipyridamole; epoetin; filgrastim; vitamins and minerals; ergotamine derivatives; narcotic agonist-antagonist nasal sprays; isotretinoin; oral antifungals; non-parenteral vasopressin derivatives; and Serotonin 5-HT1 receptor agonists. Products not covered: fertility drugs; experimental drugs; cosmetics; disposable needles and syringe combinations for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered with restriction (selected products): allergy, asthma and sinus products; analgesics; cough and cold preparations; and topical products. Products not covered: digestive products (non-H2 antagonists and H2 antagonists); feminine products; and smoking deterrent products.

The Iowa Department of Human Services adopted an administrative rule that permits coverage for these non-prescription drugs:

− Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin Enteric Coated: 325/650mg Tabs; 81mg Chewable; Aspirin Tablets Buffered, 325 mg

− Acetaminophen: 325/500mg Tablets; 120mg/5ml and 160mg/5mL Elixir; 100 mg/ml Solution; 120mg Suppositories

− Bacitracin Ointment 500 units/gm − Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,

Cream, Gel − Chlorpheniramine Maleate Tablets 4 mg − Diphenhydramine Hydrochloride: 25 mg Capsules;

6.25mg/5mL and 12.5mg/5ml Liquid − Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml

Elixir; 75 mg/0.6 ml Drops − Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml

Elixir − Ferrous Fumarate Tablets 300 mg, 325 mg − Guafenesin 100 mg/5 ml with Dextromethorphan 10

mg/5 ml liquid − Meclizine Hydrochloride Tablets 15.5 mg, 25 mg − Miconazole Nitrate: Topical and Vaginal Cream 2%,

Vaginal Suppositories, 100mg − Nicotinic Acid (Niacin) Tablets: 25/50/100/250/500

mg − Pediatric Oral Electrolyte Solutions − Permethrin Liquid 1%

− Pseudoephedrine Hydrochloride: 30/60 mg Tablets; 30mg/5mg Liquid

− Salicylic Acid Liquid 17% − Senokot: 326 mg/tsp Granules for children aged 20

and under; 187 mg Tablets for children aged 20 and under

− Sodium Chloride Solution 0.9% for inhalation, with metered dispensing valve 90 ml, 240 ml

− Tolnaftate 1% Cream, Solution, Powder − Nonprescription multiple vitamin and mineral

products specifically formulated and recommended for use as a dietary supplement during pregnancy and lactation

− With prior authorization, nonprescription multiple vitamins and minerals under the conditions specified in subparagraph 78.1(2) “a” (3)

− Insulin − Oral solid forms of the above-covered items shall be

prescribed and dispensed in a minimum quantity of 100 units per prescription or the currently available consumer package size except when dispensed via a unit dose system. When used for maintenance therapy, all of the above-listed items may be prescribed and dispensed in 90-day quantities

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; amphetamines; antihistamine drugs; growth hormones; and misc. GI drugs. Therapeutic categories not covered: anorectics; prescribed smoking deterrents; drugs for strictly cosmetic purposes and hair growth; fertility drugs; and drugs without signed Medicaid rebate agreements.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program and physician payment when used in physicians offices.

Vaccines: Vaccines reimbursable as part of the EPSDT service and the Vaccines for Children Program.




Formulary/Prior Authorization Formulary: No formulary. Prior Authorization: State currently has a formal prior authorization procedure. State appeals and a fair hearing procedure required for appeal of prior authorization decisions and coverage of an excluded product.

Prescribing and Dispensing Limitations: Prescribing or Dispensing Limitations: 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 PRODUR system implemented in July 1997. State currently has a DUR Board with a monthly review.


Ingredient Reimbursement Basis: EAC = AWP-10%.

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,” completion of a Med watch form, and prior authorization.


Patient Cost Sharing: Copayment of $1.00 for branded and generic (federal exclusions) products.



Approximately 110,000 Medicaid beneficiaries are enrolled in managed care organizations. Iowa Medicaid recipients enrolled in managed care receive pharmaceutical benefits through the State.

Managed Care Organizations John Deere Health Care, Inc. Kristine Klaver 1300 River Drive, Suite 200 Moline, IL 61265-1368 309/765-1482 Timothy J. Gibson Area Manager, Central Iowa

4201 Westown Parkway, Suite 325 West DesMoines, IA 50266-6270 515/327-2004 Coventry Health Care of Iowa Jennifer Goodell Account Manager 4600 Westown Parkway, Suite 301 Des Moines, IA 50266 515/225-1234

Iowa Health Solutions Bob Wilcox Vice President 2550 Middle Road, Suite 405 Bettendorf, IA 52722 319/359-8999

F. STATE CONTACTS State Drug Program Administrator Susan L. Parker, Pharm.D. Pharmacy Consultant Division of Medical Services Bureau of Long Term Care Hoover State Office Bldg. Des Moines, IA 50319 T: 515/281-3002 F: 515/281-8512 E-mail: [email protected]

Prior Authorization Contact Randy Brentnall, R.Ph. ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1322 F: 515/327-0945

DUR Contact Julie Kuhle, R.Ph. DUR Coordinator Iowa Pharmacy Association 8515 Douglas Ave, Suite 16 Des Moines, IA 50322 T: 515/270-0713 F: 515/270-2979



Medicaid DUR Board Ralph Stanifer, M.D. Ilyenn Wiesley, R.Ph. Sharon Meyer, Pharm.D., M.S. Ronald Miller, M.D., M.B.A. Bruce Alexander, R.Ph., Pharm. D. Sandi Birchem, D.O. George Kappos, M.D. Dan Murphy, R.Ph. Julie Kuhle, R.Ph., Project Coordinator Nancy Bell, R.Ph. Janalyn Phillips, R.Ph. Susan Parker, Pharm.D.

Prescription Price Updating Sherry Swanson Deputy Account Manager ACS P. O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1107 F: 515/327-0945

Medicaid Drug Rebate Contacts Technical: Rocco Russo, 515/327-0950 ext. 1114 Audits: Rocco Russo, 515/327-0950 ext. 1114 DUR: Julie Kuhle 515/270-0713 PA: Randy Brentnall, 515/327-0950 ext. 1322

Claims Submission Contact Mindy Ruby Claims Manager ACS P. O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1108 F: 515/327-0945

Medicaid Managed Care Contact Dennis Janssen MHC Program Manager Bureau of Managed Care and Clinical Services Hoover Building, 5th Floor T: 515/281-8747 F: 515/281-8512 E-mail: [email protected]

Mail Order Pharmacy Program State currently has a mail order pharmacy program. Participating pharmacies must be enrolled as an Iowa Medicaid provider.

Physician-Administered Drug Program Contact Sherry Swanson ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1107 F: 515/327-0945

Iowa Pharmacy Association Medicaid Pharmacy Advisory Committee Tim Becker (Chair) Mason City, IA 641/422-6100 David Brotherson (Vice Chair) Davenport, IA 563/388-1887 Hal Jackson Winterset, IA 515/462-2479 Russ Wiesley Waukee, IA 515/987-8111 Matthew Shivers Burlington, IA 319/753-0112 Jerry Hartleip Waterloo, IA 319/234-1589 Mary Tasler LaPorte City, IA 319/272-5700 Joe Mahrenholz Panora, IA 641/755-3052 Marilyn Aldrich DSM 515/255-8642 Larry Costello Mason City, IA 641/424-1343 Wally Tschopp Hartley, IA 712/728-2165 Joe Cunningham Waukon, IA 563/568-6315



Robert Dean Sioux City, IA 712/252-2761 Sue Testroet Bettendorf, IA 563/324-5004 Sally Horst Maquoketa, IA 563/652-5611 Dennis Killion Red Oak, IA 712/623-3370 Steve Firman Cedar Falls, IA 319/352-4440 Leman Olson Mason City, IA 641/422-7917 David Gavin Indianola, IA 515/961-2191 Alan Shepley Mount Vernon, IA 319/895-6248 Matt Osterhaus Maquoketa, IA 563/652-5611 Gene Lutz Altoona, IA 515/967-4213 Cora Lynn Becker West Des Moines, IA 515/360-0065 Jim Wallace Davenport, IA Iowa Human Services Department Officials Sally Titus Cunningham, Interim 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]

Title XIX Medical Assistance Advisory Council College of Medicine Stacey T. Cyphert, Ph.D. Assistant Vice President-Statewide Health Services Senior Assistant Director of University Hospitals and Clinics The University of Iowa Iowa City, IA 52242-1009 House of Representatives Andra Attenberry 1034 Sherman Avenue Manchester, IA 52057 Brad Hansen 1015 Shoal Pointe Dr. Carter Lake, IA 51510 Iowa Nurses Association Linda Goeldner 1501 42nd Street, Suite 471 West Des Moines, IA 50266 Iowa Medical Society Angela Dorsey Manager of Legislative Affairs 1001 Grand Avenue West Des Moines, IA 50265 Opticians Assn. of Iowa Vacant Iowa Senate Sen. Maggie Tinsman 3541 E. Kimberly Road Davenport, IA 52807 Senator Jack Holveck 2007 47th Street Des Moines, IA 50310 Iowa Dept. of Public Health Anne Kinzel State Planning Grant Project Director Lucas State Office Bldg., 5th Floor DesMoines, IA 50319-0075 Public Representatives Vacant Mary Ann Weber 565 Greenwood Court Dubuque, IA 52001 Orvil Nelson 1534 Second Street Boone, IA 50036



Jodi Tomlonovic Executive Director Family Planning Council of Iowa 108 Third Street, Suite 220 Des Moines, IA 50309 Iowa Speech & Hearing Association Barbara Vogen Central Rehabilitation, Ltd. 950 Office Park Road, Suite 100 West Des Moines, IA 50265 Iowa Hospital Association Tracy Warner 100 E. Grand Avenue, Suite 100 Des Moines, IA 50309-1835 Iowa Health Care Association Steve Ackerson Executive Director 6750 Westown Parkway, Suite 100 West Des Moines, IA 50266-7726 Iowa Assn. for Home Care Larry L. Breeding Executive Director 1520 High Street, Suite 203-B Des Moines, IA 50309 Iowa Chiropractic Society Dr. Terry Burk P.O. Box 370 Huxley, IA 50124 Iowa Pharmacy Association Jerry Karbeling 8515 Douglas, Suite 16 Des Moines, IA 50322 Iowa Assn. of Homes and Services for the Aging Dana Petrowsky President 1701 48th Street, Suite 203 West Des Moines, IA 50266-6723 Iowa Association of Community Providers Michelle Wray Abbe Inc. 800 First Street, NW Cedar Rapids, IA 52405 Iowa Dental Association Larry Carl Executive Director 505 5th Avenue, Suite 333 Des Moines, IA 50309 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 Osteopathic Medical Association Leah McWilliams Executive Director 950 12th St. Des Moines, IA 50309-1001 Iowa Optometric Association Gary Ellis 1454 30th Street, Suite 204 West Des Moines, IA 50266-1312 Iowa Podiatric Medical Association Dr. Richard Spencer Spencer Foot & Ankle Clinics 110 East McLane Osceola, IA 50213 Iowa Psychological Society Mark Peltan, Ph.D. Mercy Medical Center-North Iowa 1000 4th Street, SW Mason City, IA 50401-2921 Iowa Association of Hearing Health Professionals Bev Thomas Executive Director 1001 Office Park Road, Suite 105 West DesMoines, IA 50265 Alliance for the Mentally Ill of Iowa Margaret Stout 5911 Meredith Drive, Suite E Urbandale, IA 50322



Iowa Psychiatric Society Karen Loihl 2643 Beaver, Suite 338 Des Moines, IA 50310 Iowa Governor’s Developmental Disabilities Council Rick Shannon 617 E. 2nd Street Des Moines, IA 50309 Iowa Academy of Family Physicians Dr. Dave Carlyle 1215 Duff Avenue Ames, IA 50010 Iowa Physical Therapy Association Michael Mandel 1228 8th Street, Suite 106 West Des Moines, IA 50265-2624 Iowa Physician Assistant Society Michael Farley 4524 Boulevard Pl. Des Moines, IA 50311 Iowa Association of Nurse Practitioners Wanda Marshall Children’s Health Center 1212 Pleasant Avenue, Suite 300 Des Moines, IA 50309 Iowa Association of Rural Health Clinics Ed Friedmann 1013 1st Street, Box C Redfield, IA 50233 Iowa Occupational Therapy Association Angela Hansen-Abbas 161 315th St. Perry, IA 50220 The ARC of Iowa Vacant Des Moines University-Osteopathic Medical Center Howard S. Teitelbaum, D.O., Ph.D., M.P.H. Dean of OMS 3200 Grand Avenue Des Moines, IA 50312 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 Chapter-Am. Academy of Pediatrics Rizwan Z. Shah, M.D. Children’s Health Center 1212 Pleasant Street Des Moines, IA 50309

Executive Officers of State Medical and Pharmaceutical Societies Iowa Medical Society Michael Abrams Executive Vice President 1000 Grand Avenue West Des Moines, IA 50265 T: 515/223-1401 F: 515/223-0590 E-mail: [email protected] Internet addresss: www.iowamedical.org Iowa Pharmacy Association Thomas R. Temple, R.Ph., M.S. Executive Vice President & CEO 8515 Douglas, Suite 16 Des Moines, IA 50322-2927 T: 515/270-0713 F: 515/270-2979 E-mail: [email protected] Internet address: www.iarx.org Iowa Osteopathic Medical Association Leah McWilliams Executive Director 950 12th St. Des Moines, IA 50309-1001 T: 515/283-0002 F: 515/283-0355 E-mail: [email protected] Internet address: www.ioma.org State Board of Pharmacy Examiners Lloyd K. Jessen Executive Secretary/Director 400 SW 8th St., 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 The Association of Iowa Hospitals and Health Systems 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]




National Pharmaceutical Council Kansas-1

KANSAS



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $167,216,488 158,334 $189,290,260 158,515 RECEIVING CASH ASSISTANCE TOTAL $75,748,711 56,573 $85,089,631 58,792 Aged $8,192,697 4,381 $8,618,107 4,187 Blind/Disabled $61,896,472 29,392 $70,087,687 29,828 Child $2,367,507 13,048 $2,774,647 14,115 Adult $3,292,035 9,752 $3,609,190 10,662 MEDICALLY NEEDY, TOTAL $12,935,273 7,207 $11,665,933 8,314 Aged $4,876,847 3,850 $2,421,349 1,362 Blind/Disabled $7,987,152 3,102 $8,335,032 2,898 Child $53,732 166 $331,900 1,946 Adult $17,542 89 $577,652 2,108 POVERTY RELATED, TOTAL $9,870,105 53,581 $10,333,897 49,242 Aged $553,577 569 $484,846 470 Blind/Disabled $1,225,234 772 $1,460,600 867 Child $7,271,974 44,984 $7,711,591 41,266 Adult $819,320 7,256 $676,860 6,639 TOTAL OTHER EXPENDITURES/RECIPIENTS* $68,662,399 40,973 $82,200,799 42,167 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Kansas National Pharmaceutical Council

C. ADMINISTRATION

State Department of Social and Rehabilitation Services.

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; urine ketone test strips; and total parenteral nutrition. Products covered with restriction: interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs; and drugs not rebated by the manufacturer.

Over-the-Counter Product Coverage: Products covered: analgesics (for adults); digestive products (H2 antagonist); and antifungals. Products covered with restrictions: cough and cold preparations (for children), smoking deterrent products (limited time period). Products not covered: allergy, asthma and sinus products; digestive products (non-H2 antagonists); feminine products; topical products; and 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; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory 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: anxiolytics, sedatives, and hypnotics; anorectics; growth hormones; triptans; nasal steroids; PPIs, statins; H2 antagonists; and 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 Children Health Insurance Program and the Vaccines for Children Program.


Formulary/Prior Authorization Formulary: State currently maintains a closed formulary with a Preferred Drug List (PDL). Prior authorization required for non-PDL products.

Prior Authorization: State currently has a formal prior authorization procedure. The individual appealing may request an administrative hearing to appeal a prior authorization hearing by sending a request in writing to:

Administrative Hearing Office 610 S.W. 10th Ave, 2nd Floor Topeka, KS 66612-1616

Prescribing or Dispensing Limitations 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).


Other: Narcotics, Viagra, Ketorolac, Toradol and Relenza have other specific limits.

Drug Utilization Review PRODUR system implemented in November 1996. State currently has a DUR Board that meets every two months.


Ingredient Reimbursement Basis: EAC Brand, = AWP - 13%. Generics, AWP-27%. #IV fluids, AWP-50%.#Blood fraction products, AWP-30%. Prescription Charge Formula: Pharmacies are reimbursed the lesser of usual and customary, MAC, FUL, or acquisition cost (EAC) plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits on generic drugs.


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.



Approximately 44,500 Medicaid Recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through both the state and managed care plans.

Managed Care Organizations First Guard


National Pharmaceutical Council Kansas-3

3801 Blue Pkwy Kansas City, MO 64130

F. STATE CONTACTS State Drug Program Administrator Mary H. Obley, Pharmacist Health Care Policy Division Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-S Topeka, KS 66612-1570 T: 785/296-8406 F: 785/296-4813 E-mail: [email protected] Internet Address: www.srskansas.org

Prior Authorization Contact Mary H. Obley, Pharmacist 785/296-8406

DUR Contact Mary H. Obley Pharmacist 785/296-8406

DUR Board Michael Burke, M.D., Ph.D. Barry Sarvis, R.Ph. Jim Bachus, R.Ph. John Lowdermilk, R.Ph. Linda Frey, R.N. Brenda Shewe, M.D. John Whitehead, D.O.

Prescription Price Updating Mary H.Obley, Pharmacists 785/296-8406

Medicaid Drug Rebate Contacts Policy: Mary H. Obley, Pharmacist 785/296-8406 Technical: Vick Schmidt, Pharmacist Drug Rebate EDS 360 SW Topeka Boulevard Suite 204 Topeka, KS 66611 785/274-5937

Claims Submission Contact EDS 360 SW Topeka Boulevard Suite 204 Topeka, KS 66611 785/274-5939

Medicaid Managed Care Contact Debra Bachmann, R.N. IV Manager, Health Wave XIX Health Care Policy Division, Kansas Dept. of SRS 915 SW Harrison, Rm. 651-S

Topeka, KS 66612-1570 T: 785/296-3667 F: 785/296-4813 E-mail: [email protected]


Social and Rehabilitation Services Department Officials Janet Schalansky Secretary Department of Social and Rehabilitation Services Docking State Office Bldg. 915 SW Harrison Topeka, KS 66612-1570 T: 785/296-3271 F: 785/296-2173 E-mail: [email protected]

Medical Care Advisory Committee Contact Robert Day, Ph.D. Commissioner Adult and Medical Services Dept. of Social and Rehabilitation Services 915 SW Harrison Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Kansas Medical Society Karen Hagen 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 Pharmacists Association Robert R. Williams, M.S., CAE Executive Director 1020 SW Fairlawn Road Topeka, KS 66604-2275 T: 785/228-2327 F: 785/228-9147 E-mail: [email protected]


4-Kansas National Pharmaceutical Council

Internet address: www.kansaspharmacy.org Kansas Association of Osteopathic Medicine Harold Riehm, CAE Executive Director 1260 SW Topeka Boulevard Topeka, KS 66612 T: 785/234-5563 F: 785/234-5564 E-mail: [email protected] State Board of Pharmacy Susan Linn Executive Director Landon State Office Building 900 Jackson, Room 513 Topeka, KS 66612 T: 785/296-4056 F: 785/296-8420 E-mail: [email protected] Internet address: www.accesskansas.org Kansas Hospital Association Thomas Sipe President 215 Southeast Eighth Street Topeka, KS 66603 785/276-3116 E-mail: [email protected] Internet address: www.kha.org


National Pharmaceutical Council Kentucky-1

KENTUCKY



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $465,178,958 427,514 $598,093,343 475,365 RECEIVING CASH ASSISTANCE, TOTAL $326,458,102 213,429 $424,804,782 235,058 Aged $30,876,495 17,219 $37,547,483 16,692 Blind / Disabled $274,483,368 131,650 $355,245,438 137,989 Child $8,650,123 42,996 $12,748,175 51,834 Adult $12,448,116 21,564 $19,263,686 28,543 MEDICALLY NEEDY, TOTAL $17,528,881 29,057 $19,756,137 24,343 Aged $4,268,258 1,966 $4,859,165 2,018 Blind / Disabled $3,233,791 1,685 $3,736,659 1,645 Child $2,948,612 14,111 $3,032,751 11,256 Adult $7,078,220 11,295 $8,127,562 9,424 POVERTY RELATED, TOTAL $25,437,087 130,605 $40,038,880 160,513 Aged $554,301 583 $557,666 595 Blind / Disabled $994,423 786 $1,299,771 941 Child $21,676,976 112,649 $35,140,791 140,715 Adult $2,211,387 16,587 $3,040,652 18,262 TOTAL OTHER EXPENDITURES/RECIPIENTS* $95,754,888 54,423 $113,493,544 55,451

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 Data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-Kentucky National Pharmaceutical Council

C. ADMINISTRATION

Department for Medicaid Services, within the Cabinet for Health Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design 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.

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; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; anoretics; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; chemotherapy agents; prescribed cold medications; growth hormones; hypotensive agents; misc. GI drugs; and topical steroids. 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.

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.


Formulary/Prior Authorization Formulary: Closed Formulary. The Kentucky Medicaid Program maintains a closed formulary of approximately 96,800 drugs 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: 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.



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.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Necessary,” “Brand Medically Necessary,” or Prior Authorization.


Patient Cost Sharing: $1.00





Approximately 153,000 total Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through both the state and managed care plans.

Managed Care Organization Passport Health Plan Joyce Schifano, Executive Director

F. STATE CONTACTS Medicaid Drug Program Administrator Troy Koch, Pharm.D., M.B.A. 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.state.ky.us/dms

Prior Authorization Contact Troy Koch, Pharm.D., 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) Teresa Gevedon, M.D. Carmel Wallace, M.D. Janet Poe Wright, Pharm.D. Kimberly S. Croley, Pharm.D. R. Michael Cayce, R.Ph. Troy Koch, Pharm.D., M.B.A. (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 Richard Arnold, M.D. (Chair) George Rodgers Jr., M.D. (Vice-Chair) Phillip Baier, O.D. Patricia Freeman, R.Ph., Ph.D. James S. Davis, M.D. Karen Barnes, M.D. Vaughn Payne, M.D. John Spencer, Pharm.D. Edward Sorace, P.A.-C. Misha Glendening, A.R.N.P. Pam Koob, Ph.D. A.R.N.P. Kevin Wemett (non-voting) Drugs Technical Advisory Committee Steve Adams, R.Ph. 217 Lexington Street Lancaster, KY 40444 Ralph Bouvette, R.Ph., Ph.D., J.D. 102 Enterprise Drive Frankfort, KY 40601 C. Joseph Carr, R.Ph. 119 W. 22nd Street Owensboro, KY 42303 Clarence Sullivan, Pharm.D. 1095 Tatesbrook Drive Lexington, KY 40517 Rick Sutton, R.Ph. 275 Spring Valley Paducah, KY 42003

Prescription Price Updating UNYSIS Provider Services P.O. Box 2100 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]



Claims Submission Contact Unisys Provider Services P.O. Box 2100 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

Medicaid Managed Care Contact 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.

Physician-Administered Drug Program Contact Barbara Utter 275 East Main Street Frankfort, KY 40621 502/564-2687

Department for Medicaid Services Officials Marcia R. Morgan, Secretary Cabinet for Human Resources CHR Building, 5 W-A 275 East Main Street Frankfort, KY 40621 502/564-7130

State Advisory Council on Medical Assistance Chester L. Parker, Pharm.D., R.Ph. 2086 Old Nassau Lexington, KY 40504 606/277-5723 Chester A. Nava, Jr., D.P.M. 110 North Hubbards Lane Louisville, KY 40207-3903 502/897-2047 Carol J. Braun, D.D.S. 2816 Veach Road Owensboro, KY 42303 502/683-7114 James A. Burcham P.O. Box 20 Burlington, KY 41005 606/431-2244

Leslie H. Rogers 109 Daniel Drive Hazard, KY 41701 William T. Watkins, M.D. 125 Volunteer Drive Somerset, KY 42501 606/679-2169 Frank A. Butler, Hospital Director University of Kentucky Hospital 800 Rose Street Lexington, KY 40536-0084 606/323-5767 Faye Hensley, R.N. P.O. Box 85 Manchester, KY 40962 Bettie Speicher Weyler 3420 Grandview Avenue Louisville, KY 40207 502/893-4964 Bob Gray 2504 Duke Drive, Apt. 24 Owensboro, KY 42301 502/685-2976 Donnie Wilhite 106 Creekstone Court Frankfort, KY 40601 502/223-1052 Betty Rose Boyd Apt. #19, Highland Heights Prestonsburg, KY 41653 606/886-0343 Marianne Keller The Good Samaritan Center 106177 Watterson Terrace Jeffersontown, KY 40299 502/267-7403 Patricia Conner-Young 10409 Christina Court Louisville, KY 40223 502/5835034 Nancy Durham 8900 Hawley-Gibson Crestwood, KY 40014 502/241-9072 Vicki Prichard 222 Ft. Mitchell Avenue Fr. Mitchell, KY 41011 606/344-0277



Executive Officers of State Medical and Pharmaceutical Societies Kentucky Medical Association William T. Applegate 4965 U.S. Highway 42, Suite 2000 Louisville, KY 40222-6301 T: 502/426-6200 F: 502/426-6877 Internet address: www.kyma.org Kentucky Pharmacists Association Mike Mayes, FACHE Executive Director 1228 U.S. Highway 127 South Frankfort, KY 40601 T: 502/227-2302 F: 502/227-2854 Internet address: www.kphanet.org State Board of Pharmacy Michael A. Mone Executive Director 23 Millcreek Park Frankfort, KY 40601-9230 T: 502/573-1580 F: 502/573-1582 Internet address: www.state.ky.us/boards/pharmacy Kentucky Society of Health-System Pharmacists Dwaine K. Green Executive Vice President One Quality Street Lexington, KY 40507-1428 E-mail: [email protected] Internet address: www.kshp.org Kentucky Osteopathic Medical Association Tom Underwood Executive Director 1501 Twilight Trail Frankfort, KY 40601 T: 502/223-5322 F: 502/223-4937 Internet address: www.koma.org Kentucky Hospital Association Michael T. Rust President 2501 Nelson Miller Parkway Louisville, KY 40223 T: 502/992-4380 F: 502/426-6226 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




National Pharmaceutical Council Louisiana-1

LOUISIANA



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expenditures Recipients Expenditures Recipients TOTAL $476,400,908 581,356 $547,731,897 594,364 RECEIVING CASH ASSISTANCE, TOTAL $310,302,551 260,107 $351,387,693 259,405 Aged $86,327,808 43,091 $91,902,271 41,683 Blind/Disabled $196,365,331 114,002 $227,169,789 114,935 Child $13,267,175 68,187 $15,071,139 64,596 Adult $14,342,237 34,827 $17,244,494 38,191 MEDICALLY NEEDY, TOTAL $5,713,428 4,553 $7,085,668 5,470 Aged $2,409,629 1,079 $2,977,860 1,238 Blind/Disabled $2,006,295 1,160 $2,574,449 1,411 Child $54,995 252 $61,884 215 Adult $1,242,509 2,062 $1,471,475 2,606 POVERTY RELATED, TOTAL $45,860,182 206,436 $67,020,934 260,160 Aged $1,826,705 1,452 $1,987,183 1,371 Blind/Disabled $1,475,603 1,122 $1,481,920 1,336 Child $38,639,381 176,609 $59,094,838 228,683 Adult $3,918,493 27,253 $4,456,993 28,770 TOTAL OTHER EXPENDITURES/RECIPIENTS* $114,524,747 110,260 $122,237,602 69,329



2-Louisiana National Pharmaceutical Council

C. ADMINISTRATION

Department of Health and Hospitals.

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 as DME: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; and experimental drugs. Also, cough and cold preparation and anoretics.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products.

Therapeutic Category Coverage: 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; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; and misc. GI drugs.

Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities.

Vaccines: Vaccines reimbursable at cost as part of EPSDT service and Vaccines for Children Program.


Formulary/Prior Authorization Formulary: Open formulary. General restrictions include prior authorization, preferred products, and physician profiling.

Prior Authorization: State currently has a formal prior authorization procedure but no method of appealing a prior authorization decision.

Prescribing or Dispensing Limitations Prescription Refill Limit: Permitted as indicated by physician within 6 months and not to exceed 5 refills.

Monthly Quantity Limit: New prescription must be issued for drugs given on a continuing basis, after 5 refills or after 6 months. Maximum quantity for prescriptions shall

be either 30-day supply or 100 unit doses, whichever is greater. Monthly limit of 8 prescriptions per recipient.

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.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.77 maximum, effective 7/1/94.

Ingredient Reimbursement Basis: EAC = AWP-13.5% 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. 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.

2. Louisiana Maximum Allowable Costs (LMAC) or the Federal Upper Limit plus the dispensing fee.

3. AWP for multi-source drugs when lower than FUL or LMAC.

4. The provider’s usual and customary charge to other payors.

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.”


Patient Cost Sharing: $ 0.50 - $3.00 copayment depending of the cost of the prescription, effective 7/13/95.

Cognitive Services: Does not pay for cognitive services





F. STATE CONTACTS State Drug Program Administrator Mary J. Terrebonne, P.D. Pharmacy Program 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 Ben A. Bearden, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-3891 F: 225/342-9508 E-mail: [email protected] David W. Hood, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821 T: 225/342-9500 F: 225/342-9508 E-mail: [email protected]

DUR Contact Mary J. Terrebonne, P.D., 225/342-9768

DUR Committee Region I: Lisa Chetta, P.D. Donald Fellows, P.D. Donna Robinson, P.D. Paul Staab, M.D. Region II: Leslie Day, P.D. Blake Pitre, P.D. Don Ramirez, P.D. Charles Raborn, M.D. Region III: John Baker, P.D. Shawn McGee, P.D. Joseph Vizena, P.D. (Physician member vacancy) Region IV: Paul Chachere, P.D.

W. Merwin McMahen, P.D. Donna White, P.D. Johnny Johnston, M.D.

DUR Board Edwin Adams 120 Dove Drive West Monroe, LA 71291 318/343-3562 Ken Ardoin, Senior Manager State Government Relations Pfizer, Inc. 7 Village Circle, Suite 400 Westlake, TX 76262 817/491-8410 Brad Belding, P.D. Director of Pharmacy Thibodaux Hospital 402 Easy Street Thibodaux, LA 70301 504/493-4786 Sylvia Heidingsfelder, M.D. 5805 Highland Road Baton Rouge, LA 70808 225/358-1069 Susan Hinton, Pharm.D. 7680 Dune Drive New Orleans, LA 70128 504/483-7570 Richard Soileau 401 ½ St Peters Street New Iberia, LA 70560 337/365-6721 Paul Staab, M.D. 5216 Lapalco Boulevard Marrero, LA 70072 504/348-4357 Charmaine Venters, M.D. Earl K. Long Hospital 5825 Airline Highway Baton Rouge, LA 70805 225/358-1063

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 mail order pharmacy program for asthma and diabetic patients.

Medical Managed Care Contact Mary J. Terrebonne, P.D., 225/342-9768

Physician-Administered Drug Program Contact Kandis McDaniel 504/342-0127

Medical Care Advisory Committee Sandra C. Adams (Chairperson) Mary Joseph Rep. Rodney M. Alexander Sen. John L. “Jay” Dardenne, Jr. Sen. J. “Tom” Schedler Rep. Jerry L. “Luke” LeBlane Mary Tonore Robert D. Horneman Amelia Lafont Linda Welch Willa Rawls Kay Marcel Daily Dupre, Jr. Francine Boyles Brenda Armstrong Mary Scott Paul Hildreth June Peach Dr. Keith M. Perrin Greg Scott Dr. Leonard Weather, Jr. Dr. Donnie Batie Sean Prados Dr. Floys A. Buras Richard “Andy” Soileau Dr. Robert L. Marier Jennifer Canaday Wanda Ellis Tawna Pounders Warren Hebert

Ralph D. Balentine Marcia Daigle Partricia DeMichele

Medicaid Pharmaceutical and Therapeutics Committee Mr. Joe Adams 2005 Scotchpine Lane Mandeville, LA 70448 985/624-8510 State Representative Rodney Alexander 320 6th Street Jonesboro, LA 71251-0665 318/259-8694 Dr. Donnie Batie 8333 Goodwood Blvd. Baton Rouge, LA 70806 225/929-7882 Mr. Ben Bearden P.O. Box 91030 Baton Rouge, LA 70821-9030 225/342-3891 Dr. Vincent Culotta 4228 Houma Blvd. Metairie, LA 70006 504/883-3773 Dr. Richard Doskey 9605 Jefferson Highway River Ridge, LA 70123 504/738-1604 Dr. Blackwell B. Evans, Jr. 1430 Tulane Avenue New Orleans, LA 70112 504/988-6800 Dr. Conchetta Fulton 7325 Palmetto New Orleans, LA 70125 504/483-7402 Mr. David Hood P. O. Box 629 Baton Rouge, LA 70821-0629 225/342-9509 Dr. Ernest Kinchen 850 North Pierce Lafayette, LA 70501 337/233-2116 Dr. Michael Kudla 2770 2nd Avenue #203 Lake Charles, LA 70601 337/477-7871



Dr. W. Chapman Lee 5825 Airline Highway Baton Rouge, LA 70805 225/358-1078 Dr. Brobson Lutz 2622 Jena Street New Orleans, LA 70115 504/865-0361 Dr. Catherine A. McDonald 1105 S. College Road, Ste. A Lafayette, LA 70503 337/232-9113 Mr. Marty McKay 74 Foxfire Lane Alexandria, LA 71302 318/776-5646 Dr. Phillip J. Medon 700 University Avenue Monroe, LA 71209 318/342-3800 Dr. John B. Pope 1501 Kings Highway Shreveport, LA 71130 318/675-5811 Carolyn Tackett P.O. Box 485 Hammond, LA 70404 985/230-0160 Dr. Henderson Tilton 200 Henry Clay Avenue New Orleans, LA 70118 504/891-8851 Dr. Leonard Weather 7820 Chef Menteur Highway New Orleans, LA 70126 504/241-0413 Dr. Lolie C. Yu 1542 Tulane Avenue New Orleans, LA 70112 504/896-9740

Executive Officers of State Medical and Pharmaceutical Societies Louisiana State Medical Society Dave L. Tarver

Executive Vice President 6767 Perkins Road Baton Rouge, LA 70808 T: 225/763-8500 F: 225/763-6122 E-mail:[email protected] Internet Address:www.lsms.org Louisiana Osteopathic Medical Association (Inactive) Nancy Bellemare, D.O. President 215 Friedrichs Avenue Metairie, LA 70005-4516 Internet Address: www.loma-net.org State Board of Pharmacy Malcolm J. Broussard Executive Director 5615 Corporate Boulevard, Suite 8E Baton Rouge, LA 70808-2537 225/925-6496 Internet Address: www.labp.com Louisiana State Pharmacists Association Doug Cheramie Executive Director 4744 Jamestown, Suite 101 Building 7-B Baton Rouge, LA 70808 T: 225/926-2666 F: 225/926-1020 E-mail: [email protected] Internet Address:www.louisianapharmacists.org Louisiana Society of Health-System Pharmacists Mathew Thomas 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 Lynn B. Nicholsl President & CEO 9521 Brookline Avenue Baton Rouge, LA 70898-0720 T: 504/928-0026 F: 225/923-1004 Internet Address: www.laha.org




National Pharmaceutical Council Maine-1

MAINE



Aged Blind/

Disabled


Disabled

Child Adult SFO







Dental Services � � � � � � �^ �^ �

^ Routine dental services; other categories eligible for non-routine dental service only.


Expenditures Recipients Expenditures Recipients TOTAL $175,938,952 148,049 $191,785,942 RECEIVING CASH ASSISTANCE, TOTAL $89,612,435 57,012 Aged $10,108,338 4,821 Blind/Disabled $70,104,828 27,532 Child $2,867,751 14,684 Adults $6,531,518 9,975 MEDICALLY NEEDY, TOTAL $2,944,061 1,177 Aged $1,907,252 773 Blind/Disabled $981,506 328 Child $27,186 50 Adults $28,117 26 POVERTY RELATED, TOTAL $36,155,591 39,151 Aged $9,941,001 5,457 Blind/Disabled $20,666,793 7,804 Child $5,142,738 23,386 Adult $405,059 2,504 TOTAL OTHER EXPENDITURES/RECIPIENTS* $47,226,865 50,709

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report FY 2000 and CMS, HCFA-64 Report, FY 2001.


2-Maine National Pharmaceutical Council

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


Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin (not covered for nursing home patients). Covered as DME: 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);vitamin and vitamin preparations (except pregnancy); and injectables when oral medication is available for equally effective treatment.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products (limited coverage after 1/1/01); analgesics (limited coverage after 1/1/01); cough and cold preparations (limited coverage after 1/1/01); digestive products (non H2 antagonists), H2 antagonists (limited coverage after 1/1/01); topical products; smoking deterrent products (by Rx only); feminine products (limited coverage).

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics (prior authorization required for zyvox); anticoagulants; anticonvulsants; antidiabetic agents; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Partial Coverage: anti-depressants (prior authorization required. Prior authorization required for: analgesics, antipyretics, NSAIDs; anoretics; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; prescribed cold medications; growth hormones and misc. GI drugs; prescribed smoking deterrents; injectable arthritis medications; acute migraine medications; Synvisc; antifungals; EPO; and Synagis, and erectile dysfunction products.


Vaccines: Vaccines reimbursable based on cost as part of the EPSDT service (admin. fees) and as part of the Children’s Health Insurance Program.


Formulary/Prior Authorization Formulary: Closed formulary. Restrictions on use, prior authorization, and preferred products. Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization may be obtained in the case of necessary exceptions. State has no formal prior authorization committee.

Prescribing or Dispensing Limitations Monthly Quantity Limit: 34 day for brand-name drugs and 90 days for generic drugs per month. Prescription Refill Limit: maximum of 11 refills per prescription.

Drug Utilization Review PRODUR system implemented in 1995. State currently has a DUR Board that meets 10 times per year.


Dispensing Fee: $3.35 for stock supply, or for solutions or lotions involving no weighing. $4.35 for compounding ointments and for solutions/lotions involving weighing one or more ingredients and making home IV solutions. $5.35 for compounding handmade supplies, pwd. papers, capsules and tablet priturates and for mixing home TPN hyperalimentation.


Prescription Charge Formula: Lowest of usual and customary, FUL, AWP-13%, or Maine MAC. Maine MAC includes approximately 50 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 “medically necessary” or “brand medically necessary” by the physician and prior authorization for some drugs.


Patient Cost Sharing: Sliding copay scale based on cost: $0.50 to $3.00.

Cognitive Services: State does not pay for cognitive services.



E. USE OF MANAGED CARE About 100,000 Medicaid recipients are enrolled in managed care. Medicaid recipients enrolled in managed care receive pharmaceutical benefits through the State.

F. STATE CONTACTS

State Drug Program Administrator Vacant Director of Pharmacy Department of Human Services Bureau of Medical Services 442 Civic Center Drive Augusta, ME 04333-0011 T: 207/287-4018 F: 207/287-8601 E-mail: [email protected] Internet address: http://www.state.me.us/dhs/welcome_to_dhs.htm

Prior Authorization Contact Director of Pharmacy 207/287-4018

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.

DUR Contact Director of Pharmacy 207/287-4018

Maine DUR Board Timothy Clifford, M.D. Pharmacy Consultant P.O. Box 708 Augusta, ME 04332 207/622-7153 William Alto, M.D. Maine Dartmouth Family Practice 4 Sheridan Drive Fairfield, ME 04937 207/861-5000

John Grotton, R.Ph. Goold Health Systems P.O. Box 708 Augusta, ME 04332 207/622-7153 Cheryl Blaisdell, R.Ph. 94 Marston Road Waterville, ME 04901 Paula Knight, R.Ph. 31 Birch Circle Sidney, ME 04330 207/547-3681 Stephen McPike, R.Ph. 15 Wildwood Lane Gray, ME 04039 207822-7627 Michael Ouellette, R. 4235 Bassett Road Winslow, ME 04901 207/281-2727 Robert Weiss, M.D. 2 Great Falls Plaza Auburn, ME 04210 Jabbar Fazeli, M.D. 100 Campus Avenue Lewiston, ME 04240 Non-voting:

Joe Bruno (President) Goold Health Systems P.O. Box 708 Augusta, ME 04332 207/622-7153 Dennis G. Lyons, R.Ph. 255 Bear Hill Rd., 2nd Fl. Waltham, MA 02451

Prescription Price Updating Medispan

Medicaid Drug Rebate Contacts Technical: Rossi Rowe, 207/287-1838 Policy: Chris Zukas-Lessard, 207/287-2674 Rebates: Rossi Rowe, 207/287-1838 Audits: Vacant



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 Internet address: www.ghsinc.com/intro.html

Medicaid Managed Care Contact Brenda McCormick Department of Human Services Bureau of Medical Services 11 State House Station Augusta, ME 04333-0011 T: 207/287-8820 F: 207/287-1864


Elderly Expanded Drug Coverage Program Paula Knight, R. Ph. Maine Drugs for the Elderly and Disabled Program T: 207/287-1818 F: 207/287-8601 Internet address : www.state.me.us/sos/cec/rc/apa/10/chaps10.htm

Disease Management Program/Initiative Contact Director of Pharmacy 207/287-4018

Human Services Department Officials Eugene Gessow, Director Bureau of Medical Services Department of Human Services State House Station II Augusta,ME 04333-0011 T:207/287-2674 F: 207/287-2675 E-mail: [email protected] Jan Yorks Drug Program Coordinator Medical Claims Review 207/287-1818 Mark Fecteau, Director Medicaid Surveillance/Utilization Review 207/624-5220

Medical Assistance Advisory Committee Robert Philbrook MAC c/o BMS 11 State House Station Augusta, ME 04333-0011

Executive Officers of State Medical and Pharmaceutical Societies Maine Medical Association Gordon Smith, Esq. Executive Vice President Frank O. Stred Building P. O. Box 190 Manchester, ME 04351-0190 T: 207/622-3374 F: 207/622-3332 E-mail: [email protected] Internet address: www.mainemed.com Maine Pharmacy Association Lisa Asali, R.Ph., President 725 Main Street South Portland, ME 04106 T: 207/722-7235 F: 207/772-0920 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 Board of Pharmacy Geraldine “Jeri” Betts, Board Administrator 35 State House Station Augusta, ME 04333 T: 207/624-8620 F: 207/624-8637 E-mail: [email protected] Internet address: www.state.me.us/prf/olr/ Maine Society of Health-System Pharmacists Ann Marco, President 800/291-8121 E-mail: [email protected] Internet address: www.meshp.org



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




National Pharmaceutical Council Maryland - 1

MARYLAND



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $374,121,433 409,511 $244,203,084 RECEIVING CASH ASSISTANCE, TOTAL $223,765,324 145,724 Aged $26,694,367 15,553 Blind / Disabled $175,619,643 66,765 Child $8,062,216 41,683 Adult $13,389,098 21,723 MEDICALLY NEEDY, TOTAL $80,436,582 51,985 Aged $41,479,224 18,560 Blind / Disabled $30,498,787 12,449 Child $3,749,506 11,759 Adult $4,709,065 9,217 POVERTY RELATED, TOTAL $47,673,288 163,568 Aged $8,791,420 6,633 Blind / Disabled $11,713,692 4,779 Child $24,239,865 130,271 Adult $2,928,311 21,885 TOTAL OTHER EXPENDITURES/RECIPIENTS* $22,246,239 48,234

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Maryland National Pharmaceutical Council

C. ADMINISTRATION State Department of Health and Mental Hygiene.


Benefit Design

Drug Benefit Product Coverage: Products covered: legend drugs; prescribed insulin; disposable needles used for insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; 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; and aspirin for arthritis. Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (H2 and non-H2 antagonists); feminine products (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; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. 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 through both the Prescription Drug Program and physician payment when used in physician offices. No information provided on reimbursement for non-self-administered injectable medicines in extended care facilities.





Prior Authorization: State currently has a Prior Authorization procedure. A general appeals procedure is available for appeal of prior authorization decisions.

Prior authorization required from the HealthChoice and Acute Care Administration when the usual and customary charge exceeds $100 and the prescribed amount is a 34-day supply or more. Preauthorization is needed for any prescription with a usual and customary charge exceeding $400. Prior authorization is also needed for early refills, nutritional supplements, brand medically necessary and excessive quantities.


Prescription Refill Limit: Maximum of two refills. The original prescription and its refills may not exceed a 100-day supply except for birth control pills and oral sodium fluoride preparations. Refills may not be dispensed after 100 days of date of original prescription except for birth control pills and oral sodium fluoride preparations

Monthly Quantity Limit: The amount of medication to be dispensed on a prescription at one time is limited to a less than 34-day supply except for specific maintenance drugs for chronic conditions, where up to a 100-day supply may be dispensed at one time.


PRODUR system implemented January 1993. State currently has a DUR Board with a quarterly review.


Dispensing Fee: $4.21 as of July 1, 1996.

Ingredient Reimbursement Basis: Estimated Acquisition Cost (EAC) equals/lowest of: 1. Wholesale Acquisition Cost (WAC) plus 10%.

2. Direct cost plus 10%.

3. Distributor's price plus 10%.

4. Average Wholesale Price (AWP) minus 10%.

Prescription Charge Formula: Reimbursement will be the lower of: (1) the calculated ingredient cost plus a dispensing fee; (2) the usual and customary fee.


National Pharmaceutical Council Maryland-3

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Approximately 1,000 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary” and a reason.


Patient Cost Sharing: Copayment = $1.00. Does not apply to managed care, family planning, nursing home residents or recipients under 21 years old.



Approximately 400,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through the State and managed care plans.

Managed Care Organizations United Healthcare 6300 Security Boulevard Baltimore, MD 21207 FreeState Health Plan Blue Cross Blue Shield 10455 Mill Run Circle Owings Mills, MD 21117-5559 Helix Family Choice, Inc. 8094 Sandpiper Circle Baltimore, MD 21236 Jai Medical Systems, Inc. 5010 York Road Baltimore, MD 21212 Maryland Physicians Care MCO 7106 Ambassador Road Suite 100 Baltimore, MD 21244 Prime Health Corporation 9602-C M.L.K., Jr. Hwy Lanham, MD 20706 Priority Partners MCO The Candler Building 111 Market Place Baltimore, MD 21202 Ameri Group 857 Elkridge Landing Road, #300 Linthicum, MD 21040

F. STATE CONTACTS

State Drug Program Administrator Mr. Frank Tetkoski Pharmacy Services Manager DHMH, Office of Health Services Division of Pharmacy and Clinic Services 201 West Preston Street, Room 205 Baltimore, MD 21201 T: 410/767-1455 F: 410/333-7049 E-mail: [email protected]

Prior Authorization Contact Tuong Nguyen, P.D. Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston St., Rm. 132 Baltimore, MD 21201 T: 410/787-1455 F: 410/333-7049 E-mail: [email protected]

DUR Contact Judy Geisler, P.D. Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston Street Baltimore, MD 21201 T: 410/767-1455 F: 410/333-7049 E-mail: [email protected]

DUR Board Deneen Pieri, M.D. John Boronow, M.D. Michelle A. Forrest-Smith, Pharm.D. Myron Miller, M.D. (Chair) Lori Fantry, M.D., M.P.H. Vincent Ferrari, R.Ph. Steve A. Anifowshe, R.Ph. Elliot S. Gottlieb, R.Ph. Bernard J. Lechman, R.Ph.

Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578



Medicaid Drug Rebate Contacts Technical: Ed Ellis, 410/767-1455 Policy: Jeffrey Gruel, 410/767-1455 Audits: Kenneth Smoot, 410/767-5186 Disputes: Katherine Novak, 410/582-9305

Claims Submission Contact First Health Division of Claims Processing James Demery Manager, Pharmacy Services 201 W. Preston St. Baltimore, MD 21201 T: 410/767-6028 F: 410/333-7186 E-mail: [email protected]

Medicare Managed Care Contact Jim Gardner Chief Division of Health Choice Management Office of Health Services 201 W. Preston St. Baltimore, MD 21201 410/767-1482


Expanded Drug Coverage Program Paul Roeger Manager, Pharmacy Assistance Program Medical Care Operations and Eligibility 201 W. Preston St Baltimore, MD 21201 T: 410/767-5394 F: 410/333-5027 E-mail: [email protected]

Physician-Administered Drug Program Contact Edward Watters, M.D. 201 W. Preston Street Baltimore, MD 21201 410/767-1482

Health and Mental Hygiene Department Officials Nelson J. Sabatini Secretary Department of Health and Mental Hygiene 201 W. Preston Street Baltimore, MD 21201 T: 410/225-6500 F: 410/161-6489 E-mail: [email protected]

Debbie I. Chang Deputy Secretary Health Care Financing Department of Health and Mental Hygiene 201 W. Preston Street Baltimore, MD 21201 T: 410/767-4664 F: 410/333-7687 E-mail: [email protected] Susan Tucker Executive Director Office of Health Services 201 W. Preston Street Baltimore, MD 21201 Shelby Boggs Director of Healthcare and Acute Care Office of Health Services 201 W. Preston Street Baltimore, MD 21201 Jeffrey Gruel Chief Division of Pharmacy and Clinic Services Office of Health Services 201 W. Preston Street Baltimore, MD 21201 410/767-1455 Leslie S. Lyles Deputy Director Program Operations Office of Operations and Eligibility 201 W. Preston Street Baltimore, MD 21201 410/767-5161 Paul Roeger Program Manager Pharmacy Assistance Program PO Box 386 Baltimore, MD 21203 410/767-5392

Medical Assistance Staff Committee Members Judy Geisler, P.D. Division of Pharmacy and Clinic Services 201 W. Preston Street Baltimore, MD 21201 Mr. Frank Tetkoski, P.D., Manager, Pharmacy Services Division of Pharmacy and Clinic Services 201 W. Preston Street, Room 205 Baltimore, MD 21201


National Pharmaceutical Council Maryland-5

Tuong Nguyen, P.D. Division of Pharmacy and Clinic Services 201 W. Preston St. Baltimore, MD 21201

Executive Officers of State Medical and Pharmaceutical Societies Medical/Chirurgical Faculty of Maryland T. Michael Preston Executive Director 1211 Cathedral Street Baltimore, MD 21201 T: 410/539-0872 F: 410/547-0915 E-mail: [email protected] Internet Address: www.medchi.org Maryland Osteopathic Association, Inc. John Kylan Lynch, D.O. 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 21201-1572 T: 410/727-0746 F: 410/727-2253 Internet Address: users.erols.com/mpha/index.html Maryland Society of Health-System Pharmacists David A. Kotzin, President 8480-M Baltimore National Pike, Ste. 250 Ellicott City, MD 21042 T: 410/465-9975 F: 410/465-7073 E-mail: [email protected] Internet Address: www.mshp.org State Board of Pharmacy LaVerne G. Naesea Executive Director 4201 Patterson Avenue Baltimore, MD 21215-2299 T: 410/764-4794 F: 410/358-6207 E-mail: [email protected] Internet Address: www.dhmh.state.md.us/pharmacyboard

The Maryland Hospital Association, Inc. Calvin M. Pierson, President 1301 York Road, Suite 800 Lutherville, MD 21093-6087 T: 410/321-6200 F: 410/379-8239 Internet Address: www.mhaonline.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




National Pharmaceutical Council Massachusetts-1

MASSACHUSETTS



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expenditures Recipients Expenditures Recipients TOTAL $682,519,910 666,627 $797,859,072 RECEIVING CASH ASSISTANCE TOTAL $350,268,440 237,277 Aged $39,048,243 27,870 Blind/Disabled $290,432,382 129,552 Child $7,752,715 52,864 Adult $13,035,100 26,991 MEDICALLY NEEDY, TOTAL $30,341,383 16,713 Aged $11,516,242 8,076 Blind/Disabled $18,825,141 8,637 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $183,962,431 232,935 Aged $52,662,378 29,640 Blind/Disabled $101,474,974 39,208 Child $26,676,016 155,560 Adult $3,149,063 8,527 TOTAL OTHER EXPENDITURES/RECIPIENTS* $117,947,656 179,702

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY2001.


2-Massachusetts National Pharmaceutical Council

C. ADMINISTRATION

Executive Offices of Health and Human Services, Division of Medical Assistance.


Benefit Design

Drug Benefit Product Coverage: Products covered (except in LTC facilities): prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips. Products covered with restrictions: total parenteral nutrition. Ritalin and amphetamines are limited to treatment of hyperkinesis for children under age 17, except by prior authorization; and ADD by prior authorization (not covered for appetite control). Products not covered: cosmetics; fertility drugs; experimental drugs; 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 less-than-effective.

Over-the-Counter Product Coverage: Products covered with restrictions (limited OTC list-generics only): allergy, asthma and sinus products; analgesics; digestive products; feminine products and topical products. Products covered with restrictions: cough and cold preparations (only in LTC facilities). Products not covered: smoking deterrent products.

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

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.


Formulary/Prior Authorization Formulary: Open Formulary

Prior Authorization: State currently has a prior authorization procedure. A fair hearing process by the recipient on an individual basis is required for appealing a prior authorization decision.

Prescribing or Dispensing Limitations Prescription Refill Limit: Prescription may be refilled, as authorized, with a limit of up to 5 refills from the filling of the original prescription

Monthly Quantity Limit: Schedule II and III drugs are limited to a 30-day supply, except Ritalin and Dexedrine, which may be dispensed up to a 60-day supply.


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: Brand: $3.50; Generic: $5.00, effective 11/1/02.

Ingredient Reimbursement Basis: EAC = WAC + 5%.

Prescription Charge Formula: Payment shall be for the lowest of:

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; or

3. FULP plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Dispense as Written,” and/or “Brand Medically Necessary” plus prior approval.

Patient Cost Sharing: Copayment = $2.00 with the following exceptions:

− Institutionalized patients

− Children under age 19

− Pregnant and postpartum women

− Hospice care

− Family planning items




National Pharmaceutical Council Massachusetts-3

E. USE OF MANAGED CARE Approximately 616,000 Medicaid recipients were enrolled in MCOs in FY 2000. Recipients receive pharmaceutical benefits through managed care plans.

Managed Care Organization Primary Care Clinician Plan 340,690 Boston Medical Center HealthNet Plan 105,923 Fallon Community Health Plan 9,488 Neighborhood Health Plan 100,410 Network Health 49,391

F. STATE CONTACTS

State Drug Program Administrator Paul L. Jeffrey Director of Pharmacy Division of Medical Assistance 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

Medicaid DUR Board Spencer Wilking, MD (Chairman) C. Michael Bliss, MD Sarah Cheeseman, MD Thomas Hewitt, MD Anne Marie McCloskey, R.Ph. Leo McKenna, R.Ph. Dave Morgan, R.Ph. Robert Portney, MD James Scanlon, R.Ph. David Kosegarten, Ph.D. Gerry Longnecker, Pharm.D.

Prescription Price Updating First Data Bank 111 Bayhill Drive, Suite 350 San Bruno, CA 94066 650/588-5454

Medicaid Drug Rebate Contacts Martha Kessenich Rebate Analyst ACS State Health Care 365 North Ridge Road Atlanta, GA 30350 800/358-2381

Claims Submission Contact ACS State Health Care 365 North Ridge Road Atlanta, GA 30350 800/358-2381

Medicaid Managed Care Contact Kate Willrich-Nordahl, Director MCO Program Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5466 F: 617/210-5003 E-mail: [email protected]


Disease Management Program/Initiative Contact N/A

Elderly Expanded Drug Coverage Program Contact David Morales Executive Office of Elder Affairs One Ashburton Place, Room 517 Boston, MA 02108 T: 617/727-7750 F: 617/727-9368 E-mail: [email protected]

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


4-Massachusetts National Pharmaceutical Council

Wendy Warring, Commissioner Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5690 F: 617/210-5000 E-mail: [email protected] Internet address: www.state.ma.us/dma

Executive Officers of State Medical and Pharmaceutical Societies Massachusetts Medical Society Charles A. Welch, M.D. President 860 Winter Street Waltham Woods Corporate Center Waltham, MA 02451-1411 781/893-4610 E-mail: [email protected] Internet address: www.massmed.org Massachusetts Pharmacists Association Alan J. Shubin, R.Ph. President 681 Main Street, Suite 3-32 Waltham, MA 02451 T: 781/736-0101 F: 781/736-0080 Internet address: www.maspharmacists.org Massachusetts Osteopathic Society, Inc. Ron Jolda, D.O. President 49 Wawela Road Webster, MA 01570 508/949-2985 E-mail: [email protected] Internet address: www.northeastosteo.org/MOS_HP.htm Massachusetts Board of Registration in Pharmacy Charles R. Young Executive Director 239 Causeway Street, Suite 500 Boston, MA 02114 617/727-9953 E-mail: [email protected] Internet address: www.state.ma.us/reg/boards/ph Massachusetts Society of Health-Systems Pharmacists Alana Arnold Boermeester President 681 Main Street, Suite 3-32 Waltham, MA 02451 T: 781/894-9300 F: 781/894-9393 Internet address: www.mashp.org

Massachusetts Hospital Association Ronald M. Hollander President Five New England Executive Park Burlington, MA 01803 617/272-8000 Internet address: www.mhaliuk.org Massachusetts Extended Care Federation Abraham E. Morse President 2310 Washington Street, Suite 300 Newton, MA 02462 T: 617/558-0202 F : 617/558-3546 E-mail: [email protected] Internet address: www.mecf.org


National Pharmaceutical Council Michigan-1

MICHIGAN1 A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $374,334,359 435,654 $584,670,445 RECEIVING CASH ASSISTANCE TOTAL $157,228,868 156,791 Aged $22,910,676 16,186 Blind/Disabled $128,621,561 102,171 Child $2,108,586 18,695 Adult $3,588,045 19,735 MEDICALLY NEEDY, TOTAL $25,686,605 40,549 Aged $6,580,156 4,681 Blind/Disabled $12,066,396 5,606 Child $1,828,824 8,882 Adult $5,211,229 21,380 POVERTY RELATED, TOTAL $19,770,950 85,801 Aged $1,349,453 1,217 Blind/Disabled $9,758,682 4,342 Child $7,116,143 62,329 Adult $1,546,672 17,913 TOTAL OTHER EXPENDITURES/RECIPIENTS* $171,647,936 152,513


1 The State of Michigan did not respond to either the 2001 or 2002 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 Michigan Medicaid program to assess the accuracy and currency of the information included.


2-Michigan National Pharmaceutical Council

C. ADMINISTRATION

Michigan Department of Community Health, Medical Services Administration.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products covered with restrictions: total parenteral nutrition (paid to medical suppliers) and interdialytic parenteral nutrition. Prior authorization required for: brand name products equivalent to MACs; Accutane & Retin-A; Dexedrine and Adderall; Persantine; Lactulose (Cephulac); Methylphenidate (selected ages); selected benzodiazepines; Epogen administered in the home setting; dietary formulas; and drugs not listed on the formulary. Products not covered: cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered with restrictions (only selected products in each category): allergy, asthma and sinus products; analgesics; digestive products (non-H2 and H2 antagonists); feminine products; topical products; and smoking deterrent products (patches and gum). Products not covered: cough and cold preparations.

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


Vaccines: Vaccines reimbursable at cost plus a fee/or vaccine replacement as part of the EPSDT service and the Children Health Insurance Program.



Formulary: Closed formulary.

Prior Authorization: State currently has a formal prior authorization procedure. In order to appeal prior authorization decisions, a department appeals section in the Medicaid program sets up hearings for beneficiaries. The beneficiary is sent a letter with instructions on their appeal rights when appealing the coverage of an excluded product.


Prescription Refill Limit: Based on State law.

Monthly Quantity Limit: Prescribed quantities should be limited to an amount necessary to keep the recipient supplied during the therapy regimen. In certain cases and conditions, more than a month’s supply will be appropriate. However, in no instance may more than 100 days supply be dispensed per prescription.





Ingredient Reimbursement Basis: 1-4 stores = AWP-13.5%, 5 or more stores = AWP-15.1%.

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 selected $1.00 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. 800 drugs are listed on the State-specific MAC list. Override requires “Dispense as Written” and prior authorization.




Patient Cost Sharing: Ambulatory recipients age 21 and older are required to pay a $1.00 copayment for most legend drugs. If the recipient is unable to pay a required copayment on the date of service, the pharmacy cannot refuse to render the service. However, the pharmacy may bill the recipient for the copayment amount, and he/she is responsible for paying it. If the recipient fails to pay a copayment, the pharmacy could, in the future, refuse to serve the recipient as a Medicaid recipient.

Drugs not requiring a co-payment include 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.



Approximately 710,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through the State and managed care plans.

Managed Care Organizations Botsford Health Plan 28050 Grand River Farmington Hills, MI 48336 248/473-6190 800/479-5122 Cape Health Plan 26711 Northwestern Highway, Suite 300 Southfield, MI 48034 248/386-3000 888/354-2273 Care Choices HMO 34605 Twelve Mile Road Farmington Hills, MI 48331 248/489-6000 800/893-1113 Community Care Plan 2100 Raybrook, SE Grand Rapids, MI 49546 616/252-4500 800/807-5244

Community Choice Michigan 2369 Woodlake Drive Okemos, MI 48864 517/349-9922 800/390-7102 Great Lakes Health Plan, Inc. 17117 W. Nine Mile, Suite 1600 Southfield, MI 48075 248/559-5656 800/903-5253 Health Plan of Michigan 17515 W. Nine Mile, Suite 650 Southfield, MI 48075 248/557-3700 888/437-0606 HealthPlus Partners, Inc. 2050 S. Linden Road P.O. Box 1700 Flint, MI 48501-1700 810/230-2222 800/322-9161 M-Caid 2301 Commonwealth Blvd. Ann Arbor, MI 48105-1573 800/527-5549 McLaren Health Plan 401 S. Ballenger Highway Flint, MI 48532 888/327-0671 Midwest Health Plan 5050 Schaefer Road Dearborn, MI 48126 313/581-3700 888/654-2200 Molina Healthcare of Michigan 100 W. Big Beaver Road, Suite 600 Troy, MI 48084 248/925-1700 888/898-7969 OmniCare Health Plan 1155 Brewery Park Blvd. Suite 250 Detroit, MI 48207 313/259-4000 800/955-4578



PHP of Mid-Michigan, Inc. P.O. Box 30377 Lansing, MI 48909-7877 517/364-8400 800/661-8299 PHP of Southwest Michigan, Inc. 106 Farmers Alley, Suite 300 Kalamazoo, MI 49007 269/341-7200 800/261-0084 Priority Health 1231 E. Beltline, NE Grand Rapids, MI 49525-4501 616/942-0954 888/975-8102 Total Health Care 3011 W. Grand Blvd., Suite 1600 Detroit, MI 48202 313/871-2000 800/826-2862 Upper Peninsula Health Plan 228 W. Washington Street Marquette, MI 49855 906/225-7500 800/835-2556 The Wellness Plan 2875 W. Grand Blvd. Detroit, MI 48202 313/875-4200 800/875-9355

F. STATE CONTACTS

State Drug Program Administrator James Kenyon, R.Ph. Pharmacist Consultant MDCH/Medical Services Administration 400 South Pine Street Lansing, MI 48933 T: 517/335-5265 F: 517/335-5294 E-mail: [email protected] Internet address: www.michigan.gov/mdhc

Prior Authorization Contact James Kenyon, R.Ph., 517/335-5265

DUR Contact Mary Sandusky, R.Ph. Pharmacist Consultant MDCH- Medical Services Administration 400 S. Pine St. Lansing, MI 48933 T: 517/335-5280 F: 517/241-7813 E-mail: [email protected]

Medicaid DUR Board Richard Henderson, M.D. 34650 Versailles Court Farmington Hills, MI 48331 810/474-1397 Frank Check, M.D. St. Joseph Mercy Hospital 900 Woodward Avenue Pontiac, MI 48341 313/858-3233 Duane Kirking, Ph.D. College of Pharmacy University of Michigan Ann Arbor, MI 48109-1065 313/764-4483 313/764-7312 William Overkamp 2929 Walker, N.W. Grand Rapids, MI 49544 Karen Jonas, R.Ph. 13121 Willow Grove Road Dewitt, MI 48820 517/315-1243 James Kenyon, R.Ph. Michigan Department of Community Health Medical Services Administration P.O. Box 30479 Lansing, MI 48909 Otto Graesser, DO 1421 W. Mt. Hope Lansing, MI 48910

Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578



Medicaid Drug Rebate Contacts Technical: Randy Rothfuss, 517/335-5040 Audits: James Kenyon, 517/335-5265 PA: Barbara Jones, 517/335-5061

Claims Submission Contact First Health Services Corp 4300 Cox Rd. Glen Allen, VA 23060

Medicaid Managed Care Contact Rick Murdock, Director Comprehensive Health Plan Division MDCH- Medical Services Administration 400 S. Pine Street Lansing, MI 48933 T: 517/241-7933 F: 517/241-8231

Disease Management Program/Initiative Contact Mary Sandusky, 517/335-5280

Elderly Expanded Drug Coverage Contact Doris Gellert Dept. of Community Health 611 West Ottawa P.O. Box 30676 Lansing, MI 48909-8176 517/335-5182 E-mail: [email protected]

Physician-Administered Drug Program Contact Linda McCardel Medical Services Administration P.O. Box 30479 Lansing, MI 48909 517/335-5115

Michigan Dept. of Community Health (MDCH) Janet Olszewski Director Lewis Cass Building 320 South Walnut Street Lansing, MI 48913 T: 517/335-0267 F: 517-373-4288 E-mail: [email protected]

Patrick Barrie Deputy Director Health Programs Administration 400 South Pine Street Lansing, MI 48909 T: 517/335-5001 F: 517/335-5007 E-mail: [email protected]

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 David R. Johnson, M.D., M.Ph. (Chair) Robert P. Coffey, Pharm.D. Debera Hayes Eggleston, M.D. Robert Ernest, M.D. Jonathan G.A. Henry, M.D. Edward J. Keating, R.Ph. James Kenyon, R.Ph. Larry W. Lawhorne, M.D. Giovannino A. Perri, M.D. Max Robins, D.O. Sandra A. Silecchia, Pharm.D.

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



Michigan Pharmacists Association Larry D. Wagenknecht, Executive Director 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 Osteopathic Association Dennis Paradis, Executive Director 2445 Woodlake Circle Okemos, MI 48864 T: 517/347-1555 F: 517/347-1566 E-mail: [email protected] Internet address: www.moa-do.com State Board of Pharmacy Melanie Brim Licensing Manager 611 W. Ottawa, P.O. Box 30670 Lansing, MI 48909-8170 517/373-9102 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 & 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


National Pharmaceutical Council Minnesota-1

MINNESOTA





Child Adult Other SFO








B. EXPENDITURES FOR DRUGS

2000 2001**

Expenditures Recipients Expenditures Recipients TOTAL $221,682,000 180,104 $265,726,228 RECEIVING CASH ASSISTANCE, TOTAL $127,824,974 85,255 Aged $7,450,342 5,273 Blind / Disabled $113,608,005 47,543 Child $3,308,774 17,506 Adult $3,457,853 14,933 MEDICALLY NEEDY, TOTAL $15,090,970 6,848 Aged $3,644,001 2,804 Blind / Disabled $11,429,954 3,951 Child $16,970 91 Adult $45 2 POVERTY RELATED, TOTAL $710,680 722 Aged $168,845 366 Blind / Disabled $541,647 353 Child $188 3 Adult $0 0 TOTAL OTHER EXPENDITURES/RECIPIENTS* $78,055,376 87,279

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Minnesota National Pharmaceutical Council

C. ADMINISTRATION Minnesota Department of Human Services, Health Care Management Division, Medical Assistance Program.


Benefit Design

Drug Benefit Product Coverage: Products not covered: drugs used for cosmetic purposes; drugs used for hair growth; fertility drugs; appetite supressants; and experimental drugs. Products covered with limitations: interdialytic parenteral nutrition, 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.

Over-the-Counter Product Coverage: Products covered with limitations: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonist); feminine products (antifungals covered); topical products; and smoking deterrent products; vitamins; ocular lubricants; pediculocides; activated charcoal and ipecac; and insulin.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs (OTC loratadine products are preferred second generation antihistamines, all other require prior authorization); antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents.

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 EPSDT Services, the Children’s Health Insurance Program, and the Vaccines for Children Program.


Formulary/ Prior Authorization

Formulary: Open formulary with general exclusions.

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.


Monthly Quantity Limit: 3 month supply. Minimum 30-days for maintenance drugs. Contraceptives may be filled to provide a 3-month supply.


PRODUR system implemented in February 1996. State currently has a DUR Board with a quarterly review. Heritage Information Systems provides software and assistance with RetroDUR.




Prescription Charge Formula: Reimbursement is based on the lesser of submitted AWP minus 9% plus a dispensing fee, MAC plus a dispensing fee, or usual and customary. Special rules for IV admixtures.

Maximum Allowable Cost: State imposes a combination of Federal Upper Limits and State-specific MAC on generic drugs. Override requires “brand medically necessary” or “dispense as written.” Brand medically necessary must be handwritten on the prescription by the prescriber. No pre-printed DAW allowed.





Approximately 340,000 Medicaid recipients were enrolled in MCOs in FY 2001. 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: 218/327-6133 F: 218/327-5545 Blue Plus P.O. Box 64179 St. Paul, MN 55164-0179 T: 651/662-5200 First Plan Blue 1601 London Road Duluth, MN 55812 T: 218/728-6706 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 Mail Route 80920 Minneapolis, MN 55440-9310 T: 952/992-3200 F: 952/992-3198 Metropolitan Health Plan 822 South 3rd Street, Suite 140 Minneapolis, MN 55415 T: 612/347-8584 F: 612/904-4493 UCare Minnesota P.O. Box 52 Minneapolis, MN 55440-0052 T: 612/626-3300 F: 612/676-6555 South County Health Alliance 303 South Cedar Street Owatonna, MN 55060 T: 507/444-7770 F: 507/444-7774

F. STATE CONTACTS State Drug Program Administrator Cody Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet address:www.dhs.state.mn.us

Prior Authorization Contact Cody Wiberg, 651/296-8515DUR Contact

Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator 444 Lafayette Road St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected]

Medicaid DUR Board Physicians Michael F. Koch, M.D. Director, Child Psychiatry Hennepin County Medical Center 701 Park Avenue South Minneapolis, MN 55402

Andrew R. Baron, M.D. 1930 17th Street South St. Cloud, MN 56301

Roger E. Hofer, M.D. Mayo Clinic 200 SW First Street Rochester, MN 55905 Health Care Professional Marilyn M. Ulseth, MS., RN., CNP. 2909-33rd Ave South Minneapolis, MN 55406 Pharmacists Lynne M. Schneider, R.Ph. 12910 37th Avenue North Plymouth, MN 55441 Ron Johnson, R.Ph. Lloyd’s Pharmacy 720 North Snelling St. Paul, MN 55104 Peter Marshall, Pharm. D. HealthPartners Pharmacy Services



P.O. Box 1309 8100 - 34th Avenue South Minneapolis, MN 55440-1309 Wendy L. St. Peter, Pharm.D. Hennepin County Medical Center Nephrology Analytical Services USRDS Coordinating Center 914 Eighth Avenue South Minneapolis, MN 55404 Consumers Representative Vacant DHS Staff Cody Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator

Prescription Drug Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 650/588-5454 F: 650/588/4003

Claims Submission Contact 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 St. Paul, MN 55155-3849 T: 651/282-5881 F: 651/282-6744 E-mail: [email protected]

Disease Management Program/Initiative Contact Cody Wiberg, 651/296-8515

Mail Order Pharmacy Benefit

None

Elderly Expanded Drug Coverage Program Contact

Cody Wiberg, 651/296-8515

Physician-Administered Drug Program Contact

Cody Wiberg, 651/296-8515

Department of Human Services Officials Kevin Goodno Commissioner Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3815 T: 651/296-2701 F: 651/297-3230 E-mail: [email protected] Mary Kennedy Medicaid Director Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3852 T: 651/282-9921 F: 651/297-3230 E-mail: [email protected]

Drug Formulary Committee Al Heaton, Pharm.D., R.Ph. Senior Director Prime Therapeutics 1020 Discovery Road No. 100 Eagan, MN 55121 Charlene Nusman, Consumer Representative 2534 Lynn Avenue So. St. Louis Park, MN 55416 William P. Korchik, M.D. Veterans Affairs Medical Center One Veteran Drive (11L) Minneapolis, MN 55417 Jack Alexander, M.D. Chief Medical Officer Fairview Red Wing Clinic 2835 South Service Clinic Red Wing, MN 55066-0095

Paul Johnson, M.D. Metropolitan Health Plan 822 South 3rd Street, Suite 140 Minneapolis, MN 55415



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

Robert Straka, Pharm.D. University of Minnesota College of Pharmacy 7-148 Weaver-Densford Hall 308 Harvard Street, S.E. Minneapolis, MN 55455 DHS Staff Cody Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Mary Beth Reinke, Pharm.D., R.Ph. Dur Coordinator Executive Officers of State Medical and Pharmaceutical Societies Minnesota Medical Association Paul S. Sanders, M.D. Chief Executive Officer 3433 Broadway Street NE, Suite 300 Minneapolis, MN 55413-1761 T: 612/378-1875 F: 612/378-3875 E-mail: [email protected] Internet address: www.mnmed.org 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 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 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.mhlp.com Minnesota Society of Health System-Pharmacists Judy Schneider Executive Director 2419 Margaret Street North Suite 210 North St. Paul, MN 55109 T: 651/639-0506 F: 651/773-0717 E-mail: [email protected] Internet address: www.mnshp.org Care Providers of Minnesota Rick E. Carter President & CEO 2850 Metro Drive Suite 200 Bloomington, MN 55425 T: 612/854-2844 F: 612/854-6214 E-mail: [email protected] Internet address: www.careproviders.org




National Pharmaceutical Council Mississippi-1

MISSISSIPPI



Aged Blind/

Disabled


Disabled

Child Adult SFO





Skilled Nursing Home Services � � � �



B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $370,355,016 415,925 $493,177,297 RECEIVING CASH ASSISTANCE TOTAL $213,654,399 159,780 Aged $36,653,891 23,329 Blind/Disabled $169,768,566 104,316 Child $3,972,229 22,291 Adult $3,259,713 9,844 MEDICALLY NEEDY, TOTAL $0 0 Aged $0 0 Blind/Disabled $0 0 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $100,396,175 201,384 Aged $35,679,665 22,486 Blind/Disabled $37,583,340 18,026 Child $23,601,427 137,097 Adult $3,531,743 23,775 TOTAL OTHER EXPENDITURES/RECIPIENTS* $56,304,442 54,761

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Mississippi National Pharmaceutical Council

C. ADMINISTRATION

Division of Medicaid, Office of the Governor.


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; and interdialytic parenteral insulin. Prior authorization required for: Sandimmune; Viagra; enteral feeding products; 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; and all Home IV drug therapies. Products not covered: cosmetics; fertility drugs; experimental drugs.

* 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: smoking deterrent products; Products covered with restrictions; (i.e., certain rebated products) 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; certain vitamins (prenatal and dialysis), and digestive products (H2 antagonists-prior authorization required).

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic 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, antilipemic agents (PA required for xenical); sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; antihistamines; misc. GI drugs; and growth hormones. Partial coverage: Products not covered: weight loss drugs; nutritional products; fertility drugs; vitamins and minerals (except prenatal); and DESI drugs.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in extended care facilities and through physician payment when used in physicians’ offices.


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


Formulary: Open formulary, however, 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).

Prior Authorization: State currently has a prior authorization procedure. Administrative hearing required to appeal prior authorization decisions.


Prescription Refill Limit: Limited to five (5).

Monthly Quantities Limit: 34-day supply or 100 units or doses, whichever is greater. Birth control pills may be supplied in 3-month quantities.

Monthly Prescription Limit: Total prescriptions dispensed per month per recipient are limited to 5. Two additional prescriptions per month may be allowed with prior authorization.


PRODUR system implemented in 1993.


Dispensing Fee: $3.91 (effective 4/1/02). IV mixtures can receive up to a $30 per liter dispensing fee.



Ingredient Reimbursement Basis: EAC = AWP-10%, 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, AWP + 50%, or shelf price. OTC drugs are to be billed on pharmacy invoice at shelf price.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires prior authorization for brand multi-source drugs.


Patient Cost Sharing: Tiered copayment of $1.00-$3.00. $1.00 - preferred generic $2.00 - preferred brand $3.00 - non-preferred brand

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.


No Medicaid recipients receive health benefits through MCOs.

F. STATE CONTACTS

State Drug Program Administrator Rickey R. Mallory, R.Ph. Pharmacy Bureau Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Suite 801 Jackson, MS 39201-1399 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: http://www.dom.state.ms.us

Division of Medicaid Official Rica Lewis-Payton, 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]

DUR Contact Rickey Mallory 601/359-6296

Mississippi DUR Board Robert McMurray, M.D UMC-Rheumatologg Dept 2500 North State Street Jackson, MS Tim Alford, M.D. Kosciusko Medicaid Clinic Highway 12 Kosciusko, MS 39090 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 Warren Jones, M.D. 115 Cirencester Drive Ridgeland, MS 39157 Robert Smith, M.D. 971 Lakeland Drive Suite 563 Jackson, MS 39216 Joe McGuffee, R.Ph. McGuffee Drugs 102 North Main Street Mendenhall, MS 39114 Montez Carter, Pharm.D. P.O. Box 1414 Greenwood, MS 38935 Leigh Ann Ramsey, Pharm.D. 6295 Old Canton Road, #34 B Jackson, MS 39211 Diana McGowan, R.Ph., M.B.A 328 Dover Lane Madison, MS 39110 Clarence DuBose, R.Ph. Medi-Mart Pharmacy 3737 Main Street Moss Point, MS 39563



Bob Broadus, R.Ph. 7147 Creekwood Drive Mandeville, LA 70471

Prescription Price Updating Rickey Mallory 601/359-6296

Medicaid Drug Rebate Contact Glenda Grant Division of Medicaid Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 601/359-6050 E-mail: [email protected]

Claims Submission Contact Terry Childress Director of Systems Management Division of Medicaid Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 T: 601/359-6075 F: 601/359-6048 E-mail: [email protected]

Disease Management/Patient Education Programs Disease/Medical State: Asthma Program Name: Asthma Disease Management (eff. 2/03) Program Manager: Mckesson 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 Condon Director of Medical Services Division of Medicaid Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 601/359-5250 E-mail: [email protected]


Medicaid Managed Care Contact Melzana Fuller Director of Provider and Beneficiary Relations Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-6063 F: 601/359-4185 E-mail: [email protected]

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

Pharmacy and Therapeutics Committee Craig Dawkins, M.D. 1213 Broad Avenue Gulfport, MS 39501 Yolanda Wilson, M.D. 1600 North State Street Suite 301 Jackson, MS 39202 Shannon Johnson, M.D. South Mississippi Psychiatric Group 1101 B. South 28th Avenue Hattiesburg, MS 39402 Gary Davis, M.D. 571 East Beasley Road, Suite D Jackson, MS 39206 Charles Brock, M.D. 498 Hillcrest Cleveland, MS 38732 Myrna Alexander, M.D. 971 Lakeland Drive, Suite 850 Jackson, MS 39216 Betsy Commings, C.F.N.P 1740 McClain Street Greenville, MS 38701



Guy Phillips, R.Ph. 903 Highway 82 East Indianola, MS 38751 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. 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.msmed.org Mississippi Pharmacists Association Bo Dalton, R.Ph. Executive Director 341 Edgewood Terrace Drive Jackson, MS 39206-6217 601/981-0416 Mississippi State Board of Pharmacy Leland “Mac” McDivitt Executive Director 625 North State Street Jackson, MS 39202 T: 601 354-6750 F: 601/354-6071 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 Internet address: www.moma-net.org

Mississippi Hospital Association Sam W. Cameron President/CEO 6425 Lakeover Rd. Jackson, MS 39236-6444 T: 800/289-8884 F: 601/368-3200 E-mail: [email protected] Mississippi Society of Health-System Pharmacists Dianna McGowan Association Manager 328 Dover Lane Madison, MS 39110 T: 601/856-9273 F: 601/856-8539 E-mail : [email protected] Mississippi Health Care Association Martha Carole Jones Executive Director 114 Marketridge Drive Ridgeland, MS 39157 T: 601/956-3472 F: 601/977-0273 Internet address: www.mshca.com




National Pharmaceutical Council Missouri-1

MISSOURI 1



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $600,484,118 447,062 $675,647,147 RECEIVING CASH ASSISTANCE TOTAL $235,086,301 148,738 Aged $47,641,532 20,176 Blind/Disabled $164,250,713 57,092 Child $9,663,268 41,803 Adult $13,530,788 29,667 MEDICALLY NEEDY, TOTAL $0 0 Aged $0 0 Blind/Disabled $0 0 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $38,069,254 104,337 Aged $5,491,622 3,740 Blind/Disabled $10,845,153 3,533 Child $20,303,141 84,243 Adult $1,429,338 12,821 TOTAL OTHER EXPENDITURES/RECIPIENTS* $327,328,563 193,987

**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001

1 The state of Missouri did not respond to the 2002 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 Missouri Medicaid program to assess the accuracy and currency of the information included.


2-Missouri National Pharmaceutical Council

C. ADMINISTRATION

Division of Medical Services, Missouri Department of Social Services.


Benefit Design

Drug Benefit Product Coverage: Categories or drugs that are covered: prescribed insulin; disposable needles and syringe combinations used for insulin; nonlegend ophthalmic preparations; nonlegend acne preparations; nonlegend weight control preparations; hemorrhoid products; estazolam; halazepam; prazepam; and quazepam. Products covered through the Durable Medical Equipment Program: blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for: amphetamines; Isotretinoin; and Retinoic Acid. Products not covered: cosmetics; fertility drugs; anoretics; experimental drugs; smoking deterrent products; feminine products; and topical products.

(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.

Vaccines: Vaccines reimbursable as part of EPSDT program, Children Health Insurance Program, and Vaccines for Children Program.



Formulary: Open formulary with exclusions.

Prior Authorization: State currently has a prior authorization procedure and a Drug Prior Authorization Committee composed of 7 members who meet quarterly.


Prescription Refill Limit: Federal regulations must be observed for all drugs on the formulary that are listed in BNDD Schedules 2, 3, 4, and 5. All other prescriptions refilled should be in accordance with the directions given by the prescribing physician.

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: Aspirin 5 gr.; Aspirin buffered 5 gr.; Aspirin enteric-coated 5 gr.; Acetaminophen 5 gr. Prenatal vitamins must be dispensed in a quantity of at least 100.

Drug Utilization Review PRODUR system implemented in 1993. State currently has a DUR Board with a quarterly review.



Ingredient Reimbursement Rate: EAC = AWP-10.43% or WAC+10%.

Prescription Charge Formula:

1. Method of reimbursement payment is based on acquisition cost plus a dispensing fee of $4.09 per prescription filled. Acquisition may vary depending whether it is based on AWP and Federal or Missouri MAC.

2. Any drug that is not a Federal or Missouri MAC drug will be based on the AWP-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.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. 199 drugs are listed on the State-specific MAC list. Override requires prior authorization.




Patient Cost Sharing: Variable 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

($5.00 copayment for certain 1115 waiver populations (see Pharmacy Bulletin).)

Copayment retained by pharmacist.

Cognitive Services: Payment for cognitive services is provided to qualified pharmacies who enroll to provide diabetes education.


Approximately 380,000 Medicaid recipients are enrolled in managed care organizations in 2001. All receive pharmacy services through managed care.

Managed Care Organizations Healthcare USA 100 South 4th Street, Suite 1100 St. Louis, MO 63102 314/444-7239 Blue Advantage Plus Health Plan P.O. Box 419130 2301 Main St. Kansas City, MO 64141 816/395-3891 Mercy Health Plan 425 S. Woods Mill Road Chesterfield, MO 63017 314/214-8000 Care Partners Health Plan The Clayton Center 120 S. Central, 8th Floor St. Louis, MO 63105 314/505-5400 Community Care Plus Health Plan 5615 Pershing Avenue, Suite 29 St. Louis, MO 63112 314/454-0055 ext. 234 HealthNet Health Plan 2300 Main Street, Suite 700 Kansas City, MO 64108 816/221-8400

FirstGuard Health Plan 3801 Blue Parkway Kansas City, MO 64130 816/922-7250 Family Health Partners Health Plan 215 W. Pershing Road, Suite 310 P.O. Box 411806 Kansas City, MO 64141 816/855-1871 Missouri Care Health Plan 2404 Forum Blvd. Columbia, MO 65203 573/441-2100

F. STATE CONTACTS

State Drug Program Administrator Susan McCann, R.Ph. Pharmaceutical Consultant Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6963 F: 573/526-4650 E-mail: [email protected]

Social Services Department Officials Dana Katherine Martin, Director Department of Social Services Broadway State Office Building P.O. Box 1527 Jefferson City, MO 65102 T: 573/751-4815 F: 573/751-3203 E-mail: [email protected] Gregory A. Vadner, Director Division of Medical Services 615 Howerton Court, P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-3425 F: 573/751-6564 E-mail: [email protected]

Prior Authorization Contact Allison Lauf, R.N. Nurse Consultant Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 T: 573/751-3762 F: 573/751-2439 E-mail: [email protected]



DUR Contact Jayne Zemmer DUR Coordinator Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 T: 573/751-6963 F: 573/526-4650 E-mail: [email protected]

DUR Board John W. Newcomer, M.D. (Chair) Associate Professor of Psychiatry Washington University, School of Medicine Campus Box 8134 660 S. Euclid St. Louis, MO 63110 Ronald Graham, Pharm.D. Government Relations Manager Novartis Corporation 1311 Granite Creek Drive Blue Springs, MO 64015 Randall Huss, M.D. Rolla Family Practice 910 W. 10th Street Rolla, MO 65401 Joy S. Gronstedt, D.O. 30580 Summers Drive Sedalia, MO 65301 Joseph M. Yasso, D.O. 3513 NW Primrose Lane Lee’s Summit, MO 64064 Harold Lurie, M.D. Springfield, MO Karla Dwyer, R.Ph. 901 Cherry Lane Kirksville, MO 63501 Susan Abdel-Rahman, Pharm.D. Division of Clinical Pharmacology Children’s Mercy Hospital 2401 Gillham Road, Suite 0411 Kansas City, MO 64108 Peggy Wanner-Barjenbrunch, M.D. Mexico Health Services 809 Medical Park Drive, Suite 104 Mexico, MO 65265

Sandra Bollinger, Pharm.D. Health Priorities, Inc. 707 Specialty Drive Dexter, MO 63841 Stephen Calloway, Pharm.D. Columbia, MO Robert Dale Potter, R.N. 422 West Robin Ridge Road Columbia, MO 65203

Drug Prior Authorization Committee Patrick J. Bryant, Pharm.D. Drug Information Center School of Pharmacy University of Missouri - Kansas City MG-200 Medical School Building 2411 Holmes Street Kansas City, MO 64108-2792 M. Dale Terrell, M.D. Washington University School of Medicine Division of Geriatric Medicine Room M238 1402 South Grand Blvd. St. Louis, MO 63104 Gene Forrester, R.Ph. 2400 S. Blackthorne Columbia, MO 65201 Henry Petry, D.O. Laurie Clinic P.O. Box 1277 Laurie, MO 65038 James E. Edwards, M.D. 1000 Executive Pkwy, Suite 103 St. Louis, MO 63141 Lorraine C. Brown, D.O. Rt. 2, Box 247C Camdenton, MO 65020 Conrad S. Balcer, D.O. 1241 W. Stadium Blvd. Jefferson City, MO 65109




Medicaid Drug Rebate Contacts Technical: Julie Schulte, 573/751-7996 Policy: Susan McCann, 573/751-6963 Dispute Resolution: Lynn Hebenheimer, 573/526-5778 Audits: Lynn Hebenheimer, 573/526-5778

Claims Submission Contact Jim Judge Claims Process Administrator Verizon 905 Weathered Rock Road Jefferson City, MO 65101 573/635-2434

Medicaid Managed Care Contact Janice Gentile Regional Administrator Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 T: 573/526-4274 F: 573/526-4651


Physician-Administered Drug Program Contact Pam Jarrett Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 573/751-3277

Pharmacy Subcommittee Roster Bill Fitzpatrick, R.Ph. Interlock Pharmacy Systems 2292 Weldon Parkway St. Louis, MO 63146 Philip A. Bangert, R.Ph. Bangert Pharmacy, Ltd. 13300 New Halls Ferry Florissant, MO 63033 Tom Beetem, R.Ph., Chairman 1425 Eastview Drive Holts Summit, MO 65043 Robert D. Hurley, R.Ph. Walgreens 440 N. Highway 67 Florissant, MO 63031

Craig Leonard, R.Ph. Lee’s Summit Pharmacy 615 W. 3rd Street Lee’s Summit, MO 64063

Executive Officers of State Medical and Pharmaceutical Societies Missouri State Medical Association C. C. Swarens Executive Secretary 113 Madison Street, P.O. Box 1028 Jefferson City, MO 65102 573/636-5151 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 - P.O. Box 748 Jefferson City, MO 65102 T: 573/634-3415 F: 573/634-5635 E-mail: [email protected] Internet address: www.maops.com State Board of Pharmacy Kevin E. Kinkade Executive Director P. O. Box 625 Jefferson City, MO 65102 573/751-0091 E-mail: [email protected] Internet address: www.ecodev.state.mo.us/pr/pharmacy 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




National Pharmaceutical Council Montana-1

MONTANA



Aged Blind/

Disabled


Disabled

Child Adult SFO

Prescribed Drugs � � � � � � �

Inpatient Hospital Care � � � � � � �

Outpatient Hospital Care � � � � � � �

Laboratory & X-ray Service � � � � � � �

Nursing Facility Services � � � � � � �

Physician Services � � � � � � �

Dental Services � � � � � � �

B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $58,634,278 58,899 $72,577,455 RECEIVING CASH ASSISTANCE, TOTAL $27,165,774 22,015 Aged $2,488,683 1,594 Blind / Disabled $21,977,137 10,148 Child $979,128 6,707 Adult $1,720,826 3,611 MEDICALLY NEEDY, TOTAL $16,977,885 7,426 Aged $10,217,068 5,248 Blind / Disabled $6,753,450 2,145 Child $7,287 30 Adult $80 3 POVERTY RELATED, TOTAL $1,897,790 11,493 Aged $0 0 Blind / Disabled $0 0 Child $1,191,540 8,796 Adult $706,250 2697 TOTAL OTHER EXPENDITURES/RECIPIENTS* $12,592,829 17,965

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Montana National Pharmaceutical Council

C. ADMINISTRATION

Department of Public Health and Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: legend drugs, prescribed 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; fertility drugs; experimental drugs; disposable needles used for insulin, syringe combinations for insulin use; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for non-steroidal anti-inflammatory drugs; all single source NSAIDs; Celebrex, Vioxx; disease-modifying anti-rheumatic drugs (Arava, Enbrel, Remicade); growth hormones; single-source benzodiazepines; gastro-intestinal 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.

Over-the-Counter Product Coverage: Products covered with restrictions (i.e., when prescribed): analgesics (aspirin only); Insulin laxatives; antacids; head lice treatment; H2 antagonist GI products; bronchosaline; and smoking deterrent products. Products not covered: allergy, asthma, and sinus products; cold and cough preparations; feminine products; and topical products.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: antihistamines and prescribed cold medications. Prior authorization required for: anorectics; anxiolytics, sedatives, and hypnotics; analgesics, antipyretics, NSAIDs; growth hormones; and prescribed smoking deterrents.


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


Formulary/Prior Authorization Formulary: Open formulary. Drugs classified as less-than-effective (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: 25% grace period over a 3-month period is allowed. Monthly Quantity Limit: 100 doses or 34-day supply, whichever is greater.

Drug Utilization Review PRODUR system implemented in September 1994. State DUR Board has 6 members and meets monthly.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $2.00-4.70; 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 = AWP - 15%, or manufacturer’s direct price, if available.

Prescription Charge Formula: The lower of EAC, the Federal MAC (plus a dispensing fee), or the provider usual and customary charge.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Necessary” or prior authorization.


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.


National Pharmaceutical Council Montana-3



HMO availability began November 1995, to FAIM recipients. SSI and SSI-related clients were eligible to enroll October 1, 1997. HMO coverage ended June 30, 2000.

F. STATE CONTACTS

State Drug Program Administrator Dan Peterson Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected] Internet address: www.dphhs.state.mt.us

Public Health and Human Services Officials Dr. Gail Gray Director Department of Public Health and Human Services P.O. Box 4210 111 N. Sauders Helena, MT 59604 T:406/444-5622 F: 406/444-1970 E-mail: [email protected] Margaret A.Bullock, Administrator Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4141 F: 406/444-1861 E-mail: [email protected] Jeff Buska, Bureau Chief Medicaid Services Bureau 406/444-4145 Duane Pershinger Acute Services Section 406/444-4144 Mary Angela Collins, Supervisor Managed Care Section 406/444-4146

Prior Authorization Contact Mark Eichler, R.Ph. DUR Coordinator Mountain-Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 T: 406/443-4020 F: 406/443-4585 E-mail: [email protected]

DUR Contact Mark Eichler, R.Ph. T: 406/443-4020

Montana DUR Board Mark Eichler, R.Ph., FASCP DUR Coordinator V. Lee Harrison, M.D. Richard Sargent, M.D. Nathan A. Munn, M.D. Marcella Barnhill, R.Ph. Lori Fitzgerald, Pharm. D.


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]

Claims Submission Contact Kevin Quinn Executive Account Manager ACS, Inc. 34 N. Last Chance Gulch, Suite 200 Helena, MT 59601 T: 406/442-7693 F: 406/442-2819 E-mail: [email protected]


4-Montana National Pharmaceutical Council

Medicaid Managed Care Contact Jo Thompson Program Officer Dept. of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2951 T: 406/444-4148 F: 406/444-1861 E-mail: [email protected]

Disease Management Program/Initiative Contact Dan Peterson Pharmacy Program Officer Dept. of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected]


Physician-Administered Drug Program Contact Denise Brunett P.O. Box 202951 1400 Broadway Helena, MT 59624 406/444-3995 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Montana Medical Association Noel D. Drury, M.D. President 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

Montana State Pharmaceutical 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 State Board of Pharmacy Rebecca Deschamps, R.Ph. Executive Director P.O. Box 200513 111 N. Jackson Helena, MT 59620-0513 T: 406/841-2356 F: 406/841-2343 E-mail: [email protected] Internet address: discoveringmontana.com/dli/bsd/license/bsd_boards/pha_board/board_page.htm Montana Osteopathic Medical Association William Munro, D.O. Executive Director 6364 Toohey Road Bozeman, MT 59715 T: 406/522-9615 F: 406/522-9615 E-mail: [email protected] Internet address: www.momor.com Montana Hospital Association Dick Brown Sr. Vice President/Executive Director P.O. Box 5119 Helena, MT 59604 406/442-1911 E-mail: [email protected] Internet address: www.medassets.com/mtha.htm


National Pharmaceutical Council Nebraska-1

NEBRASKA



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expenditures Recipients Expenditures Recipients TOTAL $135,355,734 165,891 $170,897,014 178,365 RECEIVING CASH ASSISTANCE TOTAL $50,573,088 44,609 58,978,402 45,490 Aged $7,711,090 3,995 8,756,182 3,599 Blind/Disabled $35,790,933 14,893 42,225,001 15,234 Child $3,262,675 16,938 3,734,776 17,651 Adult $3,808,390 8,783 4,262,443 8,646 CATEGORICALLY NEEDY NON-CASH TOTAL $34,036,309 28,217 40,152,899 30,671 Aged $22,294,042 9,614 25,640,472 9,676 Blind/Disabled $5,226,769 1,557 5,365,283 1,463 Child $1,515,549 6,330 1,810,841 6,569 Adult $4,999,949 10,716 7,336,303 12,963 MEDICALLY NEEDY TOTAL $40,512,630 67,425 50,564,381 78,571 Aged $11,554,591 6,115 13,567,579 6,293 Blind/Disabled $18,849,429 7,103 22,577,439 7,496 Child $9,832,487 51,785 13,960,793 60,808 Adult $276,123 2,422 458,570 3,974 TOTAL OTHER EXPENDITURES/RECIPIENTS* $10,233,707 25,640 11,881,817 23,633

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data provided by State Department of Health and Human Services, Finance and Support, Medicaid Division. Source: CMS, MSIS Report, FY 2000 and Nebraska Medicaid Statistical information System, FY 2001.


2-Nebraska National Pharmaceutical Council

C. ADMINISTRATION State Department of Health and Human Services, Finance and Support, Medicaid Division.


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; cough and cold preparations; digestive products; and feminine products. Products not covered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anticoagulants; anticonvulsants; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; antibiotics (Zyvox); anti-depressants (Zoloft, 50mg); antidiabetic agents (Glucovance); antihistamine (low sedating); growth hormones; misc. GI drugs (PPIs); sunscreens; Erythropoetin (e.g., Epogen, Procrit); modified versions of FUL or SMAC drugs; convenience packaged drugs (e.g., Refresh Ophthalmic 0.3 ml and Novalin penfil insulin); drugs to prevent or treat Respiratory Syncytial Virus Immune Globulin (e.g., Palivizumab, RSV-IG); and drugs for sexual dysfunction (e.g., Sildenafil, Alprostadil). Partial coverage for: auxiolytics, sedatives, and hypnotics. Therapeutic categories not covered: anorectics and prescribed smoking deterrents.

Coverage of Injectables: Injectables reimbursable through the Pharmacy program when used in home health care and extended care facilities and through physician payment when used in physician offices.

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.



Formulary: Open formulary. 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 (IDF/MR) patients;

8. Over-the-counter (OTC) drugs not listed on the Department’s Drug Name/License number Listing microfiche;

9. Baby foods or metabolic agents (Lofenalac, etc.,) normally supplied by the Nebraska Department of Health;

10. Drugs distributed or manufactured by certain drug manufacturers or labelers that have not agreed to participate in the drug rebate program.

Drugs, items, or manufacturers that are identifiable as non-covered are so designated on the NE-POP system, and on the Department’s Drug Name/License Number Listing microfiche.

Prior Authorization: State currently has a formal prior authorization procedure. The Department requires that authorization be granted prior to payment for certain products. Prior authorization can be verified through the NE-POP System, or by contacting the Department. (or its designated contractor) if authorization is not verified through the NE-POP System.

Prescribing or Dispensing Limitations Prescription Refill Limit: As authorized by the prescribing physician. For controlled substances, maximum 5 refills every 6 months.



Monthly Quantity Limit: 90-day supply or 100 dosage units, whichever is greater. 31-days for injectables.

Drug Utilization Review PRODUR system implemented in April 1995. State currently has a DUR Board with a monthly review.


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.

Ingredient Reimbursement Basis: EAC = AWP - 11%. Direct price for some pharmaceutical companies.

Prescription Charge Formula: Lower of:

1. Product cost (EAC, SMAC, or FUL) plus a dispensing fee, or

2. The usual and customary price to the general public.

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.

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 a “Medically Necessary” form signed by the physician.


Patient Cost Sharing: Copayment = $2.00.


E. USE OF MANAGED CARE Approximately 156,000 unduplicated Medicaid recipients were enrolled in managed care in 2001. Recipient enrolled in MCOs receive pharmaceutical services through the State.

Managed Care Organizations Share Advantage United HealthPlans of the Midlands 2717 North 118th Circle Omaha, NE 68164 Primary Care + Blue Cross/Blue Shield of Nebraska P.O. Box 241739 Omaha, NE 68124 Value Options Mental Health 10330 Regency Parkway Omaha, NE 68114

F. STATE OFFICIALS

State Drug Program Administrator Dyke Anderson R.Ph Pharmacy Consultant Health and Human Services 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

Health and Human Services Department Officials Richard Raymond, M.D., Chief Medical Official Department of Health and Human Services 301 Centennial Mall South Lincoln, NE 68509 402/471-9105 Robert J. Seiffert, Administrator Medicaid Division 402/471-3121 Ms. Kris Azimi Utilization Review Consultant 402/471-9365 Christine Wright, M.D., Medical Director Medicaid Division 402/471-9136

Prior Authorization Contact Dyke Anderson, R.Ph. 402/471-9379



Barbara Mart Clinical Pharamacist 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 Contacts Beth Wilson DUR Director Nebraska Pharmacists Association 6221 South 58th; Ste 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. Janet Darnell, R.Ph. Patty Gollner, R.Ph. Duane Mines, R.Ph. John Guzallis, R.Ph. Kim Hamik, R.Ph. Shannon Nelson, R.Ph. Phillip Vuchetich, R.Ph. Physician Members: Kay Anderson, M.D. Fred Ayers, M.D. Kirk Muffly, M.D. Thomas B. Murray, M.D. Sam Perry, M.D.


First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

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 F: 402/471-9397 E-mail: [email protected] Policy Dyke Anderson, R.Ph. 402/471-9379

Claims Submission Contact Glenn Sharp Account Representative First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 804/527-3013 F: 804/290-4831 E-mail: [email protected]

Medicaid Managed Care Contact

David Cygan Managed Care Program Administrator HHSS-Finance & Support-Medicaid 301 Centennial Mall South Lincoln, NE 68509 T: 402/471-9050 F: 402/471-9455 E-mail: [email protected]


Physician-Administered Drug Program Contact Lorelee Novak, R.N. Department of Health and Human Services 301 Centennial Mall, 5th floor Lincoln, NE 68509 402/471-9368

Health and Human Services Department Medical Care Advisory Committee Marlene Brondel League of Human Dignity 1701 P Street Lincoln, NE 68508



Tim Bruner Director of Fiscal Services Lincoln General Hospital 2300 South 16th Street Lincoln, NE 68502 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 Pat Snyder Executive Director Nebraska Health Care Assoc. 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 Arthur Weaver, D.O. Secretary 16556 Dorcas Street Omaha, NE 68130 402/554-2374 State Board of Pharmacy Becky Wisell Executive Secretary P. O. Box 94986 Lincoln, NE 68509 T: 402/471-2115 F: 402/471-3577 E-mail: [email protected] Internet address: www.hhs.state.ne.us/lis/lis.asp Nebraska Association of Hospitals and Health Systems Laura J. Redoutey, FACHE President 1640 L St., Suite D Lincoln, NE 68508-2509 T: 402/458-4900 F: 402/475-4091 E-mail:[email protected] Internet address: www.nhanet.org




National Pharmaceutical Council Nevada-1

NEVADA



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expenditures Recipients Expenditures Recipients TOTAL $51,682,326 51,169 $72,352,089 57,891 RECEIVING CASH ASSISTANCE TOTAL $37,621,017 26,574 Aged $8,254,244 5,730 Blind/Disabled $28,548,043 15,336 Child $349,567 3,162 Adult $469,173 2,346 MEDICALLY NEEDY, TOTAL $0 0 Aged $0 0 Blind/Disabled $0 0 Child $0 0 Adult $0 0 POVERTY RELATED, TOTAL $1,498,797 9,469 Aged $116,959 129 Blind/Disabled $268,968 261 Child $668,618 5,669 Adult $444,252 3,410 TOTAL OTHER EXPENDITURES/RECIPIENTS* $12,562,512 15,126

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and Nevada Medicaid Statistical Information System, FY 2001.


2-Nevada National Pharmaceutical Council

C. ADMINISTRATION

Division of Health Care Financing and Policy of the Department of Human Resources.


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 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’ offices.

Vaccines: Vaccines reimbursable at cost plus an administration fee ($3.83) as part of the EPSDT service.



Formulary: Open formulary. General exclusions include:

1. Agents used for cosmetic purposes or hair growth.

2. Yohimbine (e.g., Yocon).

3. Radiopaque agents (e.g., Telepaque, Hypaque, Barium Sulfate).

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

5. Pharmaceuticals designed “ineffective,” or “less than effective” (including identical, related, or similar drugs) by the FDA.

6. 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.


National Pharmaceutical Council Nevada-3

Drug Utilization Review State currently has a DUR Board with a quarterly review by a PRODUR contractor. PRODUR system implemented in 2003.


Dispensing Fee: $4.76, effective 10/1/98. IV dispensing fee is $16.80 for first ingredient; $5.60 for other ingredients.


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 does not impose Upper Limits on generic drugs.





Approximately 56,000 Medicaid recipients are enrolled in MCOs in 2001; all receive pharmacy benefits through there managed care plan.

Managed Care Organizations Health Plan of Nevada P.O. Box 15645 Las Vegas, NV 89114 NevadaCare, Inc. 1701 W. Charleston Blvd. Suite 420 Las Vegas, NV 89102

F. STATE CONTACTS

State Drug Program Administrator 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 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] Chuck 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]

Prior Authorization Contact Dionne Coston, R.N. 775/684-3775

HealthInsight 800/748-6944

DUR Contact Dionne Coston, R.N. 775/684-3775

DUR Board Joseph W. Johnson, M.D. 110 E. Lake Mead Boulevard, #201 Henderson, NV 89015 Steven W. Parker, M.D. 75 Pringle Way, #603 Reno, NV 89503 David England, R.Ph. University Medical Center Pharmacy 1800 W. Charleston Boulevard Las Vegas, NV 89102 Lori Winchell, R.N. 341 Pinnacle Court Henderson, NV 89014 Vanetta Christopherson 2149 Hidden Ranch Terrace Henderson, NV 89052


4-Nevada National Pharmaceutical Council

Prescription Price Updating First DataBank 1111 Bayhill Dr., 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

Medicaid Managed Care Contact Hilary Jones, R.N. Medicaid Services Specialist III 1100 E. Williams St., Ste 204 Carson City, NV 89701 775/684-3697 E-mail: [email protected]


Physician-Administered Drug Program Contact Coleen Lawrence, 775-684-3744

Medical Care Advisory Group David England, Pharm.D. Trudy Larson, M.D. Dr. William Bannen, Medical Director, Anthem BC/BS Mr. Paul Boyar, Administrator, Plaza Regency at Sun Mountain Patricia Craddock, D.D.S. Ms. Jessie Harris Mr. Keith MacDonald, RPh. Mr. Ken Richardson, Clinic Director, Walker River Tribal Health Clinic Ms. Linda Sheldon, State Coordinator, Nevada Covering Kids Coalition Mary Guinan, M.D., Nevada State Healht Officer, Health Division

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 Nevada Pharmacy Alliance Mary Grear, R.Ph. Executive Vice President c/o Nevada College of Pharmacy 5740 S. Eastern Avenue, Suite 240 702/990-4433 E-mail: [email protected] Internet address: www.nvphall.org Nevada Osteopathic Medical Association Denise Selleck Davis Executive Director 2920 N. Green Valley Parkway, Suite 527 Las Vegas, NV 89014 T: 702/434-7112 F: 702/434-7110 E-mail: [email protected] Internet address: www.nevadaosteopathic.com 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: glsuitewww.glsuite.com/nvbopweb Nevada Hospital Association Bill M. Welch President/CEO 5250 Neil Road Suite 302 Reno, NV 89502 T: 775/827-0190 F : 775/827-0190 E-mail: [email protected] Internet address: www.nvha.net


National Pharmaceutical Council New Hampshire-1

NEW HAMPSHIRE



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001 Expenditures Recipients Expenditures Recipients TOTAL $80,562,181 73,313 $90,927,579 73,489 RECEIVING CASH ASSISTANCE, TOTAL $23,066,270 18,762 $25,669,473 18,137 Aged $2,925,696 1,455 $3,216,921 1,436 Blind/Disabled $16,212,070 5,464 $18,263,975 5,335 Child $1,409,682 7,859 $1,567,158 7,533 Adult $2,518,822 3,984 $2,621,419 3,833 MEDICALLY NEEDY, TOTAL $20,779,582 9,003 $24,027,775 9,047 Aged $8,581,974 3,980 $10,097,853 4,233 Blind/Disabled $10,016,239 2,525 $11,643,790 2,676 Child $346,290 942 $328,662 819 Adult $1,835,079 1,556 $1,957,470 1,319 POVERTY RELATED, TOTAL $5,788,703 26,423 $6,948,883 26,834 Aged $262,235 197 $421,825 293 Blind/Disabled $333,470 181 $437,532 257 Child $4,908,651 24,340 $5,787,235 24,563 Adult $284,347 1,705 $302,291 1,721 TOTAL OTHER EXPENDITURES/ RECIPIENTS* $30,927,626 19,125 $34,281,448 19,471

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

Source: CMS, MSIS Report, FY 2000 and New Hampshire Medicaid Statistical Information System, FY 2001.


2-New Hampshire National Pharmaceutical Council

C. ADMINISTRATION Office of Health Planning and Medicaid, Department of Health and Human Services.


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; 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; estrogens; growth hormones; hypotensive agents; sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterrents. Therapeutic categories/products requiring prior authorization: anorectics; analgesics, antipyretics, NSAIDs; misc. GI drugs; erectile dyfunction products; PPIs; Cox IIs; and oxycontin. Brand approval overrides required for NSAIDs, controlled substances, and GI drugs for which there are therapeutically equivalent (AB-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 providers for routine vaccines, although an administration fee is allowed.



Formulary: Open formulary. General exclusions include cosmetic agents for hair growth, experimental and fertility drugs.

Prior Authorization: State currently has a formal prior authorization procedure with an associated grievance and appeal procedure.


Monthly Quantity Limit: Limited to 30-day supply Maintenance Medications: Limited to 90-day Supply







Prescription Charge Formula: Lesser of usual and customary charge or AWP-12%, Federal Upper Limit; State MAC; or DOJ pricing, 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.” Med Watch form for PA.


Patient Cost Sharing: Copayment – Generics: $0.50; Brand: $1.00. Copayments apply to all recipients except nursing home patients in SNF or ICF facilities; home and community based care waived recipients holding form 949; pregnant women; children under 18 years; and prescriptions for family planning drugs.



Approximately 11,000 Medicaid recipients are enrolled in MCOs in 2002. None receive pharmaceutical benefits through managed care.


National Pharmaceutical Council New Hampshire-3

Managed Care Organizations Anthem Blue Cross/Blue Shield of New Hampshire Matthew Thornton Health Plan 3000 Goffs Falls Road Manchester, NH 03103-6020

F. STATE CONTACTS

State Drug Program Administrator Margaret A. Clifford Pharmacy Services Administrator Office of Health Planning & Medicaid 129 Pleasant Street, Annex Concord, NH 03301 T: 603/271-4210 F: 603/271-8701 E-mail: [email protected] Internet Address: www.dhhs.state.nh.us

Department of Health and Human Services Officials Lori Real Director Office of Health Planning & Medicaid 129 Pleasant Street, Annex Concord, NH 03301 T: 603/271-5254 F: 603/271-8431 E-mail: [email protected] Nicholas Vailas 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]

DUR Contact Lisè Farrand, R.Ph. Pharmaceutical Services Specialist Office of Health Planning & Medicaid 129 Pleasant Street Annex Concord, NH 03301 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected]

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. (Chair) John Zinka, R.Ph. Jody Goodrich, A.R.N.P.

Prescription Price Updating Farah L. Jiwa Account Manager First Health Services Corp. 17 Chenell Drive Concord, NH 03301 603/224-2083 E-mail: [email protected]

Medicaid Drug Rebate Contacts Glen Hutchinson First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F :804/965/7647 E-mail: [email protected]

Claims Submission Contact Farah L. Jiwa, 603/224-2083

Medicaid Managed Care Contact Diane M Kemp Administrator 1 Office of Health Planning & Medicaid 6 Hazen Drive Concord, NH 03301 T: 603/271-4365 F: 603/271-4376 E-mail: [email protected]


Disease Management Initiative/Program Contact State does not currently have a disease management program. Intend to implement disease management programs for asthma and diabetes through First Health Services Corp within the next year.


4-New Hampshire National Pharmaceutical Council

Disease Management/Patient Education Contact Doris Lotz, M.D. Medicaid Medical Director Office of Health Planning & Medicaid 129 Pleasant Street, Annex Concord, NH 03301 T:603/271-7348 F:603/271-8431 E-mail:[email protected]

Physician-Administered Drug Program Contact Vacant

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 Herbert, R.Ph. Paul Santos, Pharm.D. Robert Lenza, Pharm.D.

Executive Officers of State Medical and Pharmaceutical Services New Hampshire Medical Society Palmer P. Jones Executive Vice President 7 N. State Street Concord, NH 03301-6389 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 03301-8905 T: 603/229-0292 F: 603/224-7769 E-mail: [email protected] Internet Address: www.state.nh.us/pharmacy/nhpa.htm

New Hampshire Osteopathic Association, Inc. Bill Paternal, D.O. Vice President 7 North State Street Derry, NH 03301 603/224-1909 E-mail: [email protected] Internet Address: www.nh-osteopath.org State Board of Pharmacy Paul G. Boisseau Executive Secretary 57 Regional Drive Concord, NH 03301-8518 603/271-2350 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


National Pharmaceutical Council New Jersey-1

NEW JERSEY 1



Aged Blind/

Disabled


Disabled

Child Adult SFO





Nursing Facility Services � � � � � � �




Expended Recipients Expended Recipients TOTAL $584,533,211 298,450 $651,442,945 RECEIVING CASH ASSISTANCE, TOTAL $345,292,113 153,179 Aged $59,196,426 30,876 Blind / Disabled $282,211,059 98,842 Child $1,292,073 12,645 Adult $2,592,555 10,816 MEDICALLY NEEDY, TOTAL $6,684,313 3,366 Aged $5,936,189 2,927 Blind / Disabled $682,891 211 Child $65,233 228 Adult $0 0 POVERTY RELATED, TOTAL $87,818,883 61,127 Aged $28,757,139 14,783 Blind / Disabled $56,515,195 16,258 Child $1,976,812 22,013 Adult $569,737 8,073 TOTAL OTHER EXPENDITURES/RECIPIENTS* $144,737,902 80,778


1 The State of New Jersey did not respond to the 2002 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 New Jersey Medicaid program to assess the accuracy and currency of the information included.


2-New Jersey National Pharmaceutical Council

C. ADMINISTRATION

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


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: allergy, asthma, and sinus products; analgesics; topical products; and cough and cold preparations for children under age 21 and smoking deterrent products (inhaler or nasal spray). Products not covered: digestive products; feminine products; contraceptives; pregnancy test kits; family planning supplies; inhalation drugs; and antacids.

Therapeutic Category Coverage: Therapeutic categories covered: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: antilipemic agents. Partial coverage for: anabolic steroids; anorectics (for ADD); growth hormones; and prescribed smoking deterrents.


Vaccines: Vaccines reimbursable at AWP as part of the EPSDT program and the Vaccines for Children Program.

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).


Formulary: Open formulary. General exclusions include experimental drugs, cosmetics, fertility drugs, DESI drugs, and drugs for which FFP is not available (OBRA '90).

Prior Authorization: State currently has a formal prior authorization procedure. Periodic review for reconsideration possible for excluded product from formulary. Fair hearings possible for appealing prior authorization decisions.


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.


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 = AWP-10%, WAC + 30%. AAC for injectables, effective 5/1/00.

Prescription Charge Formula: “Maximum Allowable Cost,” or Average Wholesale Price-10% (reduction from AWP is pharmacy specific) plus a dispensing fee or the provider’s usual and customary charge, whichever is lower.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary”.



Cognitive Services: State pays for cognitive services.

E. USE OF MANAGED CARE Approximately 460,000 Medicaid recipients received pharmacy benefits through managed care in 2001. All receive pharmaceutical benefits from MCOs.


National Pharmaceutical Council New Jersey-3

Managed Care Organizations AMERIGROUP New Jersey, Inc 399 Thornall Street, 9th Floor Edison, NJ 08837 800/600-4441 Health Net of New Jersey, Inc. CNA Building 3501 State Highway 66 Neptune, NJ 07754 800/555-2604 AmeriChoice of New Jersey, Inc. Two Gateway Center, 13th Floor Newark, NJ 07102 800/941-4647 Horizon Mercy 275 Phillips Boulevard Trenton, NJ 08618-1426 800/656-3729 University Health Plans, Inc. 550 Broad Street, 17th Floor Newark, NJ 07102 800/564-6847

F. STATE CONTACTS

State Drug Program Administrator Carl D. Tepper, R.Ph. Chief, Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625-0712 T: 609/588-2744 F: 609/588-3889 E-mail: [email protected]

Department of Human Services Officials Gwendolyn L. Harris, Commissioner Department of Human Services Capitol Place One CN-700, 5th Floor Trenton, NJ 08625 T: 609/292-3717 F: 609/292-3824 E-mail: [email protected] Kathryn A. Plant, 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 Edward J. Vaccaro, R.Ph. Assistant Director, Office of Utilization Management Dept. of Human Services, Div. of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625 T: 609/588-2726 F: 609/588-3889 E-mail: [email protected]

Medicaid DUR Board Christopher A. Cella, R.Ph. Alfred F. Sorbelo, D.O. Edith Kessler-Feinstein, R.Ph. Joseph Nicholas Micale, M.D. Rochelle Dallago, R. Ph.. Thomas A. Cavalieri, D.O. Linda Gooen, R.Ph. Mary E Petit, Pharm.D. David Ethan Swee, M.D.

Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 415/588-5454

Medicaid Drug Rebate Contacts Technical: Daniel Upright, 609/588-2792 Policy: Carl Tepper, 609/588-2744 PA: Carl Tepper, 609/588-2744

Claims Submission Contact Peter Ringel Deputy Project Director Unisys 3705 Quakerbridge Rd., Suite 101 Trenton, NJ 08619 T:609/588-6000 F: 609/584-8270 E-mail: [email protected]

Medicaid Managed Care Contact Edward Vaccaro, 609/588-2726 Mail Order Benefit Program

State currently has a mail order benefit program. All Medicaid recipients are entitled to participate.


4-New Jersey National Pharmaceutical Council

Elderly Expanded Drug Coverage Contact Kathleen Mason Assistant Commissioner, Benefits and Utilization Management Dept. of Health and Senior Services P.O. Box 715 Trenton, NJ 08625 T: 609/588-7032 F: 609/584-7037

Physician-Administered Drug Program Contact Edward Vaccaro, 609/588-2726

Executive Officers of State Medical and Pharmaceutical Societies Medical Society of New Jersey Vincent A. Maressa 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 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 Stephen G. Papish, D.O. President 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.org State Board of Pharmacy Debora C. “Debbie” Whipple Executive Director P.O. Box 45013 Newark, NJ 07101 201/504-6450 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


National Pharmaceutical Council New Mexico-1

NEW MEXICO



Aged Blind/

Disabled


Disabled

Child Adult SFO

Prescribed Drugs � � � � �

Inpatient Hospital Care � � � � �

Outpatient Hospital Care � � � � �

Laboratory & X-ray Service � � � � �

Nursing Facility Services � � � � �

Physician Services � � � � �

Dental Services � � � � �


Expenditures Recipients Expenditures Recipients TOTAL $57,502,713 67,238 $57,995,801 RECEIVING CASH ASSISTANCE TOTAL $32,602,025 32,148 Aged $6,860,767 6,106 Blind/Disabled $24,878,408 14,756 Disabled $249,345 4,962 Child $613,505 6,324 Adult $0 0 MEDICALLY NEEDY, TOTAL $0 0 Aged $0 0 Blind/Disabled $0 0 Child $0 0 Adult $1,388,162 18,561 MEDICALLY NEEDY, TOTAL $108,303 133 Aged $177,285 121 Blind/Disabled $974,363 15,529 Child $128,211 2,778 Adult $23,512,526 16,529 TOTAL OTHER EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unknown. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-New Mexico National Pharmaceutical Council

C. ADMINISTRATION

Human Services Department (HSD).


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 (covered with restrictions). Prior Authorization required for: amphetamines and stimulants for ADD (adults only); nutritional supplements. 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;” and hypnotic drugs (barbiturates).

Over-the-Counter Product Coverage: 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); feminie products.

Therapeutic Category Coverage: Products Covered: anabolic steroids; analgesics; antipyretics; and NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents, antihistamines; antilipemic agents; anti-psychotics; anxyolitics, 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; and sympathominetics (Adrenergic-prior authorization required for adults); and thyroid agents. Partial coverage for: Viagra (prior authorization required).

Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities.

Vaccines: Only the administration for vaccines is reimbursable. The vaccines are available at no charge through the vaccine replacement program of the Health Department.

Unit Dose: Does not reimburse for unit dose packaging.



Prior Authorization: State currently has a formal prior authorization procedure screening for drug classes.


Monthly Quantity Limit: 34-day supply maximum, excluding birth control pills (1 year). Number of refills must conform to applicable state and federal laws.


PRODUR system implemented in October 1993.



Ingredient Reimbursement Basis: EAC = AWP-12.5%, effective 7/1/97.

Prescription Charge Formula: Prescriptions reimbursed at the lesser of the following:

1. Cost (EAC or MAC) dispensed plus a dispensing fee or,

2. 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 requires “Medically Necessary” or “Brand Necessary.” Also prescriber is not prohibited from generic substitution and, if due to drug shortage, requesting reimbursement at the brand level.


Patient Cost Sharing: No copayment, except for CHIP clients and working disabled clients.



Approximately 250,000 Medicaid recipients enrolled in are MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans.


National Pharmaceutical Council New Mexico-3

F. STATE CONTACTS

State Drug Program Administrator Neal Solomon, M.P.H., R.Ph. Drug Program Administrator Medical Assistance Division P. O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]

DUR Contact Neal Solomon, M.P.H., R.Ph. 505/827-3174

DUR Board

DUR Board functions to be subsumed by a new committee that is in the process of being created.

Prior Authorization Contact Neal Solomon, M.P.H., R.Ph. 505/827-3174

Medicaid Drug Rebate Contact Sonya Miera Drug Rebate Program Administrator Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7777 F: 505/827-3185

Prescription Price Updating Contact Neal Solomon, M.P.H., R.Ph. 505/874-3174

Claims Submission ACS, Inc. 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8592 F: 770/730-5198

Medicare Managed Care Contact Debra Stolk Bureau Chief Contracts Administration Bureau P.O. Box 2348 Santa Fe, NM 85705-2348 505/827-3174


Human Services Department Officials Pamela Hyde 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] Carolyn Ingram Director Medicaid Assistance Division T: 505/827-3106 F: 505/827-3185 E-mail: [email protected]

Medical Advisory Committee Members Linda Sechovec Executive Director NM Health Care 6400 Uptown Blvd., NE, Suite 520-W Albuquerque, NM 87110 Yvette Ramirez Ammerman Policy Analyst New Mexico Primary Care Association 2309 Renard, S.E., Suite 209 Albuquerque, NM 87106 Chris Isengard Executive Director Developmental Disabilities Planning Council 435 St. Michael’s Dr., Bldg. D Santa Fe, NM 87501 Michelle Lujan-Grisham New Mexico State Agency on Aging 228 East Palace Avenue Santa FE, NM 87501


4-New Mexico National Pharmaceutical Council

Sam Cata, Commissioner Office of Indian Affairs 224 E. Palace Avenue Santa FE, NM 87501 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 Lila Maples, R.N. 2769 Villa Venado Santa Fe, NM 87505 Clarice Pick, D.D.S 1405 Luisa Street Suite #2 Santa Fe, NM 87505 Richard L. Ragel, D.O. 1010 Bridge Blvd., SW Suite D Albuquerque, NM 87105-3734 Kathy Minoli, C.F.N.P. 1835 Solano, NE Albuquerque, NM 87110 Mary Lou Edward 16 Applewood Lane, N.W. Albuquerque, NM 87107 505/898-5103 Richard Honsinger, M.S. Los Alamos Medical Center Los Alamos, NM 87544 Maureen Boshier New Mexico Hospital Association 2121 Osuna Road NE Albuquerque, NM 87113 Joie Glen Executive Director New Mexico Association for Home Care 3200 Carlisle N.E., Suite 115 Albuquerque, NM 87110

Bert Umland, M.D. Division of Family Practice UNM Medical Center Albuquerque, NM 87131 505/277-2165

Executive Officers of State Medical and Pharmaceutical Societies New Mexico Medical Society G. R. “Randy” Marshall Executive Director 7770 Jefferson NE, Suite 400 Albuquerque, NM 87109 T: 505/828-0237 F: 505/828-0336 E-mail: [email protected] Internet address: nmms.org New Mexico Pharmaceutical Association R. Dale Tinker Executive Director 4800 Zuni, S.E. Albuquerque, NM 87108-2898 T: 505/265-8729 F: 505/255-8476 E-mail: [email protected] New Mexico Osteopathic Medical Association Elizabeth “Betty” Barrett Executive Director P. O. Box 53098 Albuquerque, NM 87153-3098 T: 505/332-2146 F: 505/343-0012 E-mail: [email protected] Internet address: www.nmoma.org State Board of Pharmacy Jerry Montoya, Director University Towers 1650 University Blvd., NE, Suite 400B Albuquerque, NM 87102 505/841-9102 E-mail: [email protected] Internet address: www.state.nm.us/pharmacy New Mexico Hospitals and Health Systems Association Maureen L. Boshier President/CEO 2121 Osuna Road, NE Albuquerque, NM 87113 T: 505/343-0010 F: 505/343-0012 E-mail: [email protected] Internet address: nmhsa.org


National Pharmaceutical Council New York-1

NEW YORK



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001 Expenditures Recipients Expenditures Recipients TOTAL $2,366,900,006 2,173,791 $3,390,973,955 2,481,167 RECEIVING CASH ASSISTANCE, TOTAL $1,566,162,641 1,099,774 $2,066,395,705 864,288 Aged $269,550,109 146,598 $371,073,880 142,133 Blind/Disabled $1,128,385,170 436,852 $1,576,755,987 445,939 Child $56,154,649 348,160 $46,937,418 200,026 Adult $112,072,713 168,164 $71,628,420 76,190 MEDICALLY NEEDY, TOTAL $547,905,224 677,751 $885,113,975 1,076,587 Aged $148,246,132 90,476 $227,428,001 111,017 Blind/Disabled $288,329,753 96,831 $411,454,776 107,484 Child $54,125,642 337,243 $114,487,217 514,744 Adult $57,203,697 153,201 $131,743,981 343,342 POVERTY RELATED, TOTAL $17,330,385 117,970 $406,942,387 480,355 Aged $104 1 $195 2 Blind/Disabled $0 0 $0 0 Child $16,701,956 111,422 $43,631,597 209,682 Adult $628,325 6,547 $363,310,595 270,671 TOTAL OTHER EXPENDITURES/ RECIPIENTS* $235,501,756 278,296 $32,521,888 59,937

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

Source: CMS, MSIS Report, FY 2000 and New York Medicaid Statistical Information System, FY 2001.


2-New York National Pharmaceutical Council

C. ADMINISTRATION

State Department of Health.


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 with restrictions: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (non H2 antagonist); feminine products; smoking deterrent products (max, 2 courses of treatment/ year); and topical products. Products not covered: digestive products (H2 antagonists).

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); 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 and extended care facilities, and through physician payment when used in physician offices. No special coverage policies exist for self-administered injectable medicines.

Vaccines: Vaccines are reimbursable under the EPSDT service, CHIP, and the Vaccines for Children program.



Formulary: Open formulary. General Exclusions: New York State follows OBRA '90 guidelines in the reimbursement of prescription drugs.


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.


PRODUR system implemented in March 1995. State currently has a DUR Board which meets bimonthly.


Dispensing Fee: $3.50 for brand name drugs, $4.50 for generic drugs. Effective 8/1/98.


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.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Dispense as Written” and “Brand Necessary, ” or “Brand Medically Necessary.”

Incentive Fee: $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.






Health Maintenance Organizations

− ABC − Affinity Health Plan − AmeriChoice − Broome MC − Buffalo Com. Health − Care Plus Health Plan − CDPHP − Community Choice HP − Community Premier Plus − Excellus − Fidelis/NYS Catholic Health − Health Choice − HealthFirst PHPS − Health Plus PHPS − HealthNow/BCBS-WNY/Community Blue − HealthNow/Blue Shield of NENY − HIP − IHA − Manhattan PHSP/Centercare − Metropolitan Plus Health Plan − Neighborhood Health Providers − NY Hospital Community PHSP − PCMP − Preferred Care − Primary Health − Southern Tier − Suffolk Co PHSP − Total Care/Syracuse PHSP − United Healthcare Plan of NY, Inc. − United Healthcare of Upstate − Vytra − Wellcare − Westchester Prepaid Health Services Plan F. STATE CONTACTS

State Drug Program Administrator Mark-Richard A. Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Bureau of Program Guidance Office of Medicaid Management NYS Department of Health 99 Washington Ave., Suite 606 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. Dilip Patel, R.Ph. John Navarra, R.Ph. Mohammed Saleh, R.Ph. John Westerman, R.Ph.

Formulary Contact Mark-Richard A. Butt, 518/474-9219

Prior Authorization Contact Mark-Richard A. Butt, 518/486-3209

Pharmacy and Therapeutics Committee 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.

DUR Contact Michael Zegarelli DUR Manager Office of Medicaid Management NYS Department of Health 99 Washington Ave. Suite 601 Albany, NY 12210 T: 518/474-6866 F: 518/473-5332 E-mail: [email protected]

DUR Committee Physicians Richard S. Blum, M.D. Ronald J. Dougherty, M.D. David F. Lehmann, M.D. Jill Braverman-Panza, M.D., R.Ph. 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.



DUR Experts Marilyn C. Fortin, R.Ph. Robert A. Hamilton, Pharm.D., R.Ph. Department Designee Lydia Kosinski, R.Ph.

Prescription Price Updating Carl T. Cioppa, Pharm.D. Pharmacy Operations Manager Pharmacy Policy and Operations NYS Dept. of Health, Office of Medicaid Management 99 Washington Ave., Suite 606 Albany, NY 12210 T: 518/486-3209 F: 518/473-5508 E-mail: [email protected]

Medicaid Drug Rebate Contacts Audit & Policy: Mark-Richard Butt, 518/486-3209 Disputes: Joseph Maiello, 518/486-3209 PRODUR: Dennis Pidgeon, 518/474-6866

Claims Submission Contact eMed NY Computer Sciences Corporation (CSC) One CSC Way Rensselaer, NY 12144 800/343-9000 E-mail: [email protected]

Medicaid Managed Care Contact Elizabeth Macfarlane Director, Bureau of Managed Care Program Planning NYS Department of Health, Office of Managed Care Room 1927, Corning Tower ESP Albany, NY 12237-0064 T: 518/473-0122 F: 518/474-5886 E-mail: [email protected]

Disease Management/Patient Education Programs Disease/Medical State: AIDS/HIV Program Name: Aids Intervention Management Program Program Sponser: AIDS Institute, NYSDOH Disease/Medical State: Asthma Program Name: Asthma Intervention Program Sponser: NYSDOH Disease/Medical State: Diabetes Program Name: Diabetes Intervention Program Sponser: NYSDOH

Disease/Medical State: Smoking Cessafion Program Name: Smokers’ Quit Line Program Sponser: Roswell Park

Disease Management Program/Initiative Contact Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance NYS Department of Health Office of Medicaid Management 99 Washington Ave, Suite 606 Albany, NY 12210-2806 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]


Expanded Drug Program Contact Julie Naglieri Acting Director NYS Department of Health Program Elderly Prescription Insurance Coverage (EPIC) 1 Corporate Plaza, Suite 101 260 Washington Ave., Ext. Albany, NY 12203 T: 518/452-6828 F: 518/452-6882 E-mail: [email protected] Internet Address : www.health.state.ny.us/nysdoh/epic/faq.htm

Physician-Administered Drug Program Contact Karen A. Fuller, Ph.D., 518/474-9219

Department of Health Officials

Antonia C. Novello, M.D, M.P.H., Dr. Ph. Commissioner NYS Department of Health Corning Tower The Governor Nelson A Rockefeller Empire State Plaza Albany, NY 12237 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 Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance Division of Policy and Program Guidance/Office of Medicaid Management 99 Washington Ave., Suite 606 Albany, NY 12210 518/474-9219 Mark-Richard A. Butt, MS, R.Ph. 518/474-9219

Title XIX Medical Care Advisory Committee Ruben P. Cowart, D.D.S., (Chairman) Michael C. Alfano, D.M.D. John Angerosa, M.D. Steven E. Barnes, D.O. David Cerniglia, D.C. 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. Michael P.M. Poud, M.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. Ellen M. Vossler, D.D.S

Executive Officers of State Medical and Pharmaceutical Societies Medical Society of the State of New York Charles Aswad, M.D. Executive Vice President 420 Lakeville Road P.O. Box 5404 Lake Success, NY 11042-5404 T: 516/488-6100 F: 516-488-1267 E-mail: [email protected] Internet Address: www.mssny.org

Pharmasists Society of the State of New York Craig Burridge, M.S., CAE, Executive Director Pine West Plaza IV 210 Washington Avenue Extension Albany, NY 12205-5335 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. Michael Mallie Executive Director 142 East Ontario Avenue Chicago, IL 60611-2854 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 89 Washington Avenue, Second Floor W Albany, NY 12234-1000 T: 518/474-3848 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 74 North Pearl Street Albany, NY 12207 T: 518/431-7800 F: 518/431-7915 E-mail: [email protected] Internet Address: www.hanys.org Greater New York Hospital Association Subsidiaries and Affiliates 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




National Pharmaceutical Council North Carolina-1

NORTH CAROLINA



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS

2000* 2001** Expenditures Recipients Expenditures Recipients TOTAL $794,550,074 827,039 $931,725,857 817,779 RECEIVING CASH ASSISTANCE TOTAL $456,999,341 363,502 Aged $136,264,920 67,403 Blind/Disabled $264,833,598 123,166 Child $17,861,977 97,135 Adult $38,038,846 75,798 MEDICALLY NEEDY, TOTAL $54,666,399 26,690 Aged $38,295,187 16,847 Blind/Disabled $13,515,582 5,557 Child $192,054 685 Adult $2,663,576 3,601 POVERTY RELATED, TOTAL $266,152,143 392,416 Aged $112,488,906 57,682 Blind/Disabled $102,028,657 46,101 Child $45,864,710 248,570 Adult $5,769,870 40,063 TOTAL OTHER EXPENDITURES/RECIPIENTS* $16,732,191 44,431

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and North Carolina Statistical Information System, FY 2001.

Note: North Carolina estimates 2002 drug expenditures to be $1.056 billion and the number of Medicaid recipients to be 941,491.


2-North Carolina National Pharmaceutical Council

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Product covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strip; and urine ketone test strips. Products not covered: cosmetics; fertility drugs; OTC drugs (with exceptions) and experimental drugs;

Over-the-Counter Product Coverage: North Carolina does not provide coverage for OTC products except for prescribed insulin products.

Therapeutic Category Coverage: North Carolina provides coverage for all therapeutic categories except products used for cosmetic purposes; fertility drugs; and experimental drugs. Prior authorization required for: growth hormones; prescribed smoking deterrents; drugs used to treat ADHD; Procrit/Epogen; Neupogen; OxyContin; Provigil; Rebetron; Vioxx; Celebrex; Bextra; Enbrel; Botox; Mybloc; Synagis; and RespiGam.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facility, and through both the Prescription Drug Program and physician payment when used in physician offices.

Vaccines: Vaccines reimbursable as part of the ESPDT service and The Vaccines for Children Program.




Prior Authorization: State currently has a formal prior authorization procedure. A prescriber’s written justification is required to appeal a prior authorization decision. All written justifications are approved.


Monthly Quantity Limit: 34-day supply maximum. Except birth control tablets and hormonal replacement therapy dial packs: 3 months.

Monthly Prescription Limit: Six prescriptions per month per recipient.

Prescription Dollar Limits: None.


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


Dispensing Fee: B: $4.00; G: $5.60, effective 2002.


Prescription Charge Formula: The lowest price of AWP minus 10%, state MAC or federal MAC, and a dispensing fee for each different drug dispensed during a month, or AWP plus the lowest dispensing fee accepted from other third party payers. The pharmacist filling the original prescription will not be reimbursed for refills for the same drug within a calendar month.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits generic drugs. 351 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary.”


Patient Cost Sharing: $1.00 copayment/Rx (includes refills) for generic prescriptions; $3.00 copayment/Rx for brand name prescriptions.




Managed Care Organizations SouthCare/Coventry 2815 Coliseum Center Dr. Charlotte, NC 28217


National Pharmaceutical Council North Carolina-3

F. STATE CONTACTS State Drug Program Administrator Sharman C. Leinwand Pharmacy Program Manager Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 T: 919/857-4034 F: 919/715-1255 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma

Prior Authorization Contact Sharman C. Leinwand, 919/857-4034

DUR Contact Sharman C. Leinwand, 919/857-4034

Medicaid Drug Utilization Review Board Physicians: Patricia Burns, M.D. Edward Treadwell, M.D. LaVie Ellison, M.D. David Gremillion, M.D. Steve Wegner, M.D. Pharmacists: Joseph S. Moose, R.Ph., Pharm. D. Dale Christensen, Ph.D..

Wayne Creech, R. Ph.

Martha Jones, Pharm. D.

Mary Williford, R.Ph.

Prescription Price Updating 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]

Medicaid Drug Rebate Contact Audits: Sharman C. Leinwand, 919/857-4034 Rebate Disputes: Sharon Greeson, R.Ph., 919/816-4475

Claims Submission Contact Sharon Greeson, R.Ph., 919/816-4475

Medicaid Managed Care Contact Jeffrey Simms, 919/857-4267


Disease Management Program/Initiative Contact Sharman C. Leinwand, 919/857-4034

Physician-Administered Drug Program Contact Maclyn Powell Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 919/857-4254

Department of Human Resources Officials Gary Fuquay, Acting Director Department of Health and Human Services Division of Medical Assistance 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/857-4011 F: 919/733-6608 E-mail: [email protected] 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

Office of Research Demonstration and Rural Health Development Torlen Wade 311 Ashe Avenue Raleigh, NC 27606 919/857-4267


4-North Carolina National Pharmaceutical Council

Executive Officers of State Medical and Pharmaceutical Societies North Carolina Medical Society Bob Seligson, M.B.A., CAE Executive Vice President & 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 27516-2505 T: 919/967-2237 F: 919/968-9430 E-mail: [email protected] Internet address: www.ncpharmacists.org North Carolina Osteopathic Medical Association Brenda Brow - Executive Director 1104 Medical Center Drive Wilmington, NC 28401 T: 888/626-6248 F: 910/763-4666 E-mail: www.ncoma.org Internet address: www.ncoma.org State Board of Pharmacy David R. Work Executive Director P. O. Box 459 Carrboro, NC 27510-0459 T: 919/942-4454 F: 919/967-5757 E-mail: [email protected] Internet address: www.ncbop.org 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: www.ncha.org


National Pharmaceutical Council North Dakota-1

NORTH DAKOTA



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $38,076,519 38,957 $44,067,986 RECEIVING CASH ASSISTANCE, TOTAL $17,000,686 13,169 Aged $3,973,736 2,001 Blind/Disabled $11,399,758 5,016 Child $563,277 3,894 Adult $1,063,915 2,258 MEDICALLY NEEDY, TOTAL $17,364,506 11,099 Aged $11,416,811 5,621 Blind/Disabled $5,178,138 2,103 AFDC-Child $352,340 2,247 AFDC-Adult $417,217 1,128 POVERTY RELATED, TOTAL $737,830 5,375 Aged $6,224 28 Blind/Disabled $15,592 29 AFDC-Child $606,172 4,570 AFDC-Adult $109,842 748 TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,973,497 9,314



2-North Dakota National Pharmaceutical Council

C. ADMINISTRATION

North Dakota Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles used for insulin; syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; interdialytic parenteral nutrition; drugs used for hair growth; prescription vitamins (except prenatal vitamins); and DESI drugs. Prior authorization required for: smoking cessation (lifetime limits); nutritional supplements; and orlistat.

Over-the-Counter Product Coverage: Products covered: antacids; analgesics; iron supplements; artificial tears; and digestive products; and anti-ulcer medications. Products covered with restriction: smoking deterrent products. Products not covered: allergy, asthma, and sinus products; cough and cold preparations; and feminine products.

Therapeutic Category Coverage: Categories covered: anabolic steroids; analgecics, antipyretics and NSADDs; antibiotics; anticoagulants; anticouvulsants; 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; sympathominetics (adrenergic); and thyroid agents. Prior authorization required: anoretics and prescribed smoking deterrents (limited to nicotine patches, nicotine gum, and bupropion sustained release). Categories not covered: prescribed cold medications.

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.

Vaccines: Vaccines reimbursable as part of the EPSDT service.




Prior Authorization: State does not currently have a formal prior authorization procedure.


Prescription Refill Limit: A prescription drug may be refilled for 12 months after the date of the original prescription, provided that such refills have been authorized by the physician. One refill on proton pump inhibitors.




PRODUR system implemented in July 1996.




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.”


Patient Cost Sharing: $3.00 (brand-name drugs)

Cognitive Services: Does not pay for cognitive services


Over 400 Medicaid recipients were enrolled in managed care organizations in 2001. Recipients enrolled in MCO’s receive pharmacy benefits through the State.

F. STATE CONTACTS

State Drug Program Administrator 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]



Prior Authorization Contact Brendan K. Joyce, Pharm.D. 701/328-4023

DUR Contact Brendan K. Joyce, Pharm.D. 701/328-4023

DUR Board Mark Biel, R.Ph. 517 W. Reno Ave. Bismarck, ND 58504 701/223-0936 Patricia M. Churchill, R.Ph. 103 West Ave. B Bismark, ND 58501 701/663-5188 Greg Pfister, Pharm.D., R.Ph. 505 Cottonwood Loop Bismark, ND 58504 701/530-6928 Community Practice Medical Resident (rotational contact: Susan Thompson) UND Family Practice Center 515 Broadway Avenue Bismarck, ND 58501 701/328-9950 Bob Treitline, R.Ph. 1404 C Empire Road Dickinson, ND 58601 701/225-4434 Marty Meese, Pharm.D., R.Ph. St. Alexis Pharmacy 900 East Broadway Bismarck, ND 58501 701/224-6954 Ex-Officio Members Herbert Wilson, M.D. Medical Consultant Medical Services, ND Department of Human Services 600 East Boulevard Ave, Dept 325 Bismarck, ND 58505-0250 701/328-2056

Brendan Joyce, Pharm.D., R.P.h. 701/328-4023 Karen Tescher Administrator, Utilization Management Medical Services, ND Department of Human Services 600 East Boulevard Ave, Dept 325 Bismarck, ND 58505-0250 701/328-4893

Prescription Price Updating Brendan K. Joyce, Pharm.D. 701/328-4023

Medicaid Drug Rebate Contact Brendan K. Joyce, Pharm.D. 701/328-4023

Claims Submission Contact Brendan K. Joyce, Pharm.D. 701/328-4023

Medicaid Managed Care Contact Tom Solberg, Administrator Managed Care ND Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismark, ND 58505-0250 T: 701/328-1884 F: 701/328-1544 E-mail: [email protected]

Disease Management Program/Initiative Contact Brendan K. Joyce, Pharm.D. 701/328-4023

Mail Order Pharmacy Benefit Program State currently has a mail order pharmacy program capability in which all Medicaid recipients are entitled to participate. However, the mail order pharmacy must be a North Dakota Medicaid provider.



Department of Human Services Officials 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: 701/328-2359 E-mail: [email protected] Dave Zentner Medicaid Director 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0261 T: 701/328-2321 F: 701/328-1544 E-mail: [email protected]

Department of Human Services Advisory Committees Medical Care Advisory Committee Terry Dwelle, M.D. State Health Officer State Health Department 600 East Boulevard Bismarck, ND 58505 T: 701/328-2372 Lynn Blakeman St. Vincent’s Care Center 1021 N. 26th Street Bismarck, ND 58501 T: 701/223-6888 Alison Fallgater, D.D.S. 121 E. Front Avenue Bismarck, ND 50504 T: 701/223-1194 Amy Fleck, O.D. Family Vision Clinic 111 E. Century Avenue Bismark, ND 58501 T: 701/222-1420 Howard Anderson, R.Ph. PO Box 70 Turtle Lake, ND 58575 T: 701/448-2542 Dean Rosen, M.D. 5801 Lariat Place Bismark, ND 58503 T: 701/258-7125

Herbert J. Wilson, M.D. 1244 W. Coulee Road Bismarck, ND 58501 Karla Broeckel 725 S. 12th Street, Lot 202 Bismarck, ND 58504 Delores Farrell 301 N. 19th Street Bismark, ND 58501 Carrie Steinwand 24 Santee Road Lincoln, ND 58504 Teri Lyn Aguilar 3123 Twin City Drive Mandan, ND 58554 Commission on Socio-Economic Affairs Robert F. Szczys, M.D., Chairman Grand Forks Clinic Ltd. Grand Forks, ND 58206 Russel J. Kuzel, M.D., Vice Chairman Dakota Clinic Ltd. Fargo, ND 58103 Bipin B. Amin, M.D. Mid Dakota Clinic Bismarck, ND 58502 William W. Barnes, M.D. 307 5th Avenue, SE Minot, ND 58701 Norman E. Bystol, M.D. Dakota Clinic Ltd. Fargo, ND 58108 James R. Carpenter, M.D. Meritcare Medical Group Fargo, ND 58123 Stanley T. Diede, M.D. Heart and Lung Clinic Bismarck, ND 58502 Harold W. Evans, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206 Gregory A. Gapp, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206



Stephen H. Goldberger, M.D. Grand Forks Clinic Ltd. Grand Forks, ND 58206 Genevieve M. Goven, M.D. Meritcare Clinic Valley City Valley City, ND 58072 Mark B. Hart, M.D. The Bone and Joint Center Bismack, ND 58504 George H. Hilts, M.D. Dakota Eye Institute Bismarck, ND 58504 Mark O. Jensen, M.D. 300 Main Avenue Fargo, ND 58103 Donald R. Lamb, M.D. 100 4th Street, S., Ste. 504 Fargo, ND 58103 Gregory J. Post, M.D. Meritcare Medical Group Fargo, ND 58123 David A. Rinn, M.D. Towner County Medcenter Cando, ND 58324 Pierre A. Rioux, M.D. 307 5th Avenue, SE Ste. 300 Minot, ND 58701 Thomas R. Templeton, M.D. Great Plains Clinic Dickinson, ND Brian C. Willoughby, M.D. West River Health Clinics Hettinger, ND 58639 Councilors Assigned David H. Lane, M.D. Anesthesia Associates Ltd. Grand Forks, ND 58208 Larry E. Johnson, M.D. Dakota Clinic Ltd. P. O. Box 1980 Jamestown, ND 58402

Pharmacy Advisory Committee Robert L. Treitline, Chair 941 9th Avenue West Dickinson, ND 58601

Anton P. Welder, R.Ph. P.O. Box 835 Bismarck, ND 58502 Doreen M. Beiswanger, R.Ph 1140 SE 6 Street, Unit 10 Valley City, ND 58072 David L. Just, R.Ph. P.O. Box 99 Beulah, ND 58523 David J. Olig, R.Ph. 2400 32nd Avenue South Fargo, ND 58103 DuWayne Schlittenhard, R.Ph. 3408 Par Street Fargo, ND 58102 Mary Beth Reinke, R.Ph. 3530 SW 28 #301 Fargo, ND 58104 Cindy Yeager, R.Ph. Box 9512 Fargo, ND 58108

Executive Officers of State Medical and Pharmaceutical Societies North Dakota Medical Association Bruce Levi Executive Vice President 204 W. Thayer Avenue 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 Lloyd Mark Bell President Director 1600 2nd Avenue, SW. Suite 120 Minot, ND 58701 701/852-8798 Internet Address: web.ndak.net/~ndoa/north_Dakota_osteopathic_a.htm



North Dakota Pharmaceutical Association Robert Treitline Executive Vice President 1906 E. Broadway Bismarck, ND 58501-4700 T: 701/258-4968 F: 701/258-9312 E-mail: [email protected] Internet address: www.nodakpharmacy.com State Board of Pharmacy Howard C. Anderson Executive Director P. O. Box 1354 Bismarck, ND 58502-1354 701/328-9535 E-mail: [email protected] North Dakota Hospital Association Arnold R. Thomas President 3205 E. Thayer Avenue Bismarck, ND 58501 701/224-9732 E-mail: [email protected] Internet address: www.ndha.org


National Pharmaceutical Council Ohio-1

OHIO



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expended Recipients Expended Recipients TOTAL $882,579,749 777,632 $1,087,552,923 904,380 RECEIVING CASH ASSISTANCE, TOTAL $459,330,337 295,724 $540,895,726 292,077 Aged $73,527,758 33,224 $84,684,721 32,916 Blind/Disabled $364,181,040 161,699 $430,791,473 161,509 Child $9,576,244 70,616 $11,864,467 66,278 Adult $12,045,295 30,185 $13,555,065 31,374 MEDICALLY NEEDED, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $27,219,090 151,832 $35,401,852 148,249 Aged $1,985,542 1,994 $2,188,262 1,883 Blind/Disabled $4,564,574 3,076 $5,157,289 2,989 Child $17,835,201 123,412 $24,761,193 122,129 Adult $2,833,773 23,350 $3,295,108 21,248 TOTAL OTHER EXPENDITURES/RECIPIENTS* $396,030,322 330,076 $511,255,345 464,054



2-Ohio National Pharmaceutical Council

C. ADMINISTRATION Ohio Department of Job and Family Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: most drugs. 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; Nascoral; Orgaran; Oxandrin Panretin; Periostat; Priftin; Prolastin; Proleukin; Provigil; Psoralens; Remicade; Rituxan; Stimate; Synagis; and Targretin. OTC Coverage: Selected coverage for: allergy, asthma, and sinus products; analgesics; feminine products; smoking deterrent products; cough and cold preparations; digestive products; topical products; laxatives; antacids; and vitamins and minerals. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anti-psychotics; anxiolytics, sedatives and hypnotics; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents, estrogens; sympathominetics (andrenergic); and thyroid agents. Therapeutic categories not covered: anorectics; innovator multi-source drugs; certain antibiotics (last-line therapies); selected high-risk drugs (e.g., Accutane); and drugs used in special settings (e.g., outpatient hospital). Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through both the Prescription Drug Program and physician payment when used in physicians offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable. Approved Drug List (ADL)/Prior Authorization ADL: Closed ADL with approximately 28,000 NDC-specific trade and generic drugs. Products excluded include obesity, fertility, and experimental drugs.

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization is needed for certain individual drugs (see examples above)

Prescribing or Dispensing Limitations Prescription Refill Limit: 11 for non-controlled drugs up to one year. Twelve for birth control drugs up to one year. Five for Scheduled III, IV, V drugs up to six months. None for Scheduled II drugs.

Monthly Quantity Limit: Maximum 34-day supply for acute and 102-dosage units for chronic maintenance medications. Amount designated in Ohio Approved Drug List.

Drug Utilization Review PRODUR system implemented through POS in Feb 2000. State currently has a DUR Board with quarterly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.70, effective 7/1/98. 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. Provider’s submitted charge, which should reflect usual and customary charge to the general public;

2. WAC+9% plus a dispensing fee.

3. 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. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires prior authorization. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 300,000 Medicaid recipients were enrolled in managed care in 2001. All received pharmacy services through managed care plans.

Managed Care Organizations Dayton Area Health Plan One South Main Street One Dayton Center Dayton, OH 45402 937/224-3300 Family Health Plan


National Pharmaceutical Council Ohio-3

2200 Jefferson Avenue, 6th Floor Toledo, OH 43624 419/241-6501 Paramount Care, Inc. P.O. Box 928 Toledo, Oh 43697 419/887-2550 Peoples Health Plan of Ohio 4580 Stephen Circle, N.W., Suite 200 Canton, OH 44718 330/499-3100 QualChoice Health Plan 6000 Parkland Boulevard Cleveland, OH 44124 440/460-0093 SummaCare P.O. 3620 Akron, OH 44309 330/996-8410

F. STATE CONTACT State Drug Program Administrator Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Ohio Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad St., 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

Thomas Hayes, 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] 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: 614/466-4443 F: 614/752-3986 E-mail: [email protected] Robyn Colby, Chief

Bureau of Health Plan Policy 614/466-6420 Sheila Fujii, Chief Bureau of Medical Assistance 255 E. Main Street Columbus, OH 43215 614/466-2365

Prior Authorization Contacts Drugs: Robert P. Reid, R.Ph. 614/466-6420 DME/Nutritions: Bonnie Brownlee 614/466-6065

DUR Contact Jan Lawson DUR Administrator 30 East Broad Street, 31st Floor Columbus, OH 43266-0423 T: 614/466-9698 F: 614/-466-2866

DUR Board 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.

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: JD Salvatore, 614/387-8402 Policy: Robyn Colby, 614/466-6420 Audits: Robert Reid, 614/466-6420

Claims Submission Contact First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7682


4-Ohio National Pharmaceutical Council

Medicaid Managed Care Contact Cynthia Burnell Bureau Chief Managed Health Care Ohio Department of Job and Family Services 255 E. Main St. Columbus, OH 43215 614/466-4693

Mail Order Pharmacy Benefit State has mail order providers.

Physician Administered Drug Program Contact Robert Reid, R.Ph. 614/466-6420 Pharmacy and Therapeutics Committee Robert P. Reid, R.Ph., Chairman Bureau of Health Plan Policy 30 East Broad Street, 27th Floor Columbus, OH 43266-0423 Suzanne Eastman, R.Ph., M.S. 3922 North Cliff Lane Cincinnati, OH 43220 Michael Alexander, D.O. 3219 Sullivant Avenue Columbus, OH 43204 Ruth E. Purdy, D.O. 4830 Slate Run Ct 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 Ave Bluffton, OH 43209 Tammie J. Stroup, R.Ph. 30 E. Broad Street, 27th Fl. Columbus, OH 43215-3414

Executive Officers of State Medical and Pharmaceutical Societies Ohio State Medical Association Brent Mulgrew Executive Director 3401 Mill Run Drive Hilliard, OH 43026 T: 614/527-6762 F: 614/527-6763 E-mail: [email protected] Internet address: www.osma.org Ohio Pharmacists Association Ernest “Ernie” Boyd Executive Director 6037 Frantz Road, Ste. 106 Dublin, OH 43017 T: 614/798-0037 F: 614/798-0978 E-mail: [email protected] Internet address: www.ohiopharmacists.org 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 State Board of Pharmacy William T. Winsley Executive Director 77 S. High Street, 17th Floor 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, CEO 155 E. Broad St., 15th Floor Columbus, OH 43215-3620 T: 614/221-7614 F: 614/221-4771 E-mail: [email protected] Internet address: ohanet.org


National Pharmaceutical Council Oklahoma-1

OKLAHOMA





Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $178,254,361 221,984 $215,717,760 249,678 RECEIVING CASH ASSISTANCE, TOTAL $60,522,664 58,549 $71,737,280 62,218 Aged $18,286,078 18,301 $21,886,460 21,329 Blind/Disabled $40,651,081 32,693 $48,377,145 35,113 Child $996,925 5,578 $903,823 4,161 Adult $588,580 1,977 $569,852 1,615 MEDICALLY NEEDY, TOTAL $378,918 640 $296,233 562 Aged $12,713 24 $13,911 31 Blind/Disabled $217,183 151 $149,640 137 Child $69,108 201 $61,257 210 Adult $79,914 264 $71,425 184 POVERTY RELATED, TOTAL $19,223,396 104,483 $26,864,537 129,023 Aged $142,110 248 $85,695 170 Blind/Disabled $158,133 206 $134,217 149 Child $17,386,942 88,931 $24,942,717 114,054 Adult $1,536,211 15,098 $1,701,908 14,650 TOTAL OTHER EXPENDITURES/RECIPIENTS* $98,129,383 58,312 $116,819,710 57,875



2-Oklahoma National Pharmaceutical Council

C. ADMINISTRATION Oklahoma Health Care Authority.

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). Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: birth control. Products not covered: analgesics; cough and cold preparations; digestive products, feminine products; topical products; and smoking deterrent products. Products covered with restrictions: allergy, asthma, and sinus products (Claritin OTC only for children < 21 years). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, NSAIDs; antihistamine drugs (partially covered); anxiolytics, sedatives, and hypnotics; growth hormones; misc. GI drugs; prescribed smoking deterrents (partially covered) and stimulants for ADHD. Therapeutic categories not covered: anabolic steroids; anorectics; and prescribed cold medications. OBRA ’90 Drugs identified as "coverage optional." 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 as part of EPSDT services and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization: State currently has a formal prior authorization procedure and DUR Board. Agency grievance process exists for appeal of prior authorization decisions or coverage of an excluded product.

Prescription or Dispensing Limitations Prescription Refills: None Monthly Quantity Limits: Three prescriptions per month/recipient. 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: 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 = AWP – 12.0%. 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.” Currently, 355 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.

E. USE OF MANAGED CARE Approximately 137,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive benefits through both State and managed care plans.

Managed Care Organizations Community Care P.O. Box 3249 Tulsa, OK 74033 Heartland 100 North Broadway, Ste. 1400 Oklahoma City, OK 73102-8601


National Pharmaceutical Council Oklahoma-3

Prime Advantage 1602 SW 82nd St. Lawton, OK 73505 Unicare P.O Box 268985 Oklahoma City, OK 73126

F. STATE CONTACTS State Drug Program Administrator Nancy Nesser Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105-9901 T: 405/522-7325 F: 405/522-3240 E-mail: [email protected] Internet address: www.ohca.state.ok.us

Prior Authorization Contact Ronald Graham, Pharm. D. 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]

DUR Contact Ronald Graham, Pharm. D., 405/271-9039 Medicaid DUR Board Rick Crensaw, D.O. Dick Robinson, R.Ph. (Vice-Chair) Dorothy Gourley, D.Ph. Cliff Meece, D.Ph. William Banner, M.D. Cathy E. Hollen, D.Ph. Francois DuToit, M.D. 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 E-mail: www.firstdatabank.com Medicaid Drug Rebate Contacts Tom P. Simonson Manager, Medicaid Drug Rebate Program

Oklahoma Healthcare Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105-9901 T: 405/522-7327 F: 405/530-3236 E-mail: [email protected]

Claims Submission Contact Chris Shearier EDS 2401 N.W. 63rd 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 does not sponsor a mail order pharmacy benefit. However, mail order pharmacies are allowed to contract with the Oklahoma Medicaid program to provide prescription products to Oklahoma Medicaid beneficiaries. Pharmacy must be a contracted provider.

Disease Management Program/Initiative Contact Kathe Eastham, R.N Nurse Case Manager III Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105-9901 T: 405/522-7155 F: 405/522-7378 E-mail: [email protected]

Physician-Administered Drug Program Contact J. Paul Keenan, M.D. Associate Medical Director 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 T: 405/522-7176 F: 405/530-3245


4-Oklahoma National Pharmaceutical Council

Oklahoma Health Care Authority Officials Michael Fogarty, J.D. Chief Executive Officer Oklahoma Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 T: 405/522-7300 F: 405/522-7187 E-mail: [email protected] Lynn Mitchell, M.D. State Medicaid Director Oklahomah Health Care Authority 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105 T: 405/530-7365 F: 405/530-3218 E-mail: [email protected] Darcedia McCauley, Ph.D. Director of Quality Assurance 405/530-3355

Advisory Committee on Medical Care for Public Assistance Recipients Frank Wilson, III, M.D., Chairman 4545 N. Lincoln, Ste. 124 Oklahoma City, OK 73105

Executive Officers of State Medical, Pharmaceutical, and Osteopathic Societies Oklahoma State Medical Association Brian O. Foy, Executive Director 601 NW Grand Boulevard Oklahoma City, OK 73118 T: 405/843-9571 or 800/522-9452 F: 405/842-1834 E-mail: [email protected] Internet address: www.osmaonline.org Oklahoma Pharmaceutical Association Phil Woodward, D.Ph., Executive Director 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 73105-3321 T: 405/528-4848 F: 405/528-6102 E-mail: [email protected] Internet address: okosteo.org State Board of Pharmacy Janis K. McAllister President 4545 N. Lincoln Boulevard, Ste. 112 Oklahoma City, OK 73105-3488 T: 405/521-3815 F: 405/521-3758 E-mail: [email protected] Internet address: www.state.ok.us/~pharmacy 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


National Pharmaceutical Council Oregon-1

OREGON 1



Aged Blind/

Disabled


Disabled

Child Adult SFO





Nursing Facility Services � � � � � �




Expenditures Recipients Expenditures Recipients TOTAL $163,263,562 191,901 $228,670,426 RECEIVING CASH ASSISTANCE TOTAL $58,691,711 51,031 Aged $5,742,701 6,123 Blind/Disabled $48,569,477 28,510 Child $861,860 8,089 Adult $3,517,673 8,309 MEDICALLY NEEDY, TOTAL $25,659,100 6,483 Aged $4,063,302 1,695 Blind/Disabled $21,595,798 4,788 Child $0 0 Adult $0 0 MEDICALLY NEEDY TOTAL $5,071,877 31,027 Aged $586,943 478 Blind/Disabled $1,519,991 748 Child $2,445,545 25,579 Adult $519,398 4,222 TOTAL OTHER EXPENDITURES/RECIPIENTS* $73,840,874 103,360 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.

1 The State of Oregon did not respond to the 2002 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 Oregon Medicaid program to assess the accuracy and currency of the information included.


2-Oregon National Pharmaceutical Council

C. ADMINISTRATION Office of Medical Assistance Programs (OMAP), Department of Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin and syringe combinations used for insulin (when insulin filled). Products covered under DME: disposable needles 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: fertility drugs; experimental drugs.

Over-the-Counter Product Coverage: Products requiring prior authorization and physician prescription: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; topical products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: Anabolic steroids; analgesics, antipyretics, and NSAIDs; anorectics; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic 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; prescribed smoking deterrents; sympathominetics (andrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: antihistamine drugs; growth hormones; 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.

Vaccines: Vaccines reimbursable by Medicaid as part of the Vaccines for Children Program.



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.

Prescribing or Dispensing Limitations Limit initial prescription for chronic medications to 15 days to prevent wasting if drug is changed due to intolerance, side effects, etc. Effective 4/02.

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 Dispensing Fee: $3.50, $3.80, effective 10/01/01. 1) $3.50 (retail); 2) $3.80 (institutional/SNF: providers operating a True

or Modified Dose Delivery System). Ingredient Reimbursement Basis: EAC = AWP-13%.

Prescription Charge Formula: Estimated acquisition cost (EAC) defined as the lesser of: (1) AWP-13% (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 “Dispense as Written,” or “Brand Medically Necessary.”




E. USE OF MANAGED CARE Approximately 250,000 Medicaid Recipients were enrolled in MCOs in FY 2001. Recipients enrolled in MCOs receive pharmaceutical benefits through both State and managed care plans. Care Oregon, Inc 522 SW Fifth Ave, 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 P0 Box 5729 Bend, OR 97708-5729 800/431-4155 Doctors of The Oregon Coast South (DOCS) 750 Central, Suite 202 PO Box 1096 Coos Bay, OR 97420 541/269-7400 Douglas County IPA 500 SE Cass, Suite 210 Roseburg, OR 97470 541/677-3453 Family Care, Inc 2121 SW Broadway, Suite 300 Portland, OR 97201 800/335-3205 Intercommunity Health Network, Inc 3600 NW Samaritan Drive Corvallis, OR 97330 800/757-5114 Kaiser Permanente 500 NE Multnomah, Suite 100 Portland, OR 97232-2099 800/813-2000 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 St., SE, Suite 240 Salem, OR 97301 503/584-2150 Mid Rogue IPA Health Plan 820 NE 7th Street Grants Pass, OR 97526 541/471-4106 ODS Health Plans 601 SW 2nd Ave Portland, OR 97204 800/342-0526

Oregon Health Management Services 1051 NE 6th Street, Suite 2C Grants Pass, OR 97526 541/ 471-4208 Providence Health Plan 1235 NE 47th, Suite 220 Portland, OR 97213-2196 800/ 898-8174 Tuality Health Alliance 335 SE 8th Avenue PO 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.omap.hr.state.or.us

Prior Authorization Contact Thomas Drawbaugh, 503/945-6492

DUR Contact Mariellen Rich, R.Ph. Pharmacist Account Manager First Health Service Corporation 565 Union St., NE, Suite 205 Salem, OR 97301 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

Medicaid DUR Board Rickland G. Asai, D.M.D. (Chair) 2375 SW Cedar Hills Blvd. Portland, OR 97225 Patrick Bowman, R.Ph. Portland, OR Gerald D. Fairbanks, R.Ph. Albany, OR



Dean Haxby, Pharm.D. Oregon Health Sciences University OSU College of Pharmacy 3181 SW Sam Jackson Park Rd., GH212 Portland, OR 97201-3098 Christina Heinrich, Pharm.D. Eugene, OR Robert Ingle, Jr., M.D., M.P.H. Kaiser Permanente Salem, OR Gregory Johnson, M.D. (Vice-Chair) Clackamas, OR Raymond S. Lee, D.O. Clackamas, OR Sharon Leigh, Pharm.D. Portland, OR Robert Mendelson, M.D. Portland, OR Clifford Singer, M.D. Portland, OR James W. Winde, M.D. 1212 Aspen Drive La Grande, OR 97850

Prescription Price Updating Kathy Franklin Customer Support Department First Databank, Inc. 1111 Bayhill Drive NE San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003 E-mail: [email protected]

Medicaid Drug Rebate Contacts Becky Smith Rebate Analyst First Health Services Corp. 565 Union St., NE, Suite 205 Salem, OR 97301 T: 503/391-1981 F: 503/391-1979 E-mail: [email protected]

Claims Submission Contact Mariellen Rich, R.Ph., 503/391-1980

Medicaid Managed Care Contact Joyce Riggi

Delivery Systems Manager Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97310-1014 T: 503/945-6497 F: 503/947-5221

Disease Management Program/Initiative Contact Thomas Turek, M.D. Medical Director Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97301-1097 T: 503/945-5770 F: 503/373-7689 E-mail: [email protected]

Mail Order Pharmacy Program State has a Mail Order Pharmacy Program. All beneficiaries are entitled to participate.

Physician-Administered Drug Program Contact Isabel Bickel, R.N. Office of Medical Assistance Programs Department of Human Resources 500 Summer Street, NE, E-35 Salem, OR 97301 503/945-6490

Office of Medical Assistance Officials Jean Thorne Director Department of Human Services 500 Summer Street, NE, E-15 Salem, OR 97301-1097 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] Lynn Read Director Office of Medical Assistance Programs Department of Human Services 500 Summer Street, NE Salem, OR 97301 T: 503/945-5772 F: 503/373-7689 E-mail: [email protected]



Title XIX Medical Care Advisory Committees

Elizabeth Byers Bruce Bliatout Donna Crawford Rosemari Davis Rosemari Fitts Michael Garland John Hogan Kelley Kaiser Noel Larson, D.M.D. Amy Malone Rick Wopat, M.D.

Consultants to Health and Social Services Section Thomas Turek, M.D. Medical Director Office of Medical Assistance Programs Department of Human Resources 500 Summer Street, NE Salem, OR 97301

Pharmacy Advisory Task Force 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.

Executive Officers of State Medical and Pharmaceutical Associations Oregon Medical Association Robert L. Dernedde, CAE Executive Director 5210 SW Corbett Street Portland, OR 97239-3897 T: 503/226-1555 F: 503/241-7148 E-mail: [email protected] Internet address: www.ormedassoc.org Oregon State Pharmacists Association

Tom Holt Executive Director 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: 503/222-2279 F: 503/222-2392 E-mail: [email protected] Internet address: www.opso.com State Board of Pharmacy Gary Schnabel Executive Director State Office Bldg., Room 425 800 NE Oregon St., #9 Portland, OR 97232 T: 503/731-4032 F: 503/731-4067 E-mail: [email protected] Oregon Association of Hospitals and Health Systems Kenneth M. 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




National Pharmaceutical Council Pennsylvania-1

PENNSYLVANIA



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expended Recipients Expended Recipients TOTAL $533,527,373 416,498 $533,527,373 416,498 RECEIVING CASH ASSISTANCE, TOTAL $250,790,899 157,601 Aged $54,131,823 25,385 Blind / Disabled $175,740,482 72,923 Child $6,663,349 35,013 Adult $14,255,245 24,280 MEDICALLY NEEDY, TOTAL $44,804,637 32,353 Aged $38,355,424 17,511 Blind / Disabled $2,922,397 989 Child $2,321,542 9,053 Adult $1,205,274 4,800 POVERTY RELATED, TOTAL $117,501,143 149,542 Aged $40,920,296 19,453 Blind / Disabled $59,717,317 23,957 Child $15,316,515 94,966 Adult $1,547,015 11,166 TOTAL OTHER EXPENDITURES/RECIPIENTS* $120,430,694 77,002



2-Pennsylvania National Pharmaceutical Council

C. ADMINISTRATION

Office of Medical Assistance Programs, Department of Public Welfare.

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 (non H2 antagonists). Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; 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; sympathominetics (adrenergic); thyroid agents; and prescribed smoking deterrent products; and prescribed cold medications. Therapeutic categories not covered: anorectics (unless for treatment of hyperkinesis or narcolepsy); hair restoration drugs, 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 Medical Assistance, Children Health Insurance Program, the Vaccines for Children Program, and EPSDT Program. Unit Dose: Unit dose packaging not reimbursable.

Formulary/Prior Authorization 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-rate 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.

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 including 1 vacancy 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. 465 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary”, “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 Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 886,000 unduplicated Medicaid recipients were enrolled in managed care in 2001. All receive pharmacy services, depending on their category of assistance, through managed care.

Managed Care Organizations AmeriHealth HMO/Mercy Health Plan 44,457 1901 Market Street, 45th Floor Philadelphia, PA 19103 Keystone Mercy Healthplan 244,435 200 Stevens Drive, Ste. 900 Philadelphia, PA 19113-1570 Americhoice of PA 105,102 The Wanamaker Building 100 Penn Square East, Ste. 900 Philadelphia, PA 19107 Health Partners of Philadelphia 121,176 841 Chestnut St. Ste. 900 Philadelphia, PA 19107 Three Rivers Health Plans/MedPlus+ 134,646 300 Oxford Drive Monroeville, PA 15146 UPMC Health Plan, Inc./Best 72,280 Healthcare of Western PA One Chatam Center 112 Washington Place Pittsburgh, PA 15219 Gateway Health Plan 164,431 Two Chatam Ctr, Ste. 500 Pittsburgh, PA 15219

F. STATE CONTACTS State Drug Program Administrator Joseph E. Concino, R.Ph. Office of Medical Assistance Programs Pharmacy Services Section P.O. Box 8046 Harrisburg, PA 17105 T: 717/772-6341 F: 717/772-6366 E-mail: [email protected] Internet address: www.dpw.state.pa.us/omap

Welfare Department Officials Estelle Richman Secretary Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17120 Carole W. Rebert Official-In-Charge for Medical Assistance Programs Christopher P. Gorton, M.D. Chief Medical Officer Carla Huitt, M.D. Medical Director Teresa Shuchart Director Division of Data and Claims Management Jeffrey Bechtel Director Bureau of Program Integrity Suzanne Love Director Bureau of Policy, Budget, and Planning Guy L. Ridge, III Director Bureau of Fee-for-Service Programs Christine M. Bowser Director Bureau of Managed Care Operations Andrew Major Director Bureau of Long Term Care Programs William M. Peifer, R.Ph. Pharmacy Consultant Pharmacy Services Section



Louis J. Cappello, R.Ph. Pharmacy Consultant Pharmacy Services Section John Ferrara, R.Ph. Director Division of Program Integrity

DUR Board Richard D. Baltz, M.D. 3028 Market Street Camp Hill, PA 17011 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 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 Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 800/633-3453

Medicaid Drug Rebate Contacts Technical: David Ehrhart, 717/772-6305 Policy: Suzanne Love, 717/772-6142 Disputes: Louis Cappello, 610/447-5385

Claims Submission Contact EDS 275 Grandview Avenue Camp Hill, PA 17011 (Calls with contractor must be made through state agency.)

Medicaid Managed Care Contact Michael Jacobs Director, Division of MCO Monitoring and Compliance Office of Medical Assistance Programs Cherrywood Bldg, DPW Complex #2 Harrisburg, PA 17110 T: 717/772-6300 F: 717/772-2730


Expanded Drug Coverage Program Contact Thomas M. Snedden, Director PACE Program PA Dept. of Aging 555 Walnut St., 5th Floor. Harrisburg, PA 17101 717/787-7313

Medical Assistance Advisory Committee Christine Allen PACE/LTCCAP c/o LIFE University of Pennsylvania School of Nursing 4101 Woodland Avenue Philadelphia, PA 19104-4510 215/898-4417 Shirley Beer Armstrong County Low Income Rights Organization RD, #8, Box 134 Kittanning, PA 16201 724/543-5031 Shelley Bishop Pennsylvania Mental Health Consumers Association 4105 Derry Street Harrisburg, PA 17111 717/564-4930



Kent D. W. Bream, M.D. Department of Family Practice University of Pennsylvania 2 Gates, HUP, 3400 Spruce Street Philadelphia, PA 19104 215/614-0523 Louise Brookins Philadelphia State Welfare Rights Org. 1231 N. Franklin Street Philadelphia, PA 19122 214/684-3600 Kevin Casey Pennsylvania Protection and Advocacy 1414 Cameron Street, Suite C Harrisburg, PA 17103 717/236-8110 Michael D. Chambers County commissioners Association of Pennsylvania 17 North Front Street Harrisburg, PA 17101 717/232-7554 Barbara Coffin Pennsylvania Association of Area Agencies on Aging Berks County Office of Aging County Services Center 633 Court Street Reading, PA 19601-4303 610/478-6500 Dona Dmitrovic Executive Director Pennsylvania Recovery Organization Alliance, Inc. 900 South Arlington Avenue, Suite 119 Harrisburg, PA 17109 717/545-8929 Henry R. Fiumelli Executive Director Pennsylvania Forum for Primary Health Care 1035 Mumma Road, Ste. 1 Wormleysburg, PA 17043 717/761-6443 Vickie Hoak (Vice-Chair) Pennsylvania Homecare Association 20 Erford Road, Suite 115 Lemoyne, PA 17043 717/975-9448, Ext. 28 Dolores Hodgkiss Managed Care Association of Pennsylvania 240 North Third Street, Suite 501 Harrisburg, PA 17101 717/238-2600

Kathy Hubert Pennsylvania County Drug and Alcohol Program Administrators 17 North Front Street Harrisburg, PA 17101 717/232-7554 Michelle Jones Healthy Start, Inc. 400 North Lexington Street Pittsburgh, PA 15208 412/247-4009 George Kimes Pennsylvania Community Providers Association 2400 Park Drive Harrisburg, PA 17110 717/657-7078 Christine Klejbuk PA Assn. Non-Profit Homes for the Aging Dir. of Public Policy 1100 Bent Creek Blvd. Mechanicsburg, PA 17050 717/763-5724 Ms. Carol Lavoritano AmeriChoice The Wanamaker Building 100 Penn Square East, Suite 900 Philadelphia, PA 19107 Yvette Long Philadelphia Welfare Rights Organization 1231 North Franklin Street Philadelphia, PA 19122 215/684-3600 Donald McCoy (Chair) Pennsylvania Medical Society 777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820 717/558-7823 Anne R. McHugh Hospital and Healthsystem Association of Pennsylvania 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 Donna McNonagle Philadelphia Coordinated Health Care 123 South Broad Street, 22nd Floor Philadelphia, PA 19109 717/546-7643, Ext. 3652



Jonna Miller Delaware County Office of Behavior Health 20 South 69th Street, 3rd Floor Upper Darby, PA 19082 Richard R. Orlandi Pennsylvania Medical Society 777 East Park Drive PO Box 8820 Harrisburg, PA 17105-8820 717/558-7750 Mary Ellen Rehrman 10 Bertolet School Road Spring City, PA 19475 610/469-9536 or 215/546-0300, Ext. 3251 Dale Laninga - Ex-Officio Member Department of Aging Intra Governmental Council on Long Term Care 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919 717/783-1550 Michael A. Yantis, Jr. - Ex-Officio Member Pennsylvania Department of Health Office of Policy Room 808, Health and Welfare Building Harrisburg, PA 17120 717/787-4525 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 Pennsylvania Pharmaceutical 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 State Board of Pharmacy Melanie Zimmerman Executive Secretary 124 Pine St. P.O. Box 2649 Harrisburg, PA 17105-2649 T: 717/783-7157 F: 717/787-7769 E-mail: [email protected] Internet address: www.dos.state.pa.us/bpoa/phabd/mainpage.htm Hospital Association of Pennsylvania Carolyn F. Scanlan President, CEO 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 717/564-9200 E-mail: [email protected] Internet address: www.haponline.org


National Pharmaceutical Council Rhode Island-1

RHODE ISLAND



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expended Recipients Expended Recipients TOTAL $89,482,143 49,809 $102,708,476 RECEIVING CASH ASSISTANCE TOTAL $53,505,798 27,625 Aged $6,550,737 4,487 Blind/Disabled $46,759,792 21,360 Child $66,792 840 Adult $128,477 938 MEDICALLY NEEDY, TOTAL $8,188,213 3,910 Aged $5,579,162 3,121 Blind/Disabled $2,609,010 786 Child $0 0 Adult $41 3 POVERTY RELATED, TOTAL $243,588 933 Aged $59,273 95 Blind/Disabled $119,373 115 Child $41,117 555 Adult $23,825 168 TOTAL OTHER EXPENDITURES/RECIPIENTS* $27,544,544 17,341

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.


2-Rhode Island National Pharmaceutical Council

C. ADMINISTRATION Rhode Island Department 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; 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. Over-the-Counter Product Coverage: Products covered: analgesics (acetaminophen); cough and cold preparations (guifenisin, diphenhydramine, chlorpheniramine); digestive products (non-H2 antagonists); feminine products (contraceptive foams, gels and creams); topical products; antacids; and laxatives. Products not covered: allergy, asthma, and sinus products; digestive products (H2 antagonists); and smoking deterrent products. Therapeutic Category Coverage: Products covered: anabolic steroids; 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; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anoretics; misc. GI drugs; erectile dysfunction products; and Cox 2 inhibitors; partial coverage: growth hormones. Therapeutic categories not covered: prescribed smoking deterrents; products for hair growth. 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 when used in physician offices. Vaccines: Limited coverage under the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.

Formulary/Prior Authorization Formulary: State has a formulary. Prior authorization is used to manage the formulary.

Prescribing or Dispensing Limitations Prescription Refill Limit: Refills to a maximum of 5 are allowed for specified drugs: anti-hypertensives, diuretics, anti-convulsants, coronary vasodilators, tranquilizers, antidepressants, hormones, antibiotics, etc. Refills are not allowed for specified drugs, e.g., central nervous system stimulants, narcotics (Schedule II, III), and pentazocine. Monthly Quantity Limit: One month’s supply for non-maintenance drugs. Maintenance Medication: The attending physician may prescribe certain maintenance drugs of 100 tablets, capsules or pint of liquid or a 30-day supply of these drugs - whichever is greater. Monthly Dollar Limits: None

Drug Utilization Review PRODUR system implemented in December 1994.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.40 (ambulatory) and $2.85 (nursing homes), 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 50 percent, the usual and customary charge to the general public, or the allowable cost plus the professional fee for service.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” with a documented medical reason why a generic cannot be used. Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: Does not pay for cognitive services.


National Pharmaceutical Council Rhode Island-3

E. USE OF MANAGED CARE Approximated 120,000 Medicaid recipients were enrolled in managed care in 2001. Managed care recipients receive pharmaceutical benefits through managed care plans.

Managed Care Organizations − United Healthcare of New England − Coordinated Health Partners, Inc. − Neighborhood Health Plan of Rhode Island

F. STATE CONTACTS State Drug Program Administrator Paula Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected]

DUR Contact Paula Avarista, R.Ph., 401/462-6390

Rhode Island DUR Board Raymond Maxim, MD Edward Westlake, MD Richard Wagner, MD Steve Kogurt, PhD Craig Bowen, PharmD John Zevzavadjian RPh Ellen Mauro, RN, MPH

Prescription Price Updating Paula Avarista, R.Ph., 401/462-6390

Medicaid Drug Rebate Contacts Technical: Helen Vaughn EDS, 401/784-3879 Policy: Paula Avarista, 401/462-6390 DUR: Paula Avarista, 401/462-6390

Claims Submission Contact EDS, 401/784-3879

Medicaid Managed Care Contact Tricia Leddy, Administrator Department of Human Services 600 New London Avenue Cranston, RI 02920 401/462-2127 Mail Order Pharmacy Program None

Physician-Administered Drug Program Contact Paula Avarista, R.Ph., 401/462-6390

Department of Human Services Officials 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] John Young Associate Director 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]

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 781/721-9900 E-mail: [email protected] Internet Address : www.northeastosteo.org Rhode Island Society of Health-System Pharmacists Richard Emery, President 2484 Warwick Avenue Warwick, RI 02889 T: 401/737-4144 F: 401/737-0959 E-mail: [email protected] Internet Address: www.rishp.org State Board of Pharmacy Catherine A. Cordy Chief of The Board 3 Capitol Hill, Room 205 Providence, RI 02908-5097 T: 401/277-2837 F: 401/222-2158


4-Rhode Island National Pharmaceutical Council

E-mail: [email protected] Internet Address: www.healthri.org//hsr/professions/pharmacy.htm Hospital Association of Rhode Island Edward J. Quinlan, President 880 Butler Drive, Suite One Providence, RI 02906 T: 401/274-4274 F: 401/274-1838 E-mail: [email protected] Internet Address: www.hari.org


National Pharmaceutical Council South Carolina-1

SOUTH CAROLINA



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expended Recipients Expended Recipients TOTAL $334,740,332 474,465 $438,498,935 542,764 RECEIVING CASH ASSISTANCE, TOTAL $180,174,171 156,943 $217,671,240 201,137 Aged $49,524,373 31,494 $54,051,659 30,510 Blind/Disabled $114,485,843 71,255 $133,255,085 73,126 Child $5,723,013 32,302 $11,428,870 53,959 Adult $10,440,942 21,892 $18,935,626 43,542 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $109,063,041 227,756 $135,326,028 239,631 Aged $34,833,839 21,973 $41,923,282 24,199 Blind/Disabled $41,846,031 19,519 $51,608,068 21,735 Child $30,637,849 172,055 $39,949,877 179,897 Adult $1,745,322 14,209 $1,844,801 13,800 TOTAL OTHER EXPENDITURES/RECIPIENTS* $45,503,120 89,766 $85,501,667 101,996

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000, and CMS-64 Report FY 2001; South Carolina Medicaid Statistical Information System, FY 2001.


2-South Carolina National Pharmaceutical Council

C. ADMINISTRATION South Carolina Department of Health & Human Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: 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: cosmetics; 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: smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories not covered: anoretics and prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable through the Physician Services Program when used in physicians’ offices. Injectables reimbursable through the Prescription Drug Program when used at home, through home health care, or in long-term care facilities. Vaccines: Vaccines reimbursable based on CDC price as part of the Vaccines for Children Program (age under 21).


Formulary/Prior Authorization Formulary: Open formulary; certain drug classifications excluded.

General Exclusions:

1. Weight control products. 2. Investigational pharmaceuticals or products. 3. Immunizing agents. 4. Pharmaceuticals determined by the FDA to be less

than effective and identical, related, or similar drugs. 5. Injectable pharmaceuticals administered by the

practitioner in the office in a clinic, or in a mental

health center (Synagis is reimbursable through the Physician Services Program and is non-covered through Pharmacy Services).

6. Products used as flushes to maintain patency of devices.

7. Devices and supplies (e.g., diabetic supplies, infusion supplies, etc.)

8. Fertility products. 9. Smoking cessation products, whether legend or OTC. 10. Pharmaceuticals which are not rebated. 11. Nutritional supplements 12. Oral hydration therapies for adults. 13. Pharmaceuticals used for cosmetic purposes or hair

growth. Prior Authorization: State currently has a prior authorization program. Beneficiaries can request a fair hearing and exception to policy to appeal a prior authorization decision. The prescriber must obtain prior authorization for Medicaid coverage of the following products:

1. Brand name products (excluding certain narrow, therapeutic index drugs) for which there are A-rated, therapeutically equivalent, less costly generics available.

2. COX-2 inhibitors for patients < age 60. 3. Erectile dysfunction products. 4. OxyContin® (when maximum quantity

limitation is exceeded). 5. Panretin®. 6. Proton pump inhibitors for patients > age 21. 7. Serostim®. 8. Targretin®. 9. Xenical®.

Prescribing or Dispensing Limitations Prescription Refill Limit: The prescriber authorizes the number of refills. Monthly Quantity Limit: Children (birth to age 21) are allowed unlimited prescriptions per month. 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. Quantity Limit per Prescription: 34 days’ supply per prescription. Monthly Dollar Limit: None.

Drug Utilization Review PRODUR system implemented November 2000. State currently has a DUR Board with a monthly review.


National Pharmaceutical Council South Carolina-3

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” with handwritten certification by the prescriber and prior authorization. Incentive Fee: None. Patient Cost Sharing: $3.00 copayment per prescription. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 56,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans.

Managed Care Organizations Select Health of South Carolina, Inc. Patricia Marquis, Chief Operating Officer P.O. Box 40024 Charleston, SC 29403 843/569-1759

F. STATE CONTACTS State Drug Program Administrator James M. Assey, R.Ph., Division Director Division of Health Services 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

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, 803/898-2876

DUR Committee Gwendolyn C. Galphin, M.D. F. Joseph Hodge, R.Ph. Henry Rose, R.Ph. Leslie M. Stuck, M.D. Caroline Sojourner, R.Ph. Michele Burnett, R.Ph.

Prescription Price Updating First DataBank, 1111 Bayhill Dr., Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

Medicaid Drug Rebate Contacts Technical: Rod Davis, 803/898-2610 Policy: James Assey, 803/898-2876 DUR & PA: Caroline Sojourner, 803/898-2876 Disputes: Laurel Kennerly, 803/898-2954

Claims Submission Contact Rod Davis Bureau Chief, Bureau of Information Systems S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2610 E-mail: [email protected]

Medicare Managed Care Contact Bruce Harbaugh Department of Primary Care & Alternative Reimbursement Programs S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2818

Mail Order Drug Program None

Disease Management Program/Initiative Contact Kathie Reed Division of Client Education and Outreach Services S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2638 E-mail: [email protected]


4-South Carolina National Pharmaceutical Council

Physician-Administered Drug Program Contact Susan Bowling, Division Director Division of Medical Services S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2803

South Carolina Department of Health and Human Services Officials Robert C. Toomey, 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] Darlynn Thomas, Chief Bureau of Health Services & Delivery Systems 803/898-2870 Caroline Y. Sojourner, R.Ph., Department Head Department of Pharmacy Services 803/898-2876

Executive Officers of State Medical and Pharmaceutical Societies South Carolina Medical Association William F. Mahon Chief Executive Officer 3210 Fernandina Rd. P.O. Box 11188 Columbia, SC 29211 T: 803/798-6207 F: 803/772-6783 E-mail: [email protected] Internet Address: www.scmanet.org South Carolina Osteopathic Medical Society Tom Underwood, Executive Director 655 St. Andrews Road, Suite 1 Columbia, SC 29210-5136 T: 877/886-3672 F: 502/223-4937 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 T: 803/354-9977 F: 803/354-9207 E-mail: [email protected] Internet Address: www.scrx.org/scrx

State Board of Pharmacy Lee Ann F. Bundrick, Administrator South Carolina Board of Pharmacy P. O. Box 11927 Columbia, SC 29211-1927 T: 803/898-4700 F: 803/896-4596 E-mail: [email protected] Internet Address: www.llr.state.sc.us/pol/pharmacy South Carolina Hospital Association Kenneth A. Shull, President 101 Medical Circle P.O. Box 6009 West Columbia, SC 29171-6009 T: 803/796-3080 F: 803/796-2938 E-mail: [email protected] Internet Address: www.scha.org


National Pharmaceutical Council South Dakota-1

SOUTH DAKOTA



Aged Blind/

Disabled


Disabled

Child Adult SFO

Prescribed Drugs � � � � +

Inpatient Hospital Care � � � � +

Outpatient Hospital Care � � � � +

Laboratory & X-ray Service � � � � +

Nursing Facility Services � � � � +

Physician Services � � � � +

Dental Services � � � � +

+ Renal Disease

B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $44,650,518 53,666 $52,608,524 58,203 RECEIVING CASH ASSISTANCE, TOTAL $23,756,417 20,024 $27,648,344 20,993 Aged $2,983,433 1,883 $3,255,890 1,849 Blind/Disabled $18,641,451 8,644 $21,559,128 8,701 Child $961,330 6,010 $1,147,090 6,450 Adult $1,170,203 3,487 $1,686,236 3,993 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $3,278,820 18,823 $4,526,417 21,497 Aged $35,098 50 $39,540 49 Blind/Disabled $60,276 52 $66,140 61 Child $2,898,842 16,484 $4,065,705 19,072 Adult $284,604 2,237 $355,032 2,315 TOTAL OTHER EXPENDITURES/RECIPIENTS* $17,615,281 14,819 $20,433,763 15,713

**Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-South Dakota National Pharmaceutical Council

C. ADMINISTRATION Department of Social Services, Office of Medical Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products not covered: cosmetics; DESI drugs; fertility drugs; experimental drugs; total parental nutrition; drugs for impotence; and interdialytic parenteral nutrition. Over-the-Counter Product Coverage: Products not covered: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrents. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; 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. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physicians offices, home health care, and extended care facilities. Vaccines: Vaccines reimbursable with HCPC code as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization: State currently has a formal prior authorization procedure. Request for fair hearing required for appealing coverage of an excluded product or a prior authorization decision. Prescribing or Dispensing Limitations Prescription Dollar Limit: None. Monthly Quantity Limit: None.

Drug Utilization Review PRODUR system implemented in 1996. State has a DUR Board with annual review. Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.75 to $5.55 (with unit dose fee applied), effective 7/1/1991 Ingredient Reimbursement Basis: EAC = AWP-10.5%. Prescription Charge Formula: Payment is the lower of:

1. FUL, state MAC plus a dispensing fee, or 2. 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 Medically Necessary.” Incentive Fee: $110.00 Patient Cost Sharing: Copayment is $2.00. Cognitive Services: Does not pay for cognitive services.

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

F. STATE CONTACTS State Drug Program Administrator Mark Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

Prior Authorization Contact Mark Petersen, R.Ph., 605/773-3495


National Pharmaceutical Council South Dakota-3

DUR Contact Michael Jockheck, R.Ph. Pharmacy Consultant SD Dept of Social Services 700 Governors Drive Pierre, SD 57501 605/773-6439 E-mail: [email protected]

Steering Committee (Medicaid DUR Board) Damian Prunty (Program Administrator) Tom Carlson, R.Ph. Richard Holm, M.D. Pam Jones, R.Ph. Bruce Lushbough, M.D.

Prescription Price Updating Mark Petersen, R.Ph., 605/773-3495

Medicaid Drug Rebate Contacts Helen Rokusek Rebate Coordinator Dept. of Social Services 700 Governors Drive Pierre, SD 57501 605/773-3653

Claims Submission Contact Meredith Heerman Dept. of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: (605) 773-5246 E-mail: [email protected]

Disease Management Program/Initiative Contact Mark Petersen, R.Ph., 605/773-3495

South Dakota Medicaid Agency Officials James Ellenbecker Secretary Department of Social Services 700 Governors Drive Pierre, SD 57501-2291 T: 605/773-3165 F: 605/773-4855 E-mail: [email protected] Damian Prunty Program Administrator 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 Paul Engbrecht, Chairman Tieszen Memorial Home 437 State Street Marion, SD 57043 605/648-3384 John Jones, Vice Chairman Division of Health, Medical & Laboratory Services Health Laboratory Building 615 E. 4th Street c/o 500 E. Capitol Avenue Pierre, SD 57501 605/773-3737 Jud Bergan, O.D. 103 South Eagan Madison, SD 57042 Sheryl Petersen 218 W. Third Street Pierre, SD 57501 James D. M. Russell Hospital Admin. St. Mary's Hospital 803 E. Dakota Pierre, SD 57501 605/224-3100 Herb McClellan, Jr., D.D.S. Box 189 Mobridge, SD 57601-0189 Lynn Greff Apothecary Shop at Medical Arts 719 St. Francis Street Rapid City, SD 57701 Stephen Schroeder, M.D. Hand Co. clinic P.O. Box 287 Miller, SD 57362 Michelle Miller McKennan Home Health 800 E. 21st Street Sioux Falls, SD 57105-1016 A.A. Lampert, M.D. 13075 Bogus Jim Road Rapid City, SD 57702-9720


4-South Dakota National Pharmaceutical Council

Evaluation Committee V. R. Brandenburg, M.D. Dennis Hodge, Pharm.D. Helen Fiechtner, Pharm.D. Jane Mort, Pharm.D. James Clem, Pharm.D. Marc Aldrich (Physician)

Executive Officers of State Medical and Pharmaceutical Societies South Dakota State Medical Association L. Paul Jenson Chief Executive Officer 1323 South Minnesota Avenue Sioux Falls, SD 57105 T: 605/336-1965 F: 605/336-0270 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 Pharmaceutical Association Toby Lyon Executive Director 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 State Board of Pharmacy Dennis M. Jones Executive Secretary 4305 S. Louise Ave., Suite 104 Sioux Falls, SD 57106 T: 605/362-2737 F: 605/361-2738 E-mail: [email protected] Internet Address: www.state.sd.us/dcr/pharmacy South Dakota Association of Healthcare Organizations David R. Hewett President + 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


National Pharmaceutical Council Tennessee-1

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. On January 1, 1995, TennCare reached 90% of its target enrollment and closed enrollment in the uninsured category. However, on April 1, 1997, enrollment in the uninsured category re-opened to children under the age of 18 who do not have access to health insurance through a parent or guardian. On May 21, 1997, TennCare enrollment became available for eligible dislocated workers. Enrollment remains open to persons and their dependents who have lost access to a COBRA insurance plan and do not have access to other health insurance. In an effort to expand coverage to more of Tennessee's uninsured children, the Bureau of TennCare opened enrollment on January 1, 1998 to uninsured Tennesseans under the age of nineteen (19) with access to health insurance whose individual family incomes are below 200% of the poverty level. Effective January 1, 1998, uninsured children under age nineteen (19) who meet the TennCare criteria for uninsured are being allowed to enroll in TennCare indefinitely. The Bureau of TennCare eliminated deductibles and limited co-payments to 2% for these new eligibility populations and all uninsured children under eighteen (18) years of age who enrolled in TennCare during previous open enrollment periods. Enrollment remains open to persons who are Medicaid-eligible or who are uninsurable as determined by an insurance company's denial (for medical reasons) of health insurance to the individual. Current enrollment (2/26/02) is approximately 1.4 million of which 805,000 are Medicaid eligibles and 618,000 are in the uninsured/uninsurable categories. The State of Tennessee was granted approval by the Health Care Financing Administration for a five-year demonstration project under Section 1115 of the Social Security Act. State rules were promulgated to assist in administering the statewide program (TSOP). The initial five-year demonstration project ended December 31,

1998. HCFA approved a waiver extension for three years beginning January 1, 1999 through December 31, 2001. On July 1, 2002, Tennessee reached a new five-year agreement with the federal government to continue TennCare. 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 services, as determined medically necessary by the MCO, cover inpatient and outpatient hospital care, physician services, prescription drugs, lab and x-ray services, medical supplies, home health care, hospice care, and ambulance transportation. Excluded from TennCare managed care services are long-term care services and Medicare cross-over payments which are continuing as they were under the former Medicaid system. TennCare is financed by pooling current Federal, State and local expenditures for indigent health care. 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. Source: TennCare Home Page on the World Wide Web, last updated 01/09/03. http://www.state.tn.us/tenncare/

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 and a three-tired co-payment structure that began on January 1, 2003. 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. 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,


2-Tennessee National Pharmaceutical Council

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.” TennCare Assist will be created and detailed during the 2003 legislative session. The program is targeted to be implemented in July 2003. 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 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 Health (DHS) office. There is a local Health Department office in every Tennessee County. For the applicants' convenience, DHS will make a copy of the application, date stamp it, and process the application.

Source: TennCare Home Page on the World Wide Web, last updated 01/09/03. http://www.state.tn.us/tenncare/

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, and most OTCs). Growth hormone products and oral contraceptives require approval by the TennCare Prior Approval Unit. MCOs negotiate discounts with manufacturers, however, they do not have access to rebates extended under the federal Medicaid statute. Also, behavioral health products may be carved out of managed care with the state responsible for payment. Under such circumstances, manufactures do pay a rebate on these products.

Formulary: Varying formularies used by the individual MCOs. Most are closed formularies. MCO formularies must conform to TennCare guidelines. TennCare must approve formulary additions/deletions. Prior Authorization: Prior authorization procedures are administered by the individual MCOs. Co-payment: Deductibles and co-payments 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 co-payments in order to participate in the TennCare program.

C. USE OF MANAGED CARE Medicaid recipients and the uninsured/uninsurable are enrolled in MCOs through the TennCare program. All receive pharmacy benefits through managed care.

Managed Care Organizations Better Health Plans 890 Willow Tree Circle Cordova, TN 38018 BlueCare 801 Pine Street Chattanooga, TN 37402-2555 John Deere Health Plan Executive Tower I, Suite 400 408 N. Cedar Bluff Road Knoxville, TN 37923 TLC Family Care Healthplan P.O. Box 49 Memphis, TN 38101 OmniCare Health Plan, Inc. 1991 Corporate Ave., 5th Floor Memphis, TN 38132 PHP TennCare 1420 Centerpoint Blvd. Knoxville, TN 37932 TennCare Select 801 Pine Street Chattanooga, TN 37402-2555 Universal Care of Tennessee, Inc. 1808 West End Avenue, Suite 610 Nashville, TN 37203



Xantus Health Plan of Tennessee, Inc. 3401 West End Avenue, Suite 470 Nashville, TN 37203-1069 VHP Community Care 215 Centerview Drive, Suite 300 Brentwood, TN 37027

MCO/Behavioral Health Organization Better Health Plans Blue Care John Deere Health Plan OmniCare Health Plan Preferred Health Partnership (PHP) Premier Behavioral Systems Tennessee Behavioral Health, Inc. TLC Family Health Care Health Plan Universal Care VHP Community Care Xantus Gold

D. STATE CONTACTS State Drug Program Administrator H. Leo Sullivan, D.Ph. Director of Pharmacy Services Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/253-5481 E-mail: [email protected] Internet address: www.state.tn.us/tenncare

TennCare Officials Manny Martins, Deputy Commissioner Bureau of TennCare Department of Finance and Administration 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/741-0882 E-mail: [email protected] TennCare Information Line 800/669-1851

Prior Authorization Contact H. Leo Sullivan, D.Ph., 615/741-0213

DUR Contact 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]

TennCare DUR Advisory Board Butch Benson, D.Ph. 1310 Mulberry Court Murfreesboro, TN 37130 Christi Capers, Pharm.D. Clin. Edu. Consultant, Pfizer Inc. 4043 Farmingham Woods Dr. Hermitage, TN 37076-4405 Diane Crutchfield, D.Ph. 1223 Eaglenest Lane Knoxville, TN 37922 Roger L. Davis, Pharm.D. 326 Capitol Boulevard, Suite 810 Nashville, TN 37219 Martha Drannon, Pharm.D. Frayser Family Counseling Ctr. Pharmacy 2150 Whitney Avenue Memphis, TN 38127 Don Hazlewood, D.Ph. HealthCare Pharmacy 3100 S. First Street Milan, TN 38358 Connie J. Holladay, M.D. 6432 River Tide Dr. Memphis, TN 38120 Mack A. Land, M.D. 5210 Poplar Avenue, Suite 200 Memphis, TN 38119 J. Sloan Manning, M.D. Family Practice 1112 Union Avenue Memphis, TN 38104 David Shepard, Pharm.D., B.C.P.P. Dickson Apothecary East 104 Highway 70 East Dickson, TN 37055 Daniel D. Sumrok, M.D. Family Practice 22700 Highway 22 McKenzie, TN 38201



TennCare Bureau Jeff 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] H. Leo Sullivan, D.Ph. Director of Pharmacy Services Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/253-5481 E-mail: [email protected]

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 Contacts Audits: Sybil Creekmore, 615/741-0213 Disputes: H. Leo Sullivan, D.Ph., 615/741-0213

Claims Submission Contact Becky Garrigan PBM Account Manager ACS Northridge Center One, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 800/334-5979 F: 800/793-2305 E-mail: [email protected]

Pharmacy and Therapeutics Committee – Director of the Bureau of TennCare – TennCare Medical Director – TennCare Pharmacy Director – TennCare Associate Medical Director – Associated Medical Director of the

TennCare Grievance Unit – Medical Director of the TennCare Grievance

Intervention Unit – One Public Health Physician – One Physician who is a TennCare

participating provider – One Pharmacist who is a TennCare

participating provider

Each MCO is required to have its own Pharmacy and Therapeutics Committee.

TennCare Advisory Board Joseph M. Dawson, C.E.O. (chairman) Blount Memorial Hospital Maryville, TN Calvin Anderson Vice President for Corporate Affairs BCBS of Tennessee Memphis, TN Gary Brukardt Executive Vice President Renal Care Group Nashville, TN Tom Cecil Retired Tennessee Administration Brentwood, TN Nancy Hardt, M.D., Director Institute for Women’s Health and Methodist Endowed Chair for Women’s Health Memphis, TN Senator Tommy Haun Independent Insurance Agency Greenville, TN Ricks W Mason, Jr. Public School Administrator (retired) Memphis City Schools Memphis, TN Natasha Metcalf, Commissioner Tennessee Department of Human Services Nashville, TN Timothy S. Regan, R.Ph., C.Ph. Senior Engagement Manager Applied Health Outcomes Tampa, FL Mary Rolando Behavioral Health Consultant Nashville, TN Paul Rutledge, President HCA Mid-America Division and Tri-Star Health System Brentwood, TN John S. Sergent, M.D. Chief Medical Officer Vanderbilt University Medical Group Nashville, TN Larry Stanifer, C.E.O Rural Medical Services, Inc. Newport, TN



Linda Wertz, Director Texas Medicaid and Children’s Health Insurance Program (CHIP) Austin, TX

Medicaid Managed Care Contact Lola Potter Public Information Officer Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-7542 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 Programs Program Name: TennCare Centers for Excellence Disease/Medical States: Asthma, Cardiovascular Disease, and Diabetes Program Manager: Applied Health Outcomes

Disease Management Patient Education Contact Timothy Regan, R.Ph., C.Ph. Senior Engagement Manager Applied Health Outcomes Two Urban Centre 4890 W. Kennedy Boulevard Suite 760 Tampa, FL 33609 T: 800/320-6497 F: 813/207-8119 E-mail: [email protected]

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

Tennessee Osteopathic Medical Association Dee Ann Walker, CAE Executive Director 200 4TH Avenue North, Suite 900 Nashville, TN 37219 T: 615/301-3048 F: 615/254-7047 E-mail: [email protected] Internet address: www.tomanet.org Tennessee Pharmacists Association Baeteena M. Black, Ph.D. Executive Director 226 Capitol Boulevard, Suite 840 Nashville, TN 37219-1893 T: 615/256-3023 F: 615/255-3528 E-mail: [email protected] Internet address: www.tnpharm.org 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/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 Hospital Alliance of Tennessee Adrienna Knestrick 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




National Pharmaceutical Council Texas-1

TEXAS



Aged Blind/

Disabled


Disabled

Child Adult SFO

Prescribed Drugs � � � � � �

Inpatient Hospital Care � � � � � �

Outpatient Hospital Care � � � � � �

Laboratory & X-ray Service � � � � � �

Nursing Facility Services � � � � � �

Physician Services � � � � � �

Dental Services � � � � � �

B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $1,125,238,856 1,852,801 $1,327,222,456 1,917,351 RECEIVING CASH ASSISTANCE, TOTAL $652,580,603 716,096 $757,087,849 713,254 Aged $199,571,641 155,223 $225,287,571 155,312 Blind / Disabled $369,253,617 234,712 $439,674,579 240,642 Child $45,145,922 226,431 $50,653,592 221,789 Adult $38,609,423 99,730 $41,472,107 95,511 MEDICALLY NEEDY, TOTAL $10,650,662 26,077 $13,645,641 30,183 Aged $0 0 $0 0 Blind / Disabled $0 0 $0 0 Child $41,947 250 $56,065 264 Adult $10,608,715 25,827 $13,589,576 29,919 POVERTY RELATED, TOTAL $141,274,060 770,423 $171,959,460 810,157 Aged $690,336 983 $812,066 930 Blind / Disabled $1,059,763 836 $821,022 815 Child $122,180,204 630,742 $149,515,656 665,651 Adult $17,343,757 137,862 $20,810,716 142,761 TOTAL OTHER EXPENDITURES/RECIPIENTS* $320,733,531 340,205 $384,529,506 363,757



2-Texas National Pharmaceutical Council

C. ADMINISTRATION Texas Health and Human Services Commission. Vendor drug program was implemented September 1, 1971.

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. 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: growth hormones; dextroamphetamines (>21 years of age); xenical (hyperlipidemia only). Therapeutic categories not covered: anorectics. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, through physician payment when used in physicians offices, and through both the Prescription Drug Program and Physician payment in extended care facilities. 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.

Formulary/Prior Authorization Formulary: Open formulary; however, products must be listed in the Texas Drug Code Index. General exclusions (diseases, drug categories, etc.) include: amphetamines, appliances, durable medical equipment (bedpans, etc. - either rental or purchase), elastic stockings, first aid supplies, medical supplies, oxygen, supports and suspensories, and trusses. Prior Authorization: State currently has a prior authorization procedure screening for drug classes and individual drugs.

Prescribing or Dispensing Limitations Prescription Refill Limit: Five refills, but total amount may not exceed 6-month supply. Monthly Quantity Limit: Prescribed quantity cannot exceed 6-month supply. Monthly Prescription Limit: Limited to 3 per month except for recipients under age 21 and nursing home recipients. Other Limit: Recipients in managed care pilots receive unlimited prescription coverage.

Drug Utilization Review PRODUR system implemented in February 1995. State currently has a DUR board with a quarterly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.27. The dispensing fee, including all costs of filling a prescription, was established by cost accounting and service evaluation of the expenses involved in dispensing a prescription. Therefore, fees paid to providers who experience different cost and service factors considered in arriving at the fee may receive more or less than actual costs incurred in dispensing. Ingredient Reimbursement Basis: EAC = AWP-15% or WAC + 12%, whichever is lower, AAC for hospitals and public health providers. Prescription Charge Formula: Average dispensing expense (ADE) formula for payment: 1. (EAC + 5.27) divided by 0.980 = amount paid +

$0.15 delivery service. 2. DEAC only for Wyeth-Ayerst.



Insulin and approved non-legend drugs on prescription: pharmacists and dispensing physicians will be reimbursed on the basis of usual charges to the general public or cost 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. 1,323 therapeutic classes and 8,580 NDC numbers are listed on the State-specific MAC list. Override requires “Brand Necessary” or “Brand Medically Necessary.” Incentive Fee: None. Cognitive Services: Does not pay for cognitive services. Patient Cost Sharing: No copayment.

E. USE OF MANAGED CARE Approximately 502,000 Medicaid recipients are enrolled in MCOs (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 Physician Corporation of America 8303 Mopac, Ste. 450 Austin, TX 78759-8370 Vista, Inc. 9310 North Lomar Austin, TX 78753

F. STATE CONTACTS State Drug Program Administrator Curtis Burch, R.Ph. Director, Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6992 F: 512/794-5190 E-mail: [email protected] Internet address: www.hhsc.state.tx.us/hcf/vdp/vdpstart.html

Health and Human Services Commission Officials Albert Hawkins Commissioner

Texas Health and Human Service Commission 4900 N. Lamar Boulevard Austin, TX 78751-2316 T: 512/424-6502 F: 512/424-6587 E-mail: [email protected] Jason Cooke Medicaid Director Texas Health and Human Services Commission 4900 N. Lamar Boulevard Austin, TX 78751-2316 T: 512/424-6517 F: 512/424-6587 E-mail: [email protected]

Prior Authorization Contact Don Valdes, R.Ph. Pharmacist II Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6436 F: 512/794-5189 E-mail: [email protected]

DUR Contact Curtis Burch, R.Ph. 512/338-6922

DUR Board Leroy Knodel, Pharm.D., Vice Chairman Drug Information Service Department of Pharmacology The University of Texas Health Science Center 7703 Floyd Curl Drive San Antonio, TX 78284-7766 Thomas Lee Kurt, M.D., M.P.H. 3645 Stratford Avenue Dallas, TX 75205 Mark S. Gittings, D.O., R.Ph. 4327 Grants Glen Wichita Falls, TX 76309



Robert L. Hogue, M.D. 101 A South Park Drive Brownwood, TX 75801 Daniel Saylak, D.O., Chairman 4607 Locksford Bryan, TX 77802 Mary Spies Maxwell, M.D. 4526 Burnet Road Austin, TX 78731 Adelina Barbosa, R.Ph. #10 Casa De Palmas Brownsville, TX 78521 Anita Martinez, R.Ph. 2819 Burning Hill San Antonio, TX 78247 James B. Hills, R.Ph. Lava Rock Apothecary 1907 E. Southmore Street Pasadena, TX 77502 Robert T. Reilly, Pharm.D. Thomason Hospital Department of Pharmacy 4815 Alameda Avenue, P. O. Box 2009 El Paso, TX 79998

Prescription Price Updating Martha McNeill, R.Ph. Director, Product and Prescriber Management Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6965 F: 512/338-6462 E-mail: [email protected]

Medicaid Drug Rebates Contact Heather Murphy Manager, Pharmacy Rebates Vendor Drug Program Contracts and Rebates Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6963 F: 512/338-6910 E-mail: [email protected]

Claims Submission Contact Laura Bagheri

Manager, Pharmacy Resolutions Vendor Drug Program Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78756-3174 T: 512/338-6909 F: 512/338-6910 E-mail: [email protected]

Medicaid Managed Care Contact Laura Jordan 512/794-6884

Mail Order Pharmacy Program State has a mail order pharmacy program. Participating pharmacies contract with the State.

Physician-Administered Drug Program Contact Billy Milwee Administrative Contracts Manager Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756

Executive Officers of State Medical and Pharmaceutical Societies Texas Medical Association Frederick L. Merian, M.D. President 401 W. 15th Street Austin, TX 78701-1680 T: 512/370-1300 F: 512/370-1632 E-mail: [email protected] Internet address: www.texmed.org Texas Pharmaceutical Association Jim Martin, R.Ph. Executive Director P. O. Box 14709 1624 E. Anderson Lane Austin, TX 78761-4709 T: 512/836-8350 F: 512/836-8308 E-mail: [email protected] Internet address: www.txpharmacy.com



Texas Osteopathic Medical Association Terry Boucher, M.P.H. Executive Director, Secretary/Treasurer 1415 Lavaca Street Austin, TX 78701-1634 T: 512/708-8662 F: 512/708-1415 E-mail: [email protected] Internet address: www.txosteo.org State Board of Pharmacy Gay Dodson, R.Ph. Executive Director/Secretary William P. Hobby Building, Box 21 333 Guadalupe St., 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 & 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




National Pharmaceutical Council Utah-1

UTAH



Aged Blind/

Disabled


Disabled

Child Adult SFO









Expenditures Recipients Expenditures Recipients TOTAL $100,794,076 133,164 $117,101,302

136,682

RECEIVING CASH ASSISTANCE TOTAL $42,558,127 33,499 $48,529,173 33,260 Aged $4,495,377 2,801 $5,275,146 2,848 Blind/Disabled $32,336,442 12,256 $37,273,244 12,442 Child $1,873,612 11,525 $1,949,135 11,105 Adult $3,852,696 6,917 $4,031,648 6,865 MEDICALLY NEEDY, TOTAL $5,349,920 3,160 $5,661,159 2,569 Aged $1,005,863 533 $1,083,310 528 Blind/Disabled $3,622,485 1,072 $3,965,954 965 Child $113,112 688 $82,975 441 Adult $608,462 867 $528,920 635 POVERTY RELATED, TOTAL $48,407,497 66,809 $57,527,963 77,811 Aged $13,858,966 6,383 $15,915,526 6,468 Blind/Disabled $21,777,416 7,332 $25,732,028 7,940 Child $4,548,843 30,697 $5,852,559 39,384 Adult $8,222,272 22,397 $10,027,850 24,019 TOTAL OTHER EXPENDITURES/RECIPIENTS* $4,478,532 29,696 $5,383,007 23,042



2-Utah National Pharmaceutical Council

C. ADMINISTRATION Division of Health Care Financing, State Department of Health.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: 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; and anzemet. Products covered under DME: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; and hair growth products. 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 mus present a Medicaid card and a prescription. Products covered: − Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix) − Allergy, asthma and sinus products (generics only) − Analgesics (generics only) − Contraceptives − Cough and cold preparations (generics only) − Digestive products (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 − Psyllium muciloid powder − Quinine, 5 gr. Products covered with restrictions: feminine products; topical products: Products not covered: vitamins (except for expectant mothers and children to age 5); smoking deterrent products (special program for expectant mothers); and topical products. For additional information or to obtain a list of covered over-the-counter products, contact the Utah Medicaid program at http://hlunix.hl.state.ut.us/Medicaid/.

Therapeutic Category Coverage: Products covered: analgesics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; antilipemic agents; cardiac drugs; prescribed cold medications; contraceptives; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anoretics; anabolic steroids (partial coverage); anti-deppresants; antihistamines; anti-psychotics; chemotherapy agents; ENT anti-inflammatory agents; and growth hormones (partial coverage). Products not covered: prescribed smoking deterrents; diet medications. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in home health care and in physician offices. Vaccines: Vaccines reimbursable at AWP minus 12% plus a fee as part of the Vaccines for Children Program. Unit Dose: Does not reimburse for unit dose packaging.

Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization: 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 limit on specific drugs.

Drug Utilization Review PRODUR system implemented in 1994.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.90 for urban, $4.40 for rural, effective 1993. $1.00 for OTCs. Ingredient Reimbursement Basis: EAC = AWP-15%. 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 $1.00 dispensing fee. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary” and prior authorization. Incentive Fee: None.



Patient Cost Sharing: Copayment = $3.00-$5.00 per month. $3.00 (traditional program); $4.00 (nontraditional program); $5.00 (Primary care network). Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 14,000 Medicaid recipients are enrolled in managed care. Pharmacy benefits are through the state.

Managed Care Organizations Altius 10421 S. Jordan Gateway South Jordan, UT 84095 American Family Care 2120 South 13th East #303 Salt Lake City, UT 84106 IHC Access P.O. Box 116670 Salt Lake City, UT 84147 Med Utah Healthwise P.O. Box 30804 Salt Lake City, UT 84130-0804 PHS 35 West Broadway Salt Lake City, UT 84101 United Medchoice 7910 South 3500 East Salt Lake City, UT 84121 Univ. of Utah Health Network 35 W. Broadway Salt Lake City, VT 84101

F. STATE CONTACTS State Drug Program Administrator RaeDell Ashley, R.Ph. Pharmacy Director 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]

DUR Contact Duane Parke DUR Director 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]

DUR Board Lowry Bushnell, M.D. Western Institute of Neuropsychiatry 501 Chipeta Way Salt Lake City, UT 84108 Carter Burke Hoechst-Roussel Pharmaceuticals 790 East 3800 North Provo, UT 84604 Bradford D. Hare, M.D., Ph.D. Department of Anesthesiology 50 North Medical Drive Salt Lake City, UT 84132 Jeff Jones, R.Ph. Riverton Drug 1741 West 12600 South Riverton, UT 84065 Richard Martinez, D.D.S. 2936 Highland Drive Salt Lake City, UT 84106 Karen M. Gunning, Pharm.D. Univ. of Utah College of Pharmacy 30 South 2000 East, Room 265 Salt Lake City, UT 84112-5820 Colin B. Van Orman, M.D. PCMC, Suite 2700 100 North Medical Drive Salt Lake City, UT 84113 Derek Christensen, R.Ph. 9842 Grouse Bend Circle South Jordan, UT 84095 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 Laurie Ott, PA-C 2107 West 3500 South West Valley City, UT 84119 Richard E. Swinyard, R.Ph.



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

Claims Submission Contact Brenda Bryant, Manager Bureau of Medicaid 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]

Medicaid Managed Care Contact Julie Olsen Managed Care Coordinator 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]

Mail Order Pharmacy Program State has a mail order pharmacy program. Utah Medicaid beneficiaries may choose to obtain prescription drugs through mail order.

Physician-Administered Drug Program Contact RaeDell Ashley, R.Ph., 801/538-6495

Department of Health Officials Rod Betit, 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]

Michael Deily, Director Medicaid Bureau Division of HealthCare Financing Department of Health P.O. Box 143101 Salt Lake City, UT 84114-1000 T: 801/538-6406 F: 801/538-6099 E-mail: [email protected]

Executive Officers of State Medical and Pharmaceutical Societies Utah State 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 Utah Osteopathic Medical Association Shelly Hanks Secretary 462 South 1240 East Payson, UT 84651-8533 T: 801/465-9545 F :801/794-1495 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 Board of Pharmacy Diana L. Baker Bureau Director 160 East 300 South P.O. Box 146741 Salt Lake City, UT 84116-6741 T: 801/530-6179 F: 801/530-6511 E-mail: [email protected] Internet address: www.commerce.state.ut.us/dopl/dopll.htm



Utah Hospitals and Health Systems Association Rick Kinnersley, CAE 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




National Pharmaceutical Council Vermont-1

VERMONT1



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $91,724,918 103,228 $105,673,417

109,328

RECEIVING CASH ASSISTANCE TOTAL $35,695,094 26,454 $39,685,114 25,169 Aged $3,823,777 1,869 $3,799,046 1,741 Blind/Disabled $26,616,167 10,429 $30,223,439 10,679 Child $1,822,882 9,253 $2,061,532 8,225 Adult $3,432,268 4,903 $3,601,097 4,524 MEDICALLY NEEDY, TOTAL $16,212,159 9,485 $17,804,948 9,407 Aged $6,025,101 2,903 $6,488,482 2,836 Blind/Disabled $8,274,497 2,688 $9,113,456 2,639 Child $502,599 1,824 $537,853 1,641 Adult $1,409,962 2,070 $1,665,157 2,291 POVERTY RELATED, TOTAL $4,128,353 25,450 $4,956,436 26,895 Aged $0 0 $0 0 Blind/Disabled $0 0 $0 0 Child $3,930,066 24,001 $4,726,155 25,385 Adult $198,287 1,449 $230,281 1,510 TOTAL OTHER EXPENDITURES/RECIPIENTS* $35,689,312 41,839 $43,226,919 47,857 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000 and FY 2001.

1 The State of Vermont did not respond to either the 2001 or 2002 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.


2-Vermont National Pharmaceutical Council

C. ADMINISTRATION Agency 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; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics and experimental drugs. Over-the-Counter Product Coverage: Products covered with prior authorization: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, NSAIDs; anorectics; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: prescribed smoking deterrents. Coverage of Injectables: Injectable medicines reimbursable when used in physician offices, home health care, and extended care facilities. Vaccines: Reimbursable at AWP minus 10% as part of EPSDT service. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization Formulary: Open formulary. General exclusions include cosmetics and experimental drugs. Prior Authorization: Prior authorization procedure screening for drug classes. PA is required for non-pregnancy multi-vitamins, smoking deterrents, amphetamines, food supplements, and OTC drugs. 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 = AWP–11.9%. 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 and State-specific limits on generic drugs. Override requires “Dispense as Written.” Incentive Fee: None. Patient Cost Sharing: Copayment of $1.00 per dispensation required (excluding standard Federal exemptions). Copayment of $2.00 when ingredient cost exceeds $29.99. Cognitive Services: Does not pay for cognitive services.

E. USE OF MANAGED CARE Approximately 78,000 total Medicaid recipients are enrolled in MCOs in 2001. None received pharmacy services through managed care.

F. STATE CONTACTS State Drug Program Administrator Pat House Operations Manager Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201 T: 802/241-2765 F: 802/241-2974 E-mail: [email protected]


National Pharmaceutical Council Vermont-3

Agency of Human Services Officials Charles Smith Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05671-0201 T: 802/241-2220 F: 802/241-2979 E-mail: charles@[email protected] Paul Wallace-Brodeur Medicaid Director Dept. of Prevention, Assistance, Transition, and Health Access 103 South Main Street Waterbury, VT 05676 T: 802/241-3985 F: 802/241-2897 E-mail: [email protected]

Prior Authorization Contact Pat House 802/241-2765

DUR Contact Gloria Jacobs Operations Administrator Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 T: 802/241-2763 F: 802/241-2974 E-mail: [email protected]

DUR Board James A. Gray, M.D. (Chair) Jeffrey P. Firlik, R.Ph. Cheryl A. Gibson, M.D. Richard J. Harvie, R.Ph. Virginia L. Hood, M.D. Donna M. Kiley, 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.

Prescription Price Updating Christine Dapkiewicz Drug Rebate Coordinator ACS 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

Medicaid Drug Rebate Contacts Technical: Christine Dapkiewicz, 802/979-4450 Policy: Vacant Disputes: Shona M. Lothrop, 802/879-4450

Claims Submission Contact ACS Fiscal Agent 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

Medicaid Managed Care Contact Pat House 802/241-2765

Disease Management Initiative/Program Contact Shona Mossey-Lothrop Pharmacy Consultant ACS 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440 E-mail: [email protected]

Expanded Drug Coverage Program Contact Pat House 802/241-2765

Physician-Administered Drug Program Contact Joseph Jacobs, M.D. Medical Director Office of Vermont Health Access Department of Social Welfare 103 South Main Street Waterbury, VT 05650-1201 802/241-2745

Executive Officers of State Medical and Pharmaceutical Societies 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


4-Vermont National Pharmaceutical Council

Vermont Pharmacists Association Fred Dobson Executive Director P. O. Box 245 Richmond, VT 05477 T: 877/483-2646 F: 802/433-4803 Internet address: www.vtpharmacists.org 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 F: 802/229-5619 State Board of Pharmacy Carla Preston Board Administrator 26 Terrace Street, Drawer 09 109 State Street, Pavilion Office Building Montpelier, VT 05609-1101 T: 802/828-2875 F: 802/828-2465 E-mail: [email protected] Internet address: vtprofessionals.org/oprl/pharmacists Vermont Association of Hospitals and Healthcare Systems Marie Beatrice Grause President & CEO 148 Main Street Montpelier, VT 05602 T: 802/223-3461 F: 802/223-0364 E-mail: [email protected] Internet address: www.vahhs.org


National Pharmaceutical Council Virginia-1

VIRGINIA



Aged Blind/

Disabled


Disabled

Child Adult SFO







Dental Services All eligible recipients under age 21


Expenditures Recipients Expenditures Recipients TOTAL $382,471,744 347,251 $419,133,293 333,880

RECEIVING CASH ASSISTANCE TOTAL $237,026,074 128,007 $252,905,212 102,360 Aged $66,594,390 34,976 $73,894,551 34,599 Blind/Disabled $162,401,999 67,158 $178,608,437 66,480 Child $2,924,705 16,169 $140,364 733 Adult $5,104,980 9,704 $261,860 548

MEDICALLY NEEDY, TOTAL $18,622,035 7,589 $14,259,566 6,474 Aged $6,786,997 4,026 $5,995,613 3,354 Blind/Disabled $9,403,763 3,336 $8,230,689 2,951 Child $2,420,707 164 $27,529 136 Adult $10,568 63 $5,735 33 POVERTY RELATED, TOTAL $27,169,199 127,720 $35,351,169 140,124 Aged $975,696 996 $2,442,573 2,295 Blind/Disabled $1,881,791 1,325 $3,725,012 2,539 Child $21,702,283 105,739 $26,581,071 116,636 Adult $2,609,429 19,660 $2,602,513 18,654 TOTAL OTHER EXPENDITURES/RECIPIENTS $99,654,436* 83,935 $116,617,346 84,922



2-Virginia National Pharmaceutical Council

C. ADMINISTRATION 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 and needles and syringe combinations used for insulin. Products covered with restrictions: blood glucose test strips (up to age 21 in FFS, otherwise under DME) and total parenteral nutrition (special billing format using HCVA 1500 form). Products not covered: cosmetics; fertility drugs; hair growth products; urine ketone drug test strips (paid under DME) interdialytic parenteral nutrition; designated DESI drugs; experimental drugs; non-legend drugs; and expired drugs. Over-the-Counter Drug Coverage: A majority of OTC drugs reimbursable when used in nursing homes and certain classes in outpatient populations. Therapeutic Category Coverage: Prior authorization required for: weight loss 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 physician offices. Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable in nursing homes.

Formulary/Prior Authorization Formulary: Open Formulary Prior Authorization: Prior authorization procedure screening for individual drugs 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 Dispensing Fee: $4.25, effective 7/1/95. Ingredient Reimbursement Basis: EAC = AWP – 10.25%.

Prescription Charge Formula: Based upon the lower of FUL, VMAC or EAC plus a fee, or the usual and customary charge minus a copayment of $1.00 for generics and $2.00 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 “Brand Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00/Rx for generics and $2.00/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.

E. USE OF MANAGED CARE Approximately 503,950 beneficiaries enrolled in managed care organizations in 2002. Recipients enrolled in managed care organizations receive pharmaceutical benefits through managed care plans.

1) Medallion - primary care physicians, 2) Options - optional enrollment for recipients into

HMOs, and 3) Medallion II - mandatory HMOs

Managed Care Organizations Virginia Premier Health Plan Trigon Health Keepers Plus Sentara Family Care Southern Health/CareNet UNICARE Health Plan of Virginia

F. STATE CONTACTS State Drug Program Administrator MaryAnn McNeil, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Ste. 1300 Richmond, VA 23219 T: 804/783-2196 F: 804/786-0973 E-mail: [email protected]

DUR Contact MaryAnn McNeil, R.Ph. 804/783-2196


National Pharmaceutical Council Virginia-3

DUR Board Robert O. Friedel, M.D. Matthew J. Goodman, M.D. Jason Lynam, M.D. Thomas Moffatt, M.D. Elaine Ferrary, M.S.N. Jane Settle, N.P. Geneva Briggs, Pharm.D. Sandra Johnson, R.Ph. Kelly Goode, Pharm.D. Mary Johnson, Pharm.D. Lisa McClanahan, R.Ph. Bill Rock, Pharm.D.

Prescription Price Updating David B. Shepherd, R.Ph., 804/786-8056

Medicaid Drug Rebate Contacts Policy: David B. Shepherd, R.Ph., 804/786-8056 Disputes: Lorraine Sumler, 804/965-7400

Claims Submission Contact MaryAnn McNeil, R.Ph. 804/786-2196


Medical Managed Care Contact Mary Mitchell Supervisor Department of Medical Assistance Services 600 East Broad Street, Ste. 1300 Richmond, VA 23219 T: 804/786-3594 F: 804/786-5799 E-mail: [email protected]

Physician-Administered Drug Program Contact Sally Rice, 804/786-9490

Department of Medical Assistance Services Officials Patrick W. Finnerty Director Department of Medical Assistance Services 600 East Broad Street, Ste. 1300 Richmond, VA 23219 T: 804/786-4231 F: 804/225-4512 E-mail: [email protected]

Sally Rice Manager, Provider Relations Division of Program Operations 804/786-9490

Fiscal Intermediary First Health Services P.O. Box 6987 Richmond, VA 23230

Virginia Medicaid Pharmacy Liaison Committee (PLC) Bill Hancock, R.Ph. Long Term Care Pharmacy Coalition Alexander Maculey, R.Ph. Virginia Association of Chain Drug Stores Michael Ayotte, R.Ph. Community Pharmacy Coalition Rebecca Snead, R.Ph. Virginia Association of Chain Drug Stores Jan Burrus Pharmaceutical Research and Manufacturers of America

Executive Officers of State Medical and Pharmaceutical Societies Medical Society of Virginia Paul Kitchen Executive Vice President 4205 Dover Road Richmond, VA 23221-3267 T: 804/353-2721 F: 804/355-6189 E-mail: [email protected] Internet Address: www.msv.org Virginia Pharmacists Association Rebecca Snead Executive Director 5501 Patterson Ave., Ste. 200 Richmond, VA 23226 T: 804/285-4145 F: 804/285-4227 E-mail: [email protected] Internet Address: www.vapharmacy.org 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


4-Virginia National Pharmaceutical Council

Virginia Osteopathic Medical Association Maria Harris Executive Director 48 East Square Lane Richmond, VA 23233 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 P.O. Box 1394 Richmond, VA 23294 T: 804/965-1216 F: 804/965-0475 E-mail: [email protected] Internet Address: www.vhha.com


National Pharmaceutical Council Washington-1

WASHINGTON



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $387,877,281 339,440 $458,332,414 RECEIVING CASH ASSISTANCE, TOTAL $218,126,163 136,333 Aged $34,961,221 21,931 Blind / Disabled $177,790,887 77,218 Child $1,338,427 17,639 Adult $4,035,628 19,545 MEDICALLY NEEDY, TOTAL $35,842,053 12,078 Aged $9,317,197 5,042 Blind / Disabled $26,518,846 7,001 Child $1,055 11 Adult $4,955 24 POVERTY RELATED, TOTAL $10,935,934 61,912 Aged $1,335,389 1,374 Blind / Disabled $4,043,531 2,066 Child $2,511,063 29,835 Adult $3,045,951 28,637 TOTAL OTHER EXPENDITURES/RECIPIENTS* $122,973,131 129,117



2-Washington National Pharmaceutical Council

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: digestive products (non-H2 antagonists) and contraceptives. Products covered with restrictions: allergy, asthma and sinus products (selected items); analgesics (ASA and Acetaminophen); cough and cold preparations (selected items); feminine products (selected items); and topical products. Products not covered: digestive products (H2 antagonists) and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; anti-depressants; antilipemic agents; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics; growth hormones; and misc. GI drugs. Therapeutic categories partially covered requiring prior authorization: anabolic steroids; analgesics, antipyretics, NSAIDs; and anoretics. Therapeutic categories not covered: prescribed smoking deterrents and weight loss drugs. (A complete list of drugs requiring expedited prior authorization may be found on the Medical Assistance Administration’s web site. wwws2.wa.gov/dshs/maa.) 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 Prior Authorization: State currently has a prior authorization program and a Drug Utilization and Education Review Council. Recipients can request a fair

hearing and exception to policy to appeal an excluded product or prior authorization decision.

Prescribing or Dispensing Limitations Prescription Refill Limit: Two (2) refills in 30-day period except for antibiotics, anti-asthmatics, Schedule II and III drugs, anti-neoplastic, topicals, and any propoxyphene, which may have 4 refills. Monthly 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.

Drug Utilization Review PRODUR system implemented in March 1996. State currently has a DUR Board with a bi-monthly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.20 to $5.20, effective 7/1/02. − $4.20 - Retail pharmacies, filling over 35,000 Rxs

annually. − $4.51 - Retail pharmacies, filling 15,001-35,000 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 = AWP – 14%, except drugs on the MAC list with 5 or more labelers/manufacturers are reimbursed at AWP-50%. Prescription Charge Formula: The amount shall not exceed the usual and customary charge to the public or EAC plus a dispensing fee. Any drug with more than 3 labelers will be reimbursed according to the Maximum Allowable Cost. Maximum Allowable Cost: State imposes State-specific limits on generic drugs. Override requires “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: State pays for cognitive services under the Emergency Contraceptive Program.



E. USE OF MANAGED CARE Approximately 450,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through both the State and managed care plans.

Managed Care Organizations Asuris Northwest Health Plan P.O. Box 91130 Mail Stop BR 325 Seattle, WA 98111 253/573-3248 Columbia United Providers 19120 SE. 34th Street, Ste. 201 Vancouver, WA 98683 360/449-8867 Community Health Plan of Washington 720 Olive Way, Ste. 300 Seattle, WA 98101 206/613-8940 Group Health Cooperative 521 Wall Street Seattle, WA 98121 206/448-6110 Premera Blue Cross P.O. Box 12890 Seattle, WA 98111-4890 800/869-7175 Molina Healthcare of Washington, Inc. (MHC) P.O. Box 1469 Bothell, WA 98041 800/869-7175 Regence Blue Shield P.O. Box 21267 Mail Stop BR 390 Seattle, WA 98111-3267 253/573-3248

F. STATE CONTACTS State Drug Program Administrator Siri Childs, Pharm D. Pharmacy Research Specialist/Manager Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/586-2262 E-mail: [email protected] Agency address: http://wws2.wa.gov/dshs/maa Prior Authorization Contact Siri 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: 360/586-2262 E-mail: nguyen @dshs.wa.gov

Department of Social and Health Services Drug Utilization and Education Council Council Members Carol Cordy, M.D. Gerald Yorioka, M.D. Alvin Goo, Pharm.D. Steve Williams, Pharm.D. Patti Varley, ARNP, MN, CS Kenneth Wiscomb, PA-C Dana Hadfield, R.Ph.

Medical Advisor Melicent Whinston, M.D.

Resource Staff Nancy Donigan (Client Advocate)

WSU Staff Daniel Baker, Pharm.D., FASCP, FASHP Drug Information Center

Prescription Price Updating Tom Zuchlewski Pharmacy Program 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]

Medicaid Drug Rebate Contacts Manager: Connie Riddle, 360/725-1243 Technical: Rich Boyesen, 360/586-2593 Policy: Connie Riddle, 360/725-1243 Audits/Disputes: Connie Riddle, 360/725-1243 PA: Valerie Vertz, 360/725-1717

Claims Submission Contact Chris Johnson Claims Processing Manager Medical Assistance Administrator, DSHS P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1067 F: 360/586-4994 E-mail: [email protected]



Medicaid Managed Care Contact MaryAnne Lineblad Director Division of Program Support, MAA/DSHS P.O. Box 45530 Lacey, WA 98504-5530 T: 360/725-1786 F: 360/753-7315 E-mail: [email protected]

Mail Order Pharmacy Program To be implemented for fee-for-service clients in 2003-04.

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

Disease Management Program/Initiative Contact Alice Lind Managed Care Coordination Section Medical Assistance Administration, DSHS P.O. Box 45530 Olympia, WA 98504-45530 T: 360/725-1629 F: 360/753-7315 E-mail: [email protected]

Social and Health Services Department Officials Dennis Braddock Secretary Department of Social and Health Services PO Box 45010 Olympia, WA 98504 T: 360/902-7800 F: 360/902-7848 E-mail: [email protected] Doug Porter Assistant Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5500 T: 360/902-7807 F: 360/902-7855 E-mail: [email protected] (Vacant) DRI Medical Director Office of the Medical Director

P.O. Box 5506 Olympia, WA 98504-5506

Social and Health Services Department Medical Consultants Joan Baumgartner, MD Sam Salama, M.D. Nancy Anderson, M.D. Carolyn Coyne, M.D. Eric Houghton, M.D.

Department of Social and Health Services Title XIX Advisory Committee Janet Varon, Co-chair Executive Director, NoHLA 1820 East Pine Street, Ste. 322 Seattle, WA 98122 Robert Wardell, Co-chair 3815 N. Pearl Apt. 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 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, Ste. 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, Ste. 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, Ste. 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 DSHS Staff Members Debbie Meyer Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080

Pharmacy Drug Use Review Team Members Siri Childs, Pharm.D. 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, Ste. 1100 Seattle, WA 98121 T: 206/441-9762 F: 206/441-5863 E-mail: [email protected] Internet address: www.wsma.org Washington State Pharmacists Association Rod Shafer CEO 1501 Taylor Avenue, SW Renton, WA 98055-3196 T: 425/228-7171 F: 425/277-3897 E-mail: [email protected] Internet address: www.wsparx.org Washington Osteopathic Medical Association, Inc. Kathleen 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



State Board of Pharmacy Donald H. Williams Executive Director Department of Health 1300 Quince Street, SE P. O. Box 47860 Olympia, WA 98504-7860 T: 360/236-4825 F: 360/586-4359 E-mail: [email protected] Internet address: wws2.wa.gov/doh/hpqa-licensing/HPS4/Pharmacy/default.htm Washington State Hospital Association Leo F. Greenawalt President, CEO 300 Elliott Avenue W., Ste. 300 Seattle, WA 98119-4118 T: 206/281-7211 F: 206/283-6122 E-mail: [email protected] Internet address: www.wsha.org


National Pharmaceutical Council West Virginia-1

WEST VIRGINIA



Aged Blind/

Disabled


Disabled

Child Adult SFO





Nursing Facility Service � � � � � � � �



B. EXPENDITURES FOR DRUGS 2001 2002 Expended Recipients Expended Recipients TOTAL $253,163,196 266,778 $272,457,097 273,908 RECEIVING CASH ASSISTANCE, TOTAL $195,222,420 120,106 $205,598,570 113,800 Aged $50,162,902 22,265 $50,676,511 21,404 Blind/Disabled $129,883,613 61,332 $140,221,050 63,111 Child $1,120,726 8,089 $13,569 538 Adult $14,055,179 28,420 $14,687,440 28,747 MEDICALLY NEEDY, TOTAL $6,247,834 4,529 $6,544,451 4,605 Aged $525,697 475 $504,387 458 Blind/Disabled $4,745,795 2,713 $4,797,111 2,712 Child $4,888 14 $2,652 12 Adult $971,454 1,327 $1,240,301 1,423 POVERTY RELATED, TOTAL $28,111,559 106,230 $36,538,255 135,209 Aged $477,716 275 $519,840 282 Blind/Disabled $2,877,606 1,356 $3,889,793 1,572 Child $23,597,221 97,477 $30,296,278 125,627 Adult $1,159,016 7,122 $1,832,344 7,728 TOTAL OTHER EXPENDITURES/RECIPIENTS $23,581,383 35,913 $23,775,822 20,294

Source: West Virginia Medicaid Statistical Information System, FY 2001 and FY 2002.


2-West Virginia National Pharmaceutical Council

C. ADMINISTRATION Bureau for Medical Services, Department of Health & Human Resources.

D. PROVISIONS RELATING TO DRUGS Benefit Design Drug Benefit Product Coverage: Products covered with restrictions (i.e., quanity limits): disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products covered as DME: total parenteral nutrition. Prior authorization required for: prescribed insulin (pens); branded NSAIDs, Retin-A for adults; ED drugs; proton pump inhibitors; drugs to treat impotency; most injectable medications; and non-preferred drugs. Products not covered: cosmetics; fertility drugs; experimental drugs; 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; anticonvulsants; anti-depressants; antidiabetic drugs; antilipemic agents; antihistamine drugs; antipsychotics; anxiolytics, sedatives, and hypnotics (partial coverage); cardiac drugs; contraceptives; prescribed cold mediation (partial coverage); ENT anti-inflammatory agents; estrogens; hypotensive agents; and thyroid agents. Therapeutic categories requiring prior authorization: analgesics, antipyretics, NSAIDs; antibiotics; anticoagulants; chemotherapy agents; growth hormones; prescribed smoking deterrents; misc. GI drugs; and sympathominetics (adrenergic). Therapeutic categories not covered: anorectics; and hair growth products. Coverage of Injectables: Injectable medicines reimbursable under the Prescription Drug Program when used in home health care and extended care facilities, and through both the Prescription Drug Program and physician payment in physician offices; most require prior approval. Vaccines: Vaccines reimbursable as part of CHIP and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization Formulary: Closed formulary (as of 1/17/03). Restrictions include preferred products and prior authorization. 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.

Prescribing or Dispensing Limitations All covered outpatient drugs are reimbursed up to a 34-day supply and five 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 one refill.

3. Sedatives and hypnotics are covered for a 30-day supply and one refill.

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 = AWP - 12%. 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 “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment varies - $0.50 to $2.00. Exclusions include: 1. Family planning services and supplies. 2. Prescriptions originating with the Early and Periodic

Screening, Diagnosis and Treatment Program. 3. Nursing home residents. 4. Children under the age of 18 years. Cognitive Services: Does not pay for cognitive services.



E. USE OF MANAGED CARE Approximately 50,000 unduplicated Medicaid recipients were enrolled in MCOs in 2002. Beneficiares in managed care receive pharmacy services through the State.

Managed Care Organizations Carelink Health Plans Michelle Coon Manager of Government Programs 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 Tom Samol, Director/Government Programs 52160 National Road, East St. Clairsville, OH 43950 T: 740/695-3585 F: 740/695-5297 Physician Assured Access System (PAAS) Shelley Baston, Director Office of Medicaid Managed Care Bureau for Medical Services 350 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-1700 F: 304/558-4398

F. STATE CONTACTS State Drug Program Administrator Peggy A. King, R.Ph. Director, Office of Pharmacy Services WV Department of Human Services 350 Capitol Street, Rm 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected] Internet address: www.wvdhhr.org/bma

Department of Health & Human Resources Officials Sandra Joseph, M.D. Medical Director Division of Medical Care West Virginia Department of Human Services 350 Capitol St., Rm 251 Charleston, WV 25301-3707

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]

Pharmaceutical and Therapeutics Committee Kevin W. Yingling, R.Ph., M.D. Steve R. Matulis, M.D. 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. Tom Harwood, PA-C Barbara Koster, M.S.N., R.N.C. – A.N.P.

DUR Contact Vicki M. Cunningham, R.Ph. DUR Coordinator Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected]

Medicaid DUR Board Steven C. Judy, R.Ph. Kevin W. Yingling, M.D. 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. (Chairperson) 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., Ph.D. James M. Bennett, M.D. Kerry Sitzinger, R.Ph. George Bryant, PA-C Daniel Dickman, M.D.

Prescription Price Updating Becky Garrigan PBM Account Manager ACS, Inc. 365 Northridge Rd. Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8592



F: 770/730-5198 E-mail: [email protected]

Medicaid Drug Rebate Contacts Technical: Gail Goodnight, R.Ph., 304/558-1700 Policy: Peggy A. King, 304/558-1700 Rebate: Gail Goodnight, R.Ph., 304/558-1700

Claims Submission Contact Becky Garrigan 770/352-8592

Medicaid Managed Care Contact Shelley Baston 304/558-1700


Disease Management/Patient Educated Programs Disease/Medical State: Diabetes Program Name: WV Health Initiative Project Program Manager: Bureau of Medical Services

Disease Management Initiative/Program Contact Vicki M. Cunningham, R.Ph. 304/558-1700

Physician-Administered Drug Program Contact Barbara White West Virginia Department of Human Services 350 Capitol St., Rm 251 Charleston, WV 25301-3707 304/558-1700

Medical Services Fund Advisory Council 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. Larry Robertson G. Anne Cather, M.D. Chris Cutis Fred Booth

Executive Officers of State Medical and Pharmaceutical Societies 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 West Virginia Pharmacists Association Richard D. Stevens, Executive Director 2003 Quarrier St. Charleston, WV 25311-2212 T: 304/344-5302 F: 304/344-5316 E-mail: [email protected] West Virginia Society of Osteopathic Medicine Charlotte Ann Cales Pulliam Executive Director P.O. Box 5266 Charleston, WV 25361-0266 T: 304/345-9836 F: 304/345-9865 E-mail: [email protected] Internet address: www.wvsominc.org State Board of Pharmacy William T. Douglas, Jr. Executive Director 236 Capitol Street Charleston, WV 25301 T: 304/558-0558 F: 304/558-0572 E-mail: [email protected] Internet address: www.wvbop.com/main.htm West Virginia Hospital Association Steven J. Summer President 100 Association Drive Charleston, WV 25311 T: 304/344-9744 F: 304/344-9745 E-mail: [email protected] Internet address: www.wvha.com






National Pharmaceutical Council Wisconsin-1

WISCONSIN



Aged Blind/

Disabled


Disabled

Child Adult (SFO)








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $349,558,072 267,417 $389,373,521 262,238 RECEIVING CASH ASSISTANCE TOTAL $180,127,927 110,356 $195,261,895 107,145 Aged $19,174,287 12,438 $20,208,955 11,879 Blind/Disabled $157,699,143 74,817 $171,261,361 73,646 Child $1,094,362 12,055 $1,321,948 11,038 Adult $2,160,135 11,046 $2,469,631 10,582 MEDICALLY NEEDY, TOTAL $27,283,734 16,284 $29,447,709 16,508 Aged $10,985,233 6,303 $12,300,642 6,621 Blind/Disabled $15,917,838 4,963 $16,741,054 5,048 Child $305,458 4,038 $327,772 3,962 Adult $75,205 980 $78,241 877 POVERTY RELATED, TOTAL $3,699,695 22,860 $7,821,202 24,252 Aged $398,786 596 $392,139 593 Blind/Disabled $1,414,102 756 $4,837,078 1,794 Child $1,447,789 16,197 $2,164,005 17,197 Adult $439,018 5,311 $427,980 4,668 TOTAL OTHER EXPENDITURES/RECIPIENTS* $138,446,716 117,917 $156,842,715 114,333

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 data are preliminary and subject to change. Source: CMS, MSIS Report, FY 2000, and FY 2001.


2-Wisconsin National Pharmaceutical Council

C. ADMINISTRATION State Department of Health and Family Services.

D. PROVISIONS RELATING TO DRUGS Benefit Design Formulary: Open formulary. General exclusions include progesterone for PMS; topical minoxidil; legend prenatal vitamins; fertility enhancement drugs; experimental drugs; and impotence treatment drugs. Prior Authorization: Prior authorization is required on the following drugs: Schedule III and IV stimulants; human growth hormone; enteral nutrition products; Cerezyme; Mupirocin; fertility enhancing drugs; anti-obesity drugs; alitretinoin gel; brand-name ACE inhibitors; brand-name NSADs; and medically necessary drugs with no rebate agreement. Drug Utilization Review: Implementation of PRODUR system completed in 2001. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in physician offices. Vaccines: Vaccines provided plus reimbursement for administrative fee as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable. 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.

Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications.

Dollar Limits: None.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.88 to a maximum of $40.11, effective 7/1/98. Extra fees for unit dose pharmacies. Incremental increases based on pharmaceutical care services being provided. Maximum of two dispensing fees per month, per prescription. Ingredient Reimbursement Basis: EAC = AWP–11.25%. Prescription Charge Formula: Reimbursement at the lowest of:

AWP-11.25% plus dispensing fee; Maximum Allowable Cost (MAC) plus dispensing fee; or providers usual and customary.

Maximum Allowable Cost: State imposes State-specific limits on generic drugs. Override requires hand written “Brand Medically Necessary” by the prescriber. Incentive Fee: None. Cognitive Services: Provides an expanded dispensing fee for cognitive services. Patient Cost Sharing: All legend drugs are subject to a $1.00 copay, limited to $5.00 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.

E. USE OF MANAGED CARE Approximately 321,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans. (Some mental health plans carve out pharmaceutical benefits.)

Managed Care Organizations Atrium Health Plan, Inc. c/o Group Health Cooperative of Eau Claire P.O. Box 3217 Eau Claire, WI 54702-3217 Dean Health Plan, Inc. P.O. Box 56099 Madison, WI 53705 Group Health Cooperative of Eau Claire P.O. Box 3217 Eau Claire, WI 54702 Group Health Cooperative of South Central Wisconsin P.O. Box 44971 Madison, WI 53744-4971 Health Tradition HealthPlan P.O. Box 188 LaCrosse, WI 54602-0188 Managed Health Services Insurance Corp. 1205 S. 70th Street, Ste. 500 West Allis, WI 53214 MercyCare Insurance Company P.O. Box 2770 Janesville, WI 53547-2770 Network Health Services c/o Managed Health Services 1205 S. 70th Street, Ste. 500 West Allis, WI 53214


National Pharmaceutical Council Wisconsin-3

Security Health Plan of Wisconsin, Inc. P.O. Box 8000 Marshfield, WI 54449 United Healthcare 10701 W. Research Drive Milwaukee, WI 53226 Unity Health Plans Insurance Corporation 840 Carolina Street Sauk City, WI 53583-1374 Valley Health Plan 2270 EastRidge Center P.O. Box 3128 Eau Claire, WI 54702-3128 Wraparound of Milwaukee 9501 Watertown Plank Rd. Milwaukee, WI 53226

F. STATE CONTACTS Pharmacy Practices Consultant Vacant Pharmacy Practices Consultant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-3753 F: 608/266-1096 E-mail: Vacant Agency Internet Address: www.dhfs.state.wi.us/medicaid

Prior Authorization Contact Rita Hallett, M.A., R.N. Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 608/267-0938 E-mail: [email protected]

DUR Contact Michael A. Mergener, R.Ph., Ph.D. Chief Pharmacist APS Healthcare 10 East Duty St., Ste. 210 Madison, WI 53703 T: 608/258-3348 F: 608/258-3359

Wisconsin Drug Utilization Review Committee Robert M. Breslow, R.Ph. Ward Brown, M.D. Mark E. Buhler, R.Ph.

Daniel R. Erickson, M.D. Barry Hess, R.Ph. Nancy E. Ness, M.D. Pamela Poetz, R.Ph. Lee C. Vermeulen, Jr., R.Ph., M.S. Mary Jo Willis, M.S., N.P.

Prescription Price Updating First Databank 1111 Bayhill Dr., Ste. 350 San Bruno, CA 94066 T: 800/633-3453 F: 415/588-6867

Medicaid Drug Rebate Contacts Audits: Barbara Evans, R.N.,608/261-7783 Disputes: Ellen Orsburne, 608/267-7939 Technical: Randy Zirk, 608/266-8532 Policy: Rita Hallett, 608/267-0938

Claims Submission Contact Mark Gajewski Account Director EDS 6406 Bridge Rd. Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567

Medicaid Managed Care Contact Angela Dombrowski, Director Department of Health and Family Services Division of Healthcare Financing Bureau of Managed Health Care Programs 1 West Wilson Madison, WI 53701 T: 608/266-1935 F: 608/261-7792


Physician-Administered Drug Program Contact Richard Carr, M.D. Chief Medical Officer Division of Healthcare Financing One West Wilson Street Madison, WI 53701 608/266-0957

Health and Family Services Department Officials Helene Nelson Secretary Department of Health and Family Services State Office Building One West Wilson Street Madison, WI 53701 T: 608/266-8922


4-Wisconsin National Pharmaceutical Council

F: 608/266-7882 Mark P. Moody Administrator Division of Health Care Financing One West Wilson Street P.O. Box 309 Madison, WI 53701 T: 608/266-8922 F: 608/266-1096

Executive Officers of State Medical and Pharmaceutical Societies State Medical Society of Wisconsin John Patchett, J.D. Executive Vice President 330 East Lakeside, Box 1109 Madison, WI 53701-1109 T: 608/257-6781 F: 608/442-3802 E-mail: [email protected] Internet address: wisconsinmedicalsociety.org Wisconsin Association of Osteopathic Physicians & Surgeons Robert J. Finnegan, CAE Executive Director 34615 Road E. Oconomowoc, WI 53066-2543 T: 414/567-0520 F: 262/567-0520 E-mail: [email protected] Wisconsin Pharmacists Association Christopher J. Decker Executive Vice President 701 Heartland Trail Madison, WI 53717 T: 608/827-9200 F: 608/827-9292 E-mail: [email protected] Wisconsin Pharmacy Exam Board Deanna Zychowski, Director Bureau of Health Professions P.O. Box 8935 1400 E. Washington Ave. Madison, WI 53708 T: 608/266-2812 F: 608/261-7083 E-mail: [email protected] Internet address: www.drl.state.wi.us Wisconsin Health and Hospital Association Steve Brenton, CEO 5721 Odana Road Madison, WI 53719-1289 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


National Pharmaceutical Council Wyoming-1

WYOMING



Aged Blind/

Disabled


Disabled

Child Adult SFO








B. EXPENDITURES FOR DRUGS 2000 2001** Expenditures Recipients Expenditures Recipients TOTAL $27,233,795 33,342 $31,881,860 36,704 RECEIVING CASH ASSISTANCE, TOTAL $11,778,585 12,682 $12,791,205 12,347 Aged $1,196,354 739 $1,358,763 746 Blind / Disabled $8,433,959 3,956 $8,964,573 3,913 Child $835,376 4,976 $948,764 4,687 Adult $1,312,896 3,011 $1,519,105 3,001 MEDICALLY NEEDY, TOTAL $0 0 $0 0 Aged $0 0 $0 0 Blind / Disabled $0 0 $0 0 Child $0 0 $0 0 Adult $0 0 $0 0 POVERTY RELATED, TOTAL $2,237,285 12,592 $2,817,574 14,975 Aged $11,271 19 $13,038 15 Blind / Disabled $53,863 42 $20,761 28 Child $1,871,910 10,415 $2,437,127 12,689 Adult $300,241 2,116 $346,648 2,243 TOTAL OTHER EXPENDITURES/RECIPIENTS* $13,217,925 8,068 $16,273,081 9,382

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. Source: CMS, MSIS Report, FY 2000, and FY2001.


2-Wyoming National Pharmaceutical Council

C. ADMINISTRATION Department of Health, Director’s Office.

D. PROVISIONS RELATING TO DRUGS 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 and experimental drugs. Over-the-Counter Product Coverage: Products covered: Analgesics; antacids; antidiarrheal; antihistimines; antitussive; contraceptives; food thickeners, insulin, Laxatives; nutrition products; pediatric and prenatal vitamins; sodium chloride; supplements; topical antibiotics, antifungals, antiparasitics; vaginal anti-infectives; artificial tears; bronchodiolators; misc. topical agents; and cough and cold products. Coverage of Injectables: Injectable medicines reimbursable through physician payment when used in home health care, extended care facilities and physician offices. 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. Unit Dose: Unit dose packaging not reimbursable. Formulary/Prior Authorization Formulary: Open formulary. General exclusions include anorexants, except amphetamines and derivatives which are used for narcolepsy and hyperkinetic states; products to stimulate hair growth. Prior authorization implemented 10/1/02. Prior Authorization: State currently has a formal prior authorization procedure with review/appeal process.

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 meets bimonthly.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $5.00, effective 7/01. Ingredient Reimbursement Basis: EAC = AWP – 11%. 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, 6 drugs are included on the State’s MAC list. Incentive Fee: None. Patient Cost Sharing: Copayment is $2.00. The following recipients or products are exempt from the copayment: − Pregnant women − Foster care children − Home and community based waiver recipients − Eligible recipients under age 21 − Patients residing in nursing homes − Family planning products Cognitive Services: Does not pay for cognitive services.

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

F. STATE CONTACTS State Drug Program Administrator Roxanne Homar, R.Ph. State Pharmacist Community and Family Health Division Primary Case Services 2424 Pioneer Ave, Suite 100 Cheyenne, WY 82001 T: 307/777-6032 F: 307/777-6964 Email: [email protected]


National Pharmaceutical Council Wyoming-3

Antoinette Brown Medicaid Pharmacist Department of Health 2424 Pioneer Ave., Suite 100 Cheyenne, WY 82001 T: 307/777-6016 F: 307/777-7085

Department of Health Officials Deb Fleming, Ph.D. Director Department of Health 117 Hathaway Building 2300 Capitol Ave. Cheyenne, WY 82002-0710 T: 307/777-7656 F: 307/777-7439 Roxanne Homar, R.Ph. 307/777-6032

DUR Contact Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 T: 307/766-6750 F: 307/766-2953 E-mail: [email protected]

DUR Board Debra Devereaux, R.Ph. 307/766-6750 Becky Drnas, R.Ph. K-Mart Pharmacy 2450 Foothill Blvd. Rock Springs, WY 82901 307/362-7990 Dawn Ford, R.Ph. 2022 Reagan Ave. Rock Springs, WY 82901 307/382-5437 Roxanne Homar, R.Ph. (ex-officio) 307/777-6032 Kathryn Kohler, M.D. Women’s Clinic 204 McCollum Drive, Suite 104 Laramie, WY 82070 307/745-8991

Leonard Kosirog, R.Ph. 3095 Galloway Riverton, WY 82501 307/856-6993 Scott Johnson, M.D. P.O. Bos 100 Wright, WY 82732 307/464-0422 George Zaharas, R.Ph. Town and Country Pharmacy 514 S. Greeley Cheyenne, WY 82009 307/634-6662 Stephen Brown, M.D. 2521 E. 15th St. Casper, WY 82609 307/234-3638 Michael Carpenter, PA-C 1121 Washington Blvd. Newcastle, WY 82701 307/746-3582 William Harrison, M.D. Cheyenne Medical Specialists 5050 Powderhouse Road Cheyenne, WY 82009 307/638-6820 Kendra Grande, R.Ph. University of Wyoming School of Pharmacy Drug Information P.O. Box 3375 Laramie, WY 82071 307/766-6988 Richard L. Johnson, R.Ph. Emissary Pharmacy 401 East Collins Drive Casper, WY 82601 800/281-2026 Cory L. Moss, Pharm.D. University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071 307/766-6128 Linda G. Martin, R.Ph. (ex-officio) University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 307/766-6128


4-Wyoming National Pharmaceutical Council

Prescription Price Updating First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 800/633-3453 F: 650/872-4510

Medicaid Drug Rebate Contacts Suzie Gambell ACS P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405

Claims Submission Contact ACS Northridge Center 1, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459

Disease Management Program/Initiative Contact Roxanne Homar 307/777-6032

Mail Order Pharmacy Program None Physician-Administered Drug Program Contact Antoinette Brown 307/777-6016

Executive Officers of State Medical and Pharmaceutical Societies Wyoming State Medical Society Stephen Brown, M.D. President 1920 Evans P.O. Box 4009 Cheyenne, WY 82003-4009 T: 307/635-2424 F: 307/632-1973 E-mail: [email protected] Internet address: www.wyomed.org Wyoming Pharmacists Association Keith Sande, R.Ph. 1022 Ponderosa Court Powell, WY 82435-4100 T: 307/754-4663 F: 307/754-4145 E-mail: [email protected] Internet address: www.wpha.net

State Board of Pharmacy Jim T. Carder Executive Director 1720 S. Poplar Street, Suite 4 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 Cheyenne, WY 82003 T: 307/632-9344 F: 307/632-9347 E-mail: [email protected] Internet address: www.wyohospitals.com


National Pharmaceutical Council A-1

Appendix A: State and Federal Medicaid Contacts


A-2 National Pharmaceutical Council



STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2002

ALABAMA Louise F. Jones Pharmacy Program Manager 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

ALASKA Dave Campana, R.Ph. Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected]

ARIZONA Phyllis Biedess Director Arizona Health Care Containment System 801 E. Jefferson Street Phoenix, AZ 85034 T: 602/417-4680 F: 602/252-6536 E-mail: [email protected]

ARKANSAS Suzette Bridges, P.D., Administrator Prescription Drug Program Department of Human Services Division of Medical Services P.O. Box 1437, Slot 415 Little Rock, AR 72203 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

CALIFORNIA J. Kevin Gorospe, Pharm.D. Chief, Medi-Cal Pharmaceutical Section California Department of Health Services Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/657-4213 F: 916/654-0513 E-mail: [email protected] Internet Address: www.dhs.ca.gov

COLORADO Dima Ahram, Pharm.D. Department of Health Care Policy & Financing 1575 Sherman Street, 5th Floor Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: [email protected]

CONNECTICUT Evelyn A. Dudley Pharmacy Program Manager Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] Internet Address: ww.ctmedicalassistanceprogram.com

DELAWARE Philip Soulé Deputy Director/Medicaid Department of Health and Social Services 1901 N. Dupont Highway New Castle, DE 19720 T: 302/255-9501 F: 302/255-4425



DISTRICT OF COLUMBIA Donna Bovell, R.Ph. Pharmacist Consultant 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]

FLORIDA George Kitchens, Chief Pharmacy Bureau 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.fdhc.state.fl.us

GEORGIA Lori S. Garner, R.Ph., M.P.A., M.S. Director, Pharmacy Services Department of Community Health-Medicaid Division 2 Peachtree Street, N.W., 37th Floor Atlanta, GA 30303-3159 T: 404/656-4044 F: 404/656-8366 E-mail: [email protected] Internet Address: www.dch.state.ga.us

HAWAII Lynn Donovan, R.Ph. Pharmacy Consultant Med-Quest Division 601 Kamokila Boulevard, Room 506B P.O. Box 700190 Honolulu, HI 96709-0190 T: 808/692-8116 F: 808/692-8131

IDAHO Shawna Kittridge, R.Ph., M.H.S. Medicaid Drug Program Supervisor Department of Health and Welfare Division of Medicaid 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 T: 208/364-1956 F: 208/364-1864 E-mail: [email protected] Internet Address: ww2.state.id.us/dhw/medicaid/providers/pharmacy.htm

ILLINOIS Marvin L. Hazelwood Pharmacy and Ancillary Services Programs Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut St. Springfield, IL 62702 T: 217/782-5565 F: 217/524-7194 E-mail: [email protected] Internet Address: www.state.il.us/dpa

INDIANA Marc Shirley, R.Ph. Pharmacy Program Director Office of Medicaid Policy and Planning Indiana State Government Center South-Rm. W382 402 W. Washington Street Indianapolis, IN 46204-2739 T: 317/232-4343 F: 317/232-7382 E-mail: [email protected]

IOWA Susan L. Parker, Pharm.D. Pharmacy Consultant Division of Medical Services Bureau of Long Term Care Hoover State Office Bldg. Des Moines, IA 50319 T: 515/281-3002 F: 515/281-6230 E-mail: [email protected]



KANSAS Mary H. Obley, Pharmacist Health Care Policy Division Kansas Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785/296-8406 F: 785/296-4813 E-mail: [email protected] Internet Address: www.srskansas.org

KENTUCKY Troy Koch, Pharm.D., M.B.A. 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]

LOUISIANA Mary J. Terrebonne, Pharm. D. Pharmacy Program 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

MAINE Vacant Director of Pharmacy Department of Human Services Bureau of Medical Services 442 Civic Center Drive Augusta, ME 04333-0011 T: 207/287-4018 F: 207/287-8601

MARYLAND Frank Tetkoski Pharmacy Services Manager Division of Pharmacy and Clinic Services 201 West Preston Street, Room 205 Baltimore, MD 21201 T: 410/767-1455 F: 410/333-7049 E-mail: [email protected] Internet Address: www.dhmh.state.md.us

MASSACHUSETTS Paul L. Jeffrey, Director of Pharmacy Division of Medical Assistance 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 MICHIGAN James Kenyon, R.Ph. Pharmacist Consultant MDCH/ Medical Services Administration 400 South Pine Street Lansing, MI 48933 T: 517/335-5265 F: 517/335-5294 E-mail: [email protected] Internet Address: www.Michigan.gov/mdch

MINNESOTA Cody Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet Address: www.dhs.mn.us



MISSISSIPPI Ricky R. Malloy, R.Ph. Pharmacy Bureau Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201-1399 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet Address: www.dom.state.ms.us

MISSOURI Susan McCann, R.Ph. Pharmaceutical Consultant Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6963 F: 573/526-4650 E-mail: [email protected]

MONTANA Dan Peterson Pharmacy Program Officer Department of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2951 T: 406/444-2738 F: 406/444-1861 E-mail: [email protected] Internet Address: www.dphhs.state.mt.us

NEBRASKA Dyke Anderson, R.Ph. Pharmaceutical 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

NEVADA 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]

NEW HAMPSHIRE Margaret A. Clifford Pharmacy Services Administrator Office of Health Planning & Medicaid 129 Pleasant Street, Annex Concord, NH 03301-3857 T: 603/271-4210 F: 603/271-4376 E-mail: [email protected] Internet Address: www.dhhs.state.nh.us

NEW JERSEY Carl D. Tepper, R.Ph. Chief, Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625-0712 T: 609/588-2744 F: 609/588-3889 E-mail: [email protected]

NEW MEXICO Neal Solomon, M.P.H., R.Ph. Drug Program Administrator Medicaid Assistance Division P. O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]



NEW YORK Mark-Richard Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Bureau of Program Guidance Office of Medicaid Management NYS Department of Health 99 Washington Ave., Room 606 Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Internet Address: www.health.state.ny.us

NORTH CAROLINA Sharman C. Leinwand Pharmacy Program Manager Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive 2511 Mail Service Center Raleigh, NC 27699-2511 T: 919/857-4034 F: 919/715-1255 E-mail: [email protected] Internet Address: www.dhhs.state.nc.us/dma

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. 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]

OHIO Robert P. Reid, R.Ph. Administrator, Pharmacy Services Unit Ohio Department of Job and Family Services Bureau of Health Plan Policy 30 East Broad St., 27th Floor Columbus, OH 43615-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

OKLAHOMA Nancy Nesser Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln Boulevard, Suite 124 Oklahoma City, OK 73105-9901 T: 405/522-7325 F: 405/522-3240 E-mail: [email protected] Internet Address: www.ohca.state.ok.us

OREGON 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.omap.hr.state.or.us

PENNSYLVANIA Joseph E. Concino, R.Ph. Chief, Pharmacy Services Section Office of Medical Assistance Programs P.O. Box 8046 Harrisburg, PA 17105 T: 717/772-6341 F: 717/772-6366 E-mail: [email protected] Internet Address: www.dpw.state.pa.us/omap

RHODE ISLAND Paula J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected]



SOUTH CAROLINA James M. Assey, R.Ph., Division Director Division of Health Services S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/898-4517 E-mail: [email protected] Internet Address: www.dhhs.state.sc.us

SOUTH DAKOTA Mark Petersen, R.Ph. Pharmacy Consultant Department of Social Services Office of Medical Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

TENNESSEE H. Leo Sullivan, D.Ph. Director of Pharmacy Services Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/253-5481 E-mail: [email protected] Internet Address: www.state.tn.us/health/tenncare

TEXAS Curtis Burch, R.Ph. Director, Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/338-6992 F: 512/794-5190 E-mail: [email protected] Internet Address: www.hhsc.state.tx.us/hcf/vdp/vdpstart.html

UTAH RaeDell Ashley, R.Ph. Pharmacy Director Division of Health Care Financing Utah 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]

VERMONT Pat House, Operations Manager Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201 T: 802/241-2156 F: 802/241-2974 E-mail: [email protected]

VIRGINIA David B. Shepherd, R.Ph. Pharmacy Consultant Division of Program Operations Department of Medical Assistance Services 600 East Broad Street, Ste 1300 Richmond, VA 23219 T: 804/786-2196 F: 804/786-0973 E-mail: [email protected] Internet Address: www.dmas.state.va.us

WASHINGTON Siri A. Childs, Pharm D. Pharmacy Research Specialist/Manager Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1564 F: 360/586-2262 E-mail: [email protected] Internet Address: wws2.wa.gov/dshs/maa



WEST VIRGINIA Peggy A. King, R.Ph. Director, Office of Pharmacy Services WV Department of Human 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

WISCONSIN Vacant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-3753 F: 608/266-1096 E-mail: not available Internet Address: www.dhfs.state.wi.us/medicaid

WYOMING Roxanne Homar, R.Ph. State Pharmacist 2424 Pioneer Avenue, Suite 100 Cheyenne, WY 82001 T: 307/777-6032 F: 307/777-6964 E-mail: [email protected]



DUR CONTACT INFORMATION, 2002

ALABAMA Contracted DUR

State Contact Louise F. Jones Pharmacy Program Manager 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 Not Available

ALASKA Contracted DUR

State Contact Dave Campana, R.Ph. Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 T: 907/334-2425 F: 907/561-1684 E-mail: [email protected]


ARIZONA DUR is conducted at the plan level.

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

ARKANSAS Contracted DUR

State Contact Pamela Ford Pharmacist II Arkansas Department of Human Services Division of Medical Services Pharmacy Program P.O. Box 147, Slot 415 Little Rock, AR 72203 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

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]

CALIFORNIA In-House DUR

State Contact Vic Walker, R.Ph. B.C.P.P. Senior Consulting Pharmacist California Department of Health Services Medi-Cal Policy Division 714 P Street, Rm. 1540 Sacramento, CA 95814 T: 916/657-0785 F: 916/654-0513 E-mail: [email protected]



COLORADO In-House DUR

State Contact Dima Ahram, Pharm.D. Deptartment of Health Care Policy and Financing 1575 Sherman St., 5th Floor Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: [email protected]

CONNECTICUT Contracted DUR

State Contact James Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services 25 Sigourney Street Hartford, CT 06106 T: 860/424-5150 F: 860/424-5206 E-mail: [email protected]

Contractor Michelle Lester-Bradley Account Manager ACS State Healthcare 866/322-5960 Ext. 5139 E-mail: [email protected]

DELAWARE Contracted DUR

State Contact Cynthia Denemark Pharmacist Consultant EDS 248 Chapman Road, Suite 200 Newark, DE 197029720 T: 302/453-8453 F: 302/454-7603 E-mail: [email protected]

Contractor Cynthia Denemark Pharmacist Consultant EDS

DISTRICT OF COLUMBIA In-House DUR

State Contact Donna Bovell, R.Ph. Pharmacy Consultant 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]

FLORIDA Contracted DUR

State Contact Jerry F. Wells Pharmacy Program Manager Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected]

Contractor Rita Brown DUR Coordinator Florida Pharmacy Association 610 N. Adams Street Tallahassee, FL 32301 T: 850/222-2400 F: 850/561-6758



GEORGIA In-House DUR

State Contact Jean Cox, R.Ph. Drug Utilization/Prior Approval Coordinator GA Dept. of Community Health Division of Medical Assistance 2 Peachtree St. NW, 37th Floor Atlanta, GA 30303-3159 T: 404/657-7241 F: 404/656-8366 E-mail: [email protected]

HAWAII In-House DUR

State Contact Kathleen Kang-Kaulupali DUR Coordinator Med-Quest Division P.O. Box 700190 Honolulu, HI 96709-0190 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 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 208/364-1821 E-mail: [email protected]

Contractor Vaughn Culbertson, Pharm.D. DUR Coordinator Idaho State U. - College of Pharmacy Campus Box 8356 Pocatello, ID 83209-8356 T: 208/236-4385 F: 208/236-4482 E-mail: [email protected]

ILLINOIS In-House DUR

State Contact Marvin L. Hazelwood, Manager Pharmacy and Ancillary Services Program Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut Street Springfield, IL 62702 T: 217/524-5565 F: 217/524-7194

INDIANA Contracted DUR

State Contact Karen Clifton DUR Board Secretary Office of Medicaid Policy and Planning Indiana State Government Center South-Room W382 402 West Washington Street Indianapolis, IN 46204 T: 317/232-4391 F: 317/232-7382 E-mail: [email protected]

Contractor ACS E-mail: [email protected]



IOWA Contracted DUR

State Contact Julie Kuhle, R.Ph. DUR Coordinator Iowa Pharmacy Association 8515 Douglas, Ste. 16 Des Moines, IA 50322 T: 515/270-0713 F: 515/270-2979

Contractor Julie Kuhle, R.Ph. DUR Coordinator Iowa Pharmacy Association

KANSAS Contracted DUR

State Contact Mary H. Obley 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: 785/296-8406 F: 785/296-4813 E-mail: [email protected]

Contractor New Contract Pending

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]

Contractor In-house DUR with data obtained from outside vendor - Unisys

LOUISIANA Contracted DUR

State Contact Mary J. Terrebonne, Pharm.D. Pharmaceutical Program 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 Dan Scholl Pharmacy Director Unisys 8591 United Plaza Blvd., Ste.300 Baton Rouge, LA 70809 T: 225/237-3208 F: 225/237-3334 E-mail: [email protected]



MAINE Contracted DUR

State Contact Vacant Director of Pharmacy DHS – Bureau of Medical Services 442 Civic Center Drive Augusta, ME 04333-0011 T: 207/287-4018 F: 207/287-8601

Contractor GHS Data Management P.O. Box 1090 Augusta, ME 04332 T: 207/622-7153 F: 207/623-5125

MARYLAND Contracted DUR

State Contact Judy Geisler Pharmacist Consultant DHMH-Office of Health Services Division of Pharmacy and Clinical Services 201 W. Preston St., Rm. 208A Baltimore, MD 21201 T: 410/787-1455 F: 410/333-7049 E-mail: [email protected]

Contractor Contact Judy Geisler Pharmacist Consultant

MASSACHUSETTS Contracted DUR

State Contact Paul Jeffrey Director of Pharmacy Division of Medical Assistance 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210-5865 E-mail: [email protected]

Contractor Paul L. Jeffrey Director of Pharmacy

MICHIGAN Contracted DUR

State Contact Mary Sandusky, R.Ph. Pharmacist Consultant MDCH/Medical Services Administration 400 S. Pine Street Lansing, MI 48933 T: 517/335-5280 F: 517/335-7813 E-mail: [email protected]

Contractor First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060

MINNESOTA In-House DUR

State Contact Mary Beth Reinke, Pharm.D. DUR Coordinator Minnesota Dept. of Human Services 444 Lafayette Rd. St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected]



MISSISSIPPI Contracted DUR

State Contact Rickey R. Malloy Pharmacy Bureau Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Ste. 801 Jackson, MS 39201-1399 T: 601/359-6296 F: 601/359-9555 E-mail: [email protected]

Contractor Tyrone Gibson, President Heritage Information Design 1550 Pumphrey Avenue Auburn, AL 36832 334/502-3262

MISSOURI Contracted DUR

State Contact Jayne Zemmer DUR Coordinator Div. of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6963 F: 573/526-4650 E-mail: [email protected]


MONTANA Contracted DUR

State Contact Mark Eichler, R.Ph. DUR Coordinator Mountain-Pacific Quality Health Foundation 3404 Cooney Drive Helena, MT 59602 T: 406/443-4020 F: 406/443-4585 E-mail: [email protected]

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, Ste. A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

Contractor Beth Wilson DUR Director Nebraska Pharmacists Association 6221 South 58th, Ste. A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected]



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. Health Info Design Auburn, AL 800/748-0130

NEW HAMPSHIRE Contracted DUR

State Contact Lisè Ferrand, R.Ph. Pharmaceutical Services Specialist Office of Health Planning & Medicaid 129 Pleasant Street, Annex Concord, NH 03301-3857 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected]

Contractor Clinical Manager First Health Services Corp. 17 Chenell Drive Concord, NH 03301 T: 603/224/2083 F : 603/224/6690

NEW JERSEY In-House DUR

State Contact Edward Vaccaro, R.Ph. Assistant Director Office of Utilization Management Division of Medical Assistance and Health Services Office of Health Service Administration P.O Box 712, Bldg. 11-A Trenton, NJ 08625-0712 T: 609/588-2726 F: 609/588-3889 E-mail: [email protected]

NEW MEXICO In-House and Contracted DUR

State Contact Neal Solomon, M.P.H., R. Ph. Drug Program Administrator Medical Assistance Bureau P.O. Box 2348 Sante Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]

Contractor UNM College of Pharmacy



NEW YORK In-House DUR

State Contact Michael Zegarelli DUR Manager Office of Medicaid Management NYS Dept. of Health 99 Washington Ave, Suite 601 Albany, NY 12210 T: 518/474-6866 F: 518/473-5332 E-mail: [email protected]

NORTH CAROLINA Contacted DUR

State Contact Sharman C. Leinwand Pharmacy Program Manager Division of Medical Assistance Department of Human Resources 1985 Umstead Drive 2511 Mail Services Center Raleigh, NC 27699-2511 T: 919/857-4034 F: 919/715-1255 E-mail: [email protected]

Contractor 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]

NORTH DAKOTA In-House DUR

State Contact Brendan K. Joyce, Pharm.D., R.Ph. 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 DUR

State Contact Jan Lawson DUR Administrator 30 East Broad Street, 31st Floor Columbus, OH 43266-0423 T: 614/466-9698 F: 614/466-2866

OKLAHOMA Contracted DUR

State Contact Nancy Nesser Medicaid Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln Blvd. Ste 124 Oklahoma City, OK 73105-9901 T: 405/522-7325 F: 405/522-3240 E-mail: [email protected]

Contractor Ronald Graham, Pharm.D. 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]



OREGON Contracted DUR

State Contact Mariellen Rich, R.Ph. Pharmacist Account Manager First Health Service Corporation 565 Union St., NE, Suite 205 Salem, OR 97310 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

Contractor Mariellen Rich, R.Ph. First Health Services Corporation

PENNSYLVANIA Contracted DUR

State Contact Office of Medical Assistance Programs P.O. Box 8046 Harrisburg, PA 17105 T: 717/772-6341 F: 717/772-6366

Contractor PRODUR: EDS RETRODUR: University of Maryland

RHODE ISLAND Contracted DUR

State Contact Paula Avarista, R.Ph. Chief of Pharmacy Departrment of Human Services 600 New Loudon Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected]


SOUTH CAROLINA In-House and Contracted DUR

State Contact Caroline Y. Sojourner, R.Ph. Deptartment Head, Pharmacy Services S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 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 Michael Jockheck, R.Ph. Pharmacy Consultant SD Department of Social Services 700 Governors Drive Pierre, SD 57501 605/773-6439 E-mail: [email protected]



TENNESSEE Contracted DUR

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 Walter Fitzgerald Professor of Pharmacy University of Tennessee College of Pharmacy 26 South Dunlap, Suite 202 Memphis, TN 38163 T: 901/448-2351 F: 901/448-3701 E-mail: [email protected]

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

TEXAS In-House DUR

State Contact Curtis Burch, R. Ph. Director, Vendor Drug Program Texas Health and Human Services Commision 1100 West 49th Street Austin, TX 78756-3174 T: 512/338-6922 F: 512/338-6910 E-mail: [email protected]

UTAH In-House DUR

State Contact Duane Parke DUR Director 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 Gloria Jacobs Operations Administrator Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 T: 802/241-2763 F: 802/241-2974 E-mail: [email protected]

Contractor EDS Fiscal Agent 312 Hurrican Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440



VIRGINIA In-House DUR

State Contact MaryAnn McNeil, R.Ph. Pharmacy Manager Deparment of Medical Asistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/783-2196 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: 360/586-2262 E-mail: [email protected]

WEST VIRGINIA Contracted DUR

State Contact Vicki M. Cunningham, R.Ph. DUR Coordinator Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected]

Contractor Robert Berringer, Pharm.D. Account Manager Heritage Information Systems 410 West Franklin St. Richmond, VA 23220 T: 804/644-8707 F: 804/644-8709 E-mail: [email protected]

WISCONSIN Contracted DUR

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

Contractor Same as State contact

WYOMING Contracted DUR

State Contact Debra Devereaux, R.Ph. DUR Coordinator, University of Wyoming-School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 T: 307/766-6750 F: 307/766-2953 E-mail: [email protected]

Contractor Same as State contact



CLAIMS SUBMISSION CONTACTS, 2002

ALABAMA Keith Hollis, Account Manager EDS 301 Technacenter Dr. Montgomery, AL 36117 334/215-0111

ALASKA Linda Walsh Systems Administrator Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/334-2441 F: 901/561-1684 E-mail: [email protected]

ARIZONA AHCCCS/DBF/CLMS Lori Petre, Claims Administrator 701 E. Jefferson Phoenix, AZ 85034 602/417-4547

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

CALIFORNIA EDS Federal Corp. P.O. Box 31029 Sacramento, CA 95813-4029 916/636-1000 Internet Address: www.medi-cal.ca.gov

COLORADO ACS, Inc. 600 17th Street Suite 600 North Denver CO 80202 T: 800/237-0757 F: 303/534-0439

CONNECTICUT Kevin Walsh EDS 100 Stanley Street New Britain, CT 06053 860/832-5858

DELAWARE Robert Cornutt System Manager EDS 248 Chapman Rd Newark, DE 19702 T: 302/453-8453 F: 302/454-7603

DISTRICT OF COLUMBIA Contact not provided

FLORIDA Kevin Whittington Clinical Program Coordinator ACS 2308 Killearn Center Blvd. Tallahassee, FL 32308 850/201-1418



GEORGIA Dustin Gruhlke Account Manager Express Scripts, Inc. 6625 W. 78th St., BL-0420 Bloomington, MN 55439 T: 952/837-7741 F: 952/837-7741 E-mail: [email protected]

HAWAII ACS P.O. Box 1220 Honolulu, HI 96807-1220 808/952-5570

IDAHO EDS P.O. Box 23 Boise, ID 83707 T: 208/395-2000 F: 208/395-2030

ILLINOIS Illinois Dept. of Public Aid 1001 North Walnut Street Springfield, IL 62702 T: 217/782-5565 F: 217524-7194 E-mail: [email protected]

INDIANA ACS E-mail: [email protected]

IOWA Mindy Ruby Claims Manager ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 x1108 F: 515/327-0945

KANSAS EDS 3600 SW Topeka Boulevard Suite 204 Topeka, KS 66611 785/274-5939

KENTUCKY Unisys Provider Services P.O. Box 2100 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

LOUISIANA Doug Hasty Project Manager Unisys 8591 United Plaza Blvd., Ste. 300 Baotn Rouge, LA 70809 T: 225/237-3391 F: 225/237-3334 E-mail: [email protected]

MAINE Marcia Pykare Data Processing Manager Goold Health Systems P.O. Box 1090 Augusta, ME 04332 T: 207/622-7153 F: 207/623-5125

MARYLAND 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: 410/333-7186 E-mail: [email protected]



MASSACHUSETTS ACS State Health Care 365 Northridge Road Atlanta, GA 30350 800/358-2381

MICHIGAN First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060

MINNESOTA Dwaine Voas MMIS Unit Supervisor Minnesota Dept. of Human Services 800 Minnehaha Avenue St. Paul, MN 51555

MISSISSIPPI Terry Childress Director of Systems Management Division of Medicaid Robert E. Lee Building 239 North Lamar St. Jackson, MS 39201-1399 T: 601/359-6075 F: 601/359-6048 E-mail: [email protected]

MISSOURI Jim Judge Claims Process Administrator Verzion 905 Weathered Rock Rd. Jefferson City, MO 65101 573/635-2434

MONTANA Kevin Quinn Executive Account Manager ACS, Inc. 34 N. Last Chance Gulch, Suite 200 Helena, MT 59601 T: 406/449-7693 F: 406/442-2819 E-mail: [email protected]

NEBRASKA Glenn Sharp Account Representative First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 804/527-3013 F: 804/290-4831

NEVADA First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 800/884-3238

NEW HAMPHSHIRE Farah Jiwa Account Manager First Health Services Corp 17 Chenell Drive Concord, NH 03301 603/224-2083 E-mail: [email protected]

NEW JERSEY Peter Ringel, Deputy Project Director Unisys 3705 Quakerbridge Rd., Suite 101 Trenton, NJ 08619 T: 609/588-6000 F: 609/584-8270 E-mail: [email protected]

NEW MEXICO ACS, Inc. 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350-2348 T: 770/352-8592 F: 770/730-5198

NEW YORK eMed NY Computer Sciences Corporation One CSC Way Rensselaer, NY 12144 T: 800/343-9000 E-mail: [email protected]



NORTH CAROLINA 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]

NORTH DAKOTA Brendan K. Joyce, Pharm. D., R.Ph. 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]

OHIO First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7682

OKLAHOMA Chris Shearier EDS 2401 N.W. 63rd Street, Suite 11 Oklahoma City, OK 73107 405/416-6794

OREGON Mariellen Rich, R.Ph. Pharmacist Account Manager First Health Services Corporation 565 Union St., NE, Suite 205 Salem, OR 97301 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

PENNSYLVANIA EDS 275 Grandview Avenue Camp Hill, PA 17011 (Calls to contractor must be made through State agency.)

RHODE ISLAND EDS 401/784-3879

SOUTH CAROLINA Rod Davis Bureau Chief, Bureau of Information Systems S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2610 E-mail: [email protected]

SOUTH DAKOTA Meredith Heerman SD Dept. of Social Services Claims Processing Supervisor 700 Governors Dr. Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

TENNESSEE Becky Garrigan PBM Account Manager ACS, Inc. Northridge Center One, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 800/334-5979 F: 800/793-2305 E-mail: [email protected]



TEXAS Laura Bagheri Manager, Pharmacy Resolutions Vendor Drug Program Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78756-3174 T: 512/338-6909 F: 512/794-6190 E-mail: [email protected]

UTAH Brenda Bryant, Manager Bureau of Medicaid 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]

VERMONT EDS 312 Hurricane Lane, Ste 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA MaryAnn McNeil, R.Ph. Pharmacy Manager Department of Medical Assistance 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/783-2196 F: 804/786-0973 E-mail: [email protected]

WASHINGTON Chris Johnson Claims Processing Manager Medical Assistance Administrator-DSHS P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1067 F: 360/586-4994 E-mail: [email protected]

WEST VIRGINIA Becky Garrigan PBM Account Manager ACS, Inc. 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352/8592 F: 770/730-5198 E-mail: [email protected]

WISCONSIN Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567

WYOMING ACS Northridge Center, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459



PRESCRIPTION PRICE UPDATING CONTACTS, 2002

ALABAMA Beverly R. Churchwell, Administrator Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5034 F: 334/353-7014 E-mail: [email protected]

ALASKA Dave Campana, R.Ph Pharmacy Program Manager Division of Medical Assistance 4501 Business Park Blvd., Suite 24 Anchorage, AK 99503 T: 907/273-3224 F: 907/561-1684 E-mail: [email protected]

ARIZONA Joan Terry DBF/CLMS/AHCCCS 701 E. Jefferson Phoenix, AZ 85034 602/417-7927

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

CALIFORNIA EDS Federal Corporation P.O. Box 31029 Sacramento, CA 95813-4029 916/636-1000

COLORADO First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

CONNECTICUT Ellen Arce EDS Federal Corp 100 Stanley Drive New Britain, CT 06053 860/832-5885

DELAWARE Cynthia Denemark Pharmacy Manager EDS 248 Chapman Road, Suite 200 Newark, DE 197029720 T: 302/453-8453 F: 302/454-7603 E-mail: [email protected]

DISTRICT OF COLUMBIA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

FLORIDA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578



GEORGIA Andrew Shim, Pharm.D. Clinical Program Manager Express Scripts, Inc. 6625 W 78th Street, BL0420 Bloomington, MN 55439 T: 952-837-5326 F: 952-837-7184 E-mail: [email protected]

HAWAII First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 800/633-3453

IDAHO Kaydeen Burkett, R. Ph. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid Bureau of Care Management 3380 Americana Terrace, Suite 140 Boise, ID 87320-0036 208/364-1826 E-mail: [email protected]

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

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

IOWA Sherey Swanson Deputy Account Manager ACS, Inc. P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 x1107 F: 515/327-0945

KANSAS Mary H. Obley Pharmacist Health Care Policy Division Kansas 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]

KENTUCKY Unisys Provider Services P.O. Box 2100 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

LOUISIANA 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]

MAINE Medispan

MARYLAND First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578

MASSACHUSETTS First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578



MICHIGAN First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

MINNESOTA First DataBank 1111 Bay Hill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

MISSISSIPPI Rickey R. Mallory Pharmacy Bureau Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Suite. 801 Jackson, MS 39201-1399 T: 601/359-6296 F: 601/369-4185 E-mail: [email protected]

MISSOURI First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

MONTANA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEBRASKA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEVADA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEW HAMPSHIRE Farah Jiwa Account Manager First Health Services Corp. 17 Chenell Drive Concord, NH 03301 T: 603/224-2083 E-mail: [email protected]

NEW JERSEY First DataBank, Inc. 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

NEW MEXICO Neal Solomon, M.P.H, R.Ph. Drug Program Administrator Medicaid Assistance Division P. O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]

NEW YORK Carl Cioppa, Pharm. D. Pharmacy Operations Manager Pharmacy Policy and Operations Office of Medicaid Management NYS Dept. of Health 99 Washington Ave., Suite 606 Albany, NY 12210 T: 518/486-3209 F: 518/473-5508 E-mail: [email protected]



NORTH CAROLINA Sharon Greeson, R.Ph. Pharmacy Programs Manager EDS 4905 Waters Edge Drive Raleigh, NC 27606 T: 919/816-4475 F: 919/816-4399 E-mail: [email protected]

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R. Ph. North Dakota Department of Human Services 600 East Boulevard Ave. Dept. 325 Bismark, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

OHIO First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

OKLAHOMA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 800/633-3453

OREGON Kathy Frankiln Customer Support Department First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T 650/588-5454 F: 650/588-4003 E-mail: [email protected]

PENNSYLVANIA First DataBank, Inc. 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 800/633-3453

RHODE ISLAND Paula J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6336 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

SOUTH DAKOTA Mark Petersen, R.Ph. Pharmacy Consultant Department of Social Services 700 Governors Drive Pierre, SD 57501 T: 605/773-3495 F: 605/773-5246 E-mail: [email protected]

TENNESSEE First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588/6867



TEXAS Martha McNeill, R.Ph. Director, Product and Prescriber Management Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78756-3174 T: 512/338-6965 F: 512/338-6462 E-mail: [email protected]

UTAH RaeDell Ashley, R.Ph. Pharmacy Director 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]

VERMONT Christine Dapkiewicz Drug Rebate Coordinator EDS 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA David B. Shepherd, R.Ph. Pharmacy Consultant Department of Medical Asisstance Services

WASHINGTON Tom Zuchlewski Medical Assistance Administration, DSHS P.O. Box 45510 Olympia, WA 98504-5510 T: 360/725-1837 F: 360/753-9152 E-mail: [email protected]

WEST VIRGINIA Becky Garrigan PBM Account Manager ACS, Inc. 365 Northridge Road Northridge Center, Suite 400 Atlanta, GA 30350 T: 770/352-8592 F: 770/730-5198 E-mail: [email protected]

WISCONSIN First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453 F: 650/827-4578

WYOMING First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 800/633-3453

600 East Broad Street, Suite 1300 Richmond, VA 23112 T: 804/786-8056 F: 804/786-0414 E-mail: [email protected]



MEDICAID DRUG REBATE CONTACTS, 2002

ALABAMA Gladys Gray, Associate Director Alabama Medicaid Agency 501 Dexter Avenue P.O. 5624 Montgomery, AL 36103-5624 334/242-2323 E-mail: [email protected]

ALASKA Peter Yan Accountant Division of Medical Assistance 4501 Business Park Blvd., Ste. 24 Anchorage, AK 99503 T: 907/334-2409 F: 907/561-1684 E-mail: [email protected]

ARIZONA AHCCCS/DBF/CLMS Lori Petre, Claims Administrator 701 E. Jefferson Phoenix, AZ 85034 602/417-4547

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

CALIFORNIA Craig Miller Chief, Medi-Cal Rebate and Vision Section Medi-Cal Policy Division 714 P Street, Room 1540 Sacramento, CA 95814 T: 916/654-0532 F: 916/654-0513 E-mail: [email protected]

COLORADO Vince Sherry Drug Rebate Manager Department of Health Care Policy and Financing 1575 Sherman St., 5th Floor Denver, CO 80203 T: 303/866-5408 F: 303/866-2573

CONNECTICUT Mark Heuschkel Lead Planning Analyst - Pharmacy Department of Social Services Medical Operations 25 Sigourney Street Hartford, CT 06106 T: 860/424-5347 F: 860/424-5206 E-mail: [email protected]

DELAWARE Lynessa Reynoso Rebate Analyst EDS 248 Chapman Road Newark, DE 19702 T: 302/454-7622 F: 302/454-7603



DISTRICT OF COLUMBIA Donna Bovell Pharmacist Consultant Department of Health Medical Assistance Administration 825 North Capitol Street, NE 5th Floor Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected]

FLORIDA Jason Ottinger Agency for Health Care Administration 2727 Mahan Dr. Tallahassee, FL 32308 T: 850/922-7794 F: 850/922-0685 E-mail: [email protected]

GEORGIA Patricia Zeigler Jeter, M.P.A., R.Ph. Pharmacist Pharmacy Services Unit, Program Policy Section Division of Medical Assistance 2 Peachtree St., NW, 37th Floor Atlanta, GA 30303 T: 404/657-9181 F: 404/656-8366 E-mail: [email protected]

HAWAII Lynn Donovan, R.Ph. Medicaid Pharmacy Consultant Med-Quest Division 601 Kamokila Boulevard, Room 506B P.O. Box 700190 Kapolei, HI 96709-0190 T: 808/692-8116 F: 808/692-8131

IDAHO Carl Jeffrey, Pharm.D. Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid Bureau of Care Management 3380 Americana Terrace, Suite 140 Boise, ID 83720-0036 T: 208/364-1832 E-mail: [email protected]

ILLINOIS Bradley Wallner Manager Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62704 217/785-6114 E-mail: [email protected]

INDIANA ACS E-mail: [email protected]

IOWA Rocco Russo Third Party Liability Manager ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 Ext. 1114 F: 515/327-0945

KANSAS Mary H. Obley Pharmacist Health Care Policy Division KS Dept of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785/296-8406 F: 785/296-4813 E-mail: [email protected]



KENTUCKY Betsy Scott Department for Medicaid Services CHR Building, 6 E-B 275 E. Main St. Frankfort, KY 40621 T: 502/564-5472 F: 502/564-0223 E-mail: [email protected]

LOUISIANA Mary J. Terrebonne, Pharm.D Pharmacy Program 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]

MAINE Rossi Rowe TPL Manager DHS/Bureau of Medical Services 11 State House Station Augusta, ME 04333-0011 T: 207/287-1838 F: 207/287-1788 E-mail: [email protected]

MARYLAND Kenneth Smoot Deputy Director Office of Management and Finance 201 W. Preston St. Baltimore, MD 21201 T: 401/767-5186 F: 410/333-5409

MASSACHUSETTS Martha Kessenich Rebate Analyst ACS State Health Care 365 North Ridge Road Atlanta, GA 30350 800/358-2381

MICHIGAN James Kenyon, R.Ph. Pharmacist Consultant MDCH/Medical Services Administration 400 S. Pine St. Lansing, MI 48933 T: 517/335-5265 F: 517/335-5294 E-mail: [email protected]

MINNESOTA Jarvis P. Jackson, R.Ph. Drug Rebate Coordinator Dept. of Human Services 444 Lafayette Rd. St. Paul, MN 55155-3849 T: 651/282-5881 F: 651/282-6744 E-mail: [email protected]

MISSISSIPPI Glenda Grant Division of Medicaid Robert E. Lee Building 239 North Lamar St., Suite 801 Jackson, MS 39201 601/359-6050 E-mail: [email protected]



MISSOURI Lynn Hebenheimer Drug Rebate Unit Supervisor Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102 T: 573/526-5778 F: 573/522-2594 E-mail: [email protected]

MONTANA 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]

NEBRASKA 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]

NEVADA 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]

NEW HAMPHSHIRE Glen Hutchinson 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 Carl D. Tepper, R.Ph. Chief, Pharmaceutical Services Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg 11-A Trenton, NJ 08625 T: 609/588-2744 F: 609/588-3889 E-mail: [email protected]

NEW MEXICO Sonya Miera Drug Rebate Program Administration Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-7777 F: 505-827-3185

NEW YORK Mark-Richard Butt, M.S., R.Ph. Director, Pharmacy Policy and Operations Bureau of Program Guidance Office of Medicaid Management NYS Department of Health 99 Washington Ave., Room 606 Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected]



NORTH CAROLINA 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]

NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. 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]

OHIO 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]

OKLAHOMA Tom Simonson Drug Rebate Program Manager Oklahoma Health Care Authority 4545 N. Lincoln Blvd, Suite 124 Oklahoma City, OK 73105-9901 T: 405/522-7327 F: 405/522-3236 E-mail: [email protected]

OREGON Becky Smith Rebate Analyst First Health Services Corporation 565 Union St. NE, Suite 205 Salem, OR 97301 T: 503/391-1981 F: 503/391-1979 E-mail: [email protected]

PENNSYLVANIA Louis J. Cappello Dispute Resolution Coordinator Office of Medical Assistance Programs 701 Crosby Street, Suite A Chester, PA 19013 T: 610/447-5385 F: 610/447-5385 E-mail: [email protected]

RHODE ISLAND Paula Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected]

SOUTH CAROLINA Caroline Y. Sojurner, R.Ph. Department Head Department of Pharmacy Services 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]



SOUTH DAKOTA Helen Rokusek Rebate Coordinator SD Dept. of Social Services 700 Governors Drive Pierre, SD 57501 605/773-3653

TENNESSEE H. Leo Sullivan, D.Ph. Director of Pharmacy Services Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/253-5481 E-mail: [email protected]

TEXAS Heather Murphy Manager, Pharmacy Rebates Vendor Drug Program Contracts and Rebates Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78756-3174 T: 512/338-6963 F: 512/338-6910 E-mail: [email protected]

UTAH Raedell Ashley, R.Ph. Pharmacy Director 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]

VERMONT Christine Dapkiewicz Drug Rebate Coordinator EDS 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA David B. Shepherd, R. Ph. Pharmacy Consultant Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-8056 F: 804/786-0414 E-mail: [email protected]

WASHINGTON Connie Riddle Medical Assistance Administration, DSHS P.O. Box 45503 Olympia, WA 98504-5503 360/725-1243

WEST VIRGINIA Gail Goodnight, R.Ph. Rebate Coordinator Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3707 T: 304/558-1700 F: 304/558-1542 E-mail: [email protected]

WISCONSIN 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 F: 608/261-7793 E-mail: [email protected]

WYOMING Suzie Gambell ACS P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405



STATE OFFICIALS, 2003 ALABAMA 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 Single State Agency Director Mr. Mike Lewis, Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5010 F: 334/242-0556 E-mail: [email protected] Medicaid Director Mr. Mike Lewis, Commissioner Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103-5624 T: 334/242-5600 F: 334/242-0556 E-mail: [email protected]

ALASKA 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 Single State Agency Director Mr. 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] Internet address: www.hss.state.ak.us Medicaid Director Mr. Bob Labbe, Director Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, AK 99811-0660 T: 907/465-3355 F: 907/465-2204 E-mail: [email protected] Internet address: www.hss.state.ak.us/dma

ARIZONA 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. Phyllis Beidess, Director Arizona Health Care Cost Containment System 80l East Jefferson Street Phoenix, AZ 85034 T: 602/417-4680 F: 602/252-6536 E-mail: [email protected] Internet address: www.ahcccs.state.az.us Medicaid Director Ms. Phyllis Beidess, Director Arizona Health Care Cost Containment System 801 East Jefferson Street Phoenix, AZ 85034 T: 602/417-4680 F: 602/252-6536 E-mail: [email protected] Internet address: www.ahcccs.state.az.us



ARKANSAS Governor Honorable Mike Huckabee State Capitol Building Little Rock, AR 72201 T: 501/682-2345 F: 501/682-1382 E-mail: [email protected] Internet address: www.state.ar.us/governor/staff.html Single State Agency Director Mr. Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 329 Little Rock, AR 72203-1437 T: 501/682-8650 F: 501/682-6836 E-mail: [email protected] Internet address: www.accessarkansas.org/dhs Medicaid Director Mr. Ray Hanley, Director Division of Medical Services, Dept. of Human Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 T: 50l/682-8292 F: 501/682-1197 E-mail: [email protected] Internet address: www.accessarkansas.org/dhs

CALIFORNIA Governor Honorable Gray Davis 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 Single State Agency Director Ms. Diana M. Bonta, Director Medical Care Services Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814 T: 916/657-1425 F: 916/657-5183 E-mail: [email protected] Internet address: www.dhs.cahwnet.gov Medicaid Director Mr. Stan Rosenstein, Deputy Director Medical Care Services Department of Health Services 714 P Street, Room 1253 Sacramento, CA 95814 T: 916/654-0391 F: 916/657-1156 E-mail: [email protected] Internet address: www.medi-cal.ca.gov

COLORADO Governor Honorable Bill Owens State Capitol Room 136 Denver, CO 80203 T: 303/866-2471 F: 303/866-2003 E-mail: [email protected] Internet address: www.state.co.us/gov_dir/governor_office.html Single State Agency Director Ms. Marva Livingston Hammons Executive Director Department of Human Services l575 Sherman Street Denver, CO 80203-1714 T: 303/866-5096 F: 303/866-4740 E-mail: [email protected] Internet address: www.cdhs.state.co.us Medicaid Director Mr. Richard Allen Executive Director Department of Health Care Policy and Financing 1575 Sherman Street Denver, CO 80203-1714 T: 303/866-2859 F: 303/866-2803 TDD: 303/866-3883 E-mail: [email protected] Internet address: www.chcpf.state.co.us



CONNECTICUT Governor Honorable John G. Rowland State Capitol, Room 202 Hartford, CT 06l06 T: 860/566-4840 F: 820/524-7395 E-mail: [email protected] Internet address: www.state.ct.us/governor 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.us.ct Medicaid Director Mr. David Parella, Deputy Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06106-5116 T: 860/424-5116 F: 860/424-5114 E-mail: [email protected] Internet address: www.dss.state.ct.us

DELAWARE Governor Honorable Ruth Ann Minner Tatnall Building William Penn Street Dover, DE 19901 T: 302/739-4101 F: 302/739-2775 E-mail: [email protected] Internet address: www.state.de.us/governor/index.htm Single State Agency Director Mr. Vincent P. Meconi, Secretary Department of Health and Social Services 1901 North DuPont Highway New Castle, DE l9720 T: 302/421-6705 F: 302/255-4429 E-mail: [email protected] Internet address: www.state.de.us/dhss/index.html Medicaid Director Mr. Philip Soulé Deputy Director/Medicaid Department of Health and Social Services 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9501 F: 302/255-4425

DISTRICT OF COLUMBIA 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 Mr. James A. Buford, Director Department of Health 825 North Capitol Street, NE Fourth Floor Washington, DC 20002 T: 202/442-5999 F: 202/442-4788 E-mail: [email protected] Internet address: www.dchealth.dc.gov Medicaid Director Ms. Wanda R. Tucker, Interim 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



FLORIDA 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 Single State Agency Director Dr. Rhonda Medows, 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.fdhc.state.fl.us Medicaid Director Mr. Bob Sharpe, Deputy Secretary Agency for Health Care Administration 2727 Mahan Drive, Mail Stop 8 Tallahassee, FL 32308 T: 850/488-3560 F: 850/488-0043 E-mail: [email protected] Internet address: www.fdhc.state.fl.us

GEORGIA 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 Single State Agency Director Mr. Gary Redding, 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 4043 Atlanta, GA 30303-3159 T: 404/656-4496 F: 404/651-6880 E-mail: [email protected] Internet address: www.dch.state.ga.us

GUAM 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. Peter John 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



HAWAII 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 Single State Agency Director Ms. Lillian B. Koller Department of Human Services 1390 Miller Street, Room 209 Honolulu, HI 96813 808/586-4997 E-Mail: [email protected] Internet address: www.state.hi.us/dhs Medicaid Director Ms. Aileen Hiramastu, Administrator Med-Quest Division Department of Human Services P.O. Box 399 Honolulu, HI 96809-0339 T: 808/692-8050 F: 808/586-4890 E-mail: [email protected] Internet address: www.state.hi.us/dhs

IDAHO 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.id.us/gov/index.htm 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: www2.state.id.us/dhw Medicaid Director Mr. Joe Brunson, Administrator Division of Medicaid Department of Health and Welfare Americana Building P.O. Box 83720 Boise, ID 83720-0036 T: 208/364-5747 F: 208/334-1811 E-mail: [email protected] Internet address: www2.state.id.us/dhw

ILLINOIS Governor Honorable Rod Blagojevich 207 Capitol Building State Capitol 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. 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.state.il.us/dpa Medicaid Director (Medical Operations) Mr. A. George Hovanec, Administrator Division of Medical Programs Department of Public Aid 20l South Grand Avenue, East, Third Floor Springfield, IL 62763-0001 T: 2l7/782-2570 F: 217/524-7979 E-mail: [email protected] Internet address: www.state.il.us/dpa



INDIANA Governor Honorable Frank O’Bannon 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 Single State Agency Director Mr. John Hamilton, 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 Medicaid Director Ms. Melanie Bella, Assistant Secretary Medicaid Policy and Planning Family and Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN 46204-2739 T: 317/233-4455 F: 317/232-7382 E-mail: [email protected] Internet address: www.state.in.us/fssa

IOWA 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 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. Sally Titus Cunningham, Interim Director Division of Medical Services Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 T: 5l5/281-5452 F: 515/281-7791 E-mail: [email protected] Internet address: www.dhs.state.ia.us

KANSAS 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.accesskansas.org/governor Single State Agency Director Ms. Janet Schalansky, Secretary Kansas Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison Street Topeka, KS 66612 T: 785/296-3271 F: 785/296-2173 E-mail: [email protected] Internet address: www.srskansas.org Medicaid Director Mr. Robert Day, Commissioner Adult and Medical Services Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison Street, Room 651 South Topeka, KS 66612 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected] Internet address: www.srskansas.org



KENTUCKY Governor Honorable Paul E. Patton State Capitol Building 700 Capitol Avenue Frankfort, KY 4060l T: 502/564-2611 F: 502/564-2517 E-mail: [email protected] Internet address: www.gov.state.ky.us Single State Agency Director Ms. Marcia Morgan, Secretary Cabinet for Health 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 Mr. Mike Robinson, Commissioner Department for Medicaid Services Sixth Floor 275 East Main Street Frankfort, KY 40621 T: 502/564-4321 F: 502/564-0509 E-mail: [email protected] Internet address: www.chs.ky.us/dms/default.htm

LOUISIANA Governor Honorable M. J. “Mike” Foster 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 Single State Agency Director Mr. David W. Hood, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821-0629 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

MAINE 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.state.me.us/governor.index .html Single State Agency Director Mr. Peter Walsh Acting Commissioner Department of Human Services State House Station 11 Augusta, ME 04333-0011 T: 207/287-2736 F: 207/287-3005 E-mail: [email protected] Internet address: www.state.me.us/dhs/wecolme_to_dhs.htm Medicaid Director Mr. Eugene Gessow, Director Bureau of Medical Services Department of Human Services State House Station 11 Augusta, ME 04333-0011 T: 207/287-2674 F: 207/287-2675 E-mail: [email protected]



MARYLAND 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 Single State Agency Director Mr. Nelson J. Sabatini Secretary Department of Health & Mental Hygiene Herbert R. O'Connor Building 201 West Preston Street Fifth Floor Baltimore, MD 21201 T: 410/225-6500 F: 410/161-6489 E-mail: [email protected] Internet address: www.dhmh.state.md.us Medicaid Director Ms. Debbie Chang Deputy Secretary for Health Care Financing Department of Health & Mental Hygiene 201 West Preston Street Baltimore, MD 21201 T: 410/767-4664 F: 410/333-7687 E-mail: [email protected] Internet address: www.dhmh.state.md.us

MASSACHUSETTS 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] 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 Mr. Wendy Warring, Commissioner Division of Medical Assistance 600 Washington Street Boston, MA 02111 T: 617/210-5690 T: 617/210-5000 F: 617/210-5697 E-mail: [email protected]

MICHIGAN Governor Honorable Jennifer Granholm P.O. Box 30013 Lansing, MI 48909 T: 5l7/335-7858 F: 517/335-6863 E-mail: wwwimichigan.gov/gov Internet address: www.michigan.gov/gov 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. Patrick Barrie Deputy Director Health Programs Administration Michigan Department of Community Health 400 S. Pine Street Lansing, MI 48909 T: 517/335-5001 F: 517/335-5007 E-mail: [email protected] Internet address: www.michigan.gov/mdch



MINNESOTA Governor Honorable Tim Pawlenty 130 State Capitol St. Paul, MN 55155-1099 T: 651/296-3391 F: 651/296-0674 E-mail: [email protected] Internet address: www.governor.state.mn.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. Mary B. Kennedy, Medicaid Director Assistant Commissioner Health Care Minnesota Department of Human Services 444 Lafayette Road St. Paul, MN 55l55-3852 T: 651/297-7515 F: 651/297-3230 E-mail: [email protected] Internet address: www.dhs.state.mn.us

MISSISSIPPI Governor Honorable Ronnie Musgrove State Capitol P.O. Box 139 Jackson, MS 39205 60l/359-3150 E-mail: www.governor.state.ms.us/aboutthegov/writetoindex.html Internet address: www.governor.state.ms.us Single State Agency Director Ms. Thelma Brittain Executive Director Department of Human Services 750 North State Street Jackson, MS 39201-1399 T: 601/359-4500 F: 601/359-4910 E-mail: [email protected] Internet address: www.mdhs.state.ms.us Medicaid Director Ms. Rica Lewis Payton 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] Internet address: www.mdhs.state.ms.us

MISSOURI Governor Honorable Bob Holden State Capitol Building, Room 218 P.O. Box 720 Jefferson City, MO 65102-0720 T: 573/751-3222 F: 573/751-1495 E-mail: www.gov.state.mo.us/mail1.html Internet address: www.gov.state.mo.us Single State Agency Director Mr. Dana Katherine Martin, Director Department of Social Services 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. Gregory A. Vadner Division of Medical Services Department of Social Services 615 Howerton Court P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-3425 F: 573/751-6564 E-mail: [email protected]



MONTANA Governor Honorable Judy Martz State Capitol Helena, MT 59620-0801 T: 406/444-3111 F: 406/444-4151 E-mail: www.discoveringmontana.com/gov/contact.tm Internet address: www.state.mt.us/governor/css/default.asp Single State Agency Director Dr. Gail Gray, Director 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 Ms. Margaret A. Bullock, Administrator Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4141 F: 406/444-1861 E-mail: [email protected] Internet address: www.dphhs.state.mt.us/hpsd/index.htm

NEBRASKA Governor Honorable Mike Johanns 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 Single State Agency Director Mr. Stephen Curtiss, Director Nebraska Department of Health and Human Services Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-8533 F: 402/471-9449 E-mail: [email protected] Internet address: www.hhs.state.ne.us/fin/finindex.htm Medicaid Director Mr. Bob Seiffert, Administrator Medicaid Division Nebraska Department of HHS Finance and Support P.O. Box 95026 301 Centennial Mall South, 5th Floor Lincoln, NE 68509-5026 T: 402/471-9147 F: 402/471-9092 E-mail: [email protected] Internet address: www.hhs.state.ne.us/med/medindex.htm

NEVADA Governor Honorable Kenny C. Guinn State Capitol Carson City, NV 89710 T: 702/687-5670 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 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. Chuck Duarte, Administrator Division of Health Care Financing and Policy 1100 East William Street, Suite 116 Carson City, NV 89710 T: 775/684-3676 F: 775/684-8792 E-mail: [email protected] Internet address: www.dhcfp.state.nv.us



NEW HAMPSHIRE Governor Honorable Craig Benson State House Room 208 107 North Main Street Concord, NH 03301-4990 T: 603/271-2121 F: 603/271-5686 E-mail: www.state.nh.us/governor/ comment.html Internet address: www.state.nh.us/governor Single State Agency Director Mr. Nicholas Vailas, 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 Ms. Lori Read, Director Office of Health Planning & Medicaid Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-5254 F: 603/271-8431 Internet address: www.dhhs.state.nh.us/DHHS/ OHPM/default.htm

NEW JERSEY Governor Honorable Jim McGreevey 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 Single State Agency Director Ms. Gwendolyn L. Harris, Commissioner Department of Human Services Capitol Place One CN-700, Fifth Floor 222 South Warren Street 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. Kathryn A. Plant, 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

NEW MEXICO Governor Honorable Bill Richardson Office of The Governor State Capitol Suite 400 Santa Fe, NM 87503 T: 505/827-3000 F: 505/476-2226 E-mail: [email protected] Internet address: www.governor.state.nm.us Single State Agency Director Ms. Pamela Hyde, 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



NEW YORK 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 Single State Agency Director Antonio 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]

NORTH CAROLINA Governor Honorable Mike Easley Office of the Governor 116 West Jones Street 20301 Mail Service Center Raleigh, NC 27699-0301 T: 919/733-4240 F: 919/733-2120 E-mail: www.governor.state.nc.us/email.asp?to=1 Internet address: www.governor.state.nc.us 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. Gary Fuquay, Acting Director Division of Medical Assistance Department of Health and Human Services 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/857-4011 F: 919/733-6608 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma

NORTH DAKOTA 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. Carol Olson, Executive Director Department of Human Services 600 East Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-2538 F: 701/328-2359 E-mail: [email protected] Internet address: www.lnotes.state.nd.us/dhs/dhsweb.nsf Medicaid Director Mr. David J. Zentner, Director Division of Medical Assistance 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.lnotes.state.nd.us/dhs/dhsweb.nsf



NORTHERN MARIANA ISLANDS Governor Honorable Juan N. Babauta Commonwealth of the Northern Mariana Islands Caller Box 10007 Capitol Hill 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 E-mail: [email protected] (info officer)

OHIO 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 Single State Agency Director Mr. Tom Hayes, Director Ohio Department of Job and Family Services 30 East Broad Street, 32nd Floor Columbus, OH 43215-3414 614/466-6282 Medicaid Director Ms. Barbara Edwards, Deputy Director Office of Medicaid Ohio Department of Job and Family Services 30 East Broad Street, 31st Floor Columbus, OH 43215-3414 T: 614/466-4443 F: 614/752-3986 E-mail: [email protected]

OKLAHOMA Governor Honorable Brad Henry 212 State Capitol 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 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.oh.us Medicaid Director Lynn Mitchell, M.D. 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



OREGON Governor Honorable Ted Kulongoski State Capitol 900 Court Street NE Salem, OR 97310-4047 T: 503/378-3111 F: 503/378-4863 E-mail: [email protected] Internet address: www.governor.state.or.us Single State Agency Director Ms. Jean Thorne, Director Department of Human Resources 500 Summer Street, NE Human Resources Building Salem, OR 97301 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] Internet address: www.hr.state.or.us Medicaid Director Ms. Lynn Read, Director Office of Medical Assistance Programs Department of Human Services 500 Summer Street, NE Salem, OR 97301 T: 503/945-5772 F: 503/373-7689 E-mail: [email protected] Internet address: www.omap.state.or.us

PENNSYLVANIA 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/site/ default.asp Single State Agency Director Ms. Estelle B. Richman, Acting 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/default.html Medicaid Director Ms. Carole Rebert Office in Charge 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/dpwomap.asp

PUERTO RICO Governor Honorable Sila Maria Calderon La Fortaleza P.O. Box 82 San Juan, PR 00901 809/721-7000 Single State Agency Director 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 Medical Assistance Program Department of Health G.P.O. Box 70184 San Juan, PR 00936 T: 787/765-1230, ext. 201 F: 787/250-0990



RHODE ISLAND Governor Honorable Don Carcieri 222 State House Providence, RI 02903-1196 T: 401/222-2080 F: 401/861-5894 E-mail: [email protected] Internet address: www.governor.state.ri.us 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 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

SOUTH CAROLINA Governor Honorable Mark Sanford P.O. Box 11829 Columbia, SC 29211 T: 803/734-9400 F: 803/734-9413 E-mail: [email protected] Internet address: www.state.sc.us/governor Single State Agency Director Mr. Robert C. Toomey, 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 C. Toomey, Director Department of Health and Human Services P.O. Box 8206 1801 Main Street Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Internet address: www.dhhs.state.sc.us

SOUTH DAKOTA 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/state/executive/ governor/governor.htm 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. Damian Prunty, Adninistrator 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



TENNESSEE Governor Honorable Phil Brendsen 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 Single State Agency Director Mr. Dave Goetz, Commissioner Department of Finance and Administration 1st Floor, State Capitol Nashville, TN 37219 T: 615/741-2401 F: 615/741-9872 E-mail: [email protected] Internet address: www.state.tn.us/finance Medicaid Director Mr. Manny Martins Deputy Commissioner Department of Finance and Administration 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/741-0882 E-mail: [email protected] Internet address: www.state.tn.us/tenncare

TEXAS 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_ email.htm Internet address: ww.governor.state.tx.us Single State Agency Director Mr. Albert Hawkins, Commissioner Health and Human Services Commission 4900 N. Lamar Boulevard P.O. Box 13247 Austin, TX 78711 T: 5l2/424-6502 F: 512/424-6587 E-mail [email protected] Internet address: www.hhsc.state.tx.us Medicaid Director Mr. Jason Cooke State Medicaid Director Health and Human Services Commission 4900 N. Lamar Boulevard P.O. Box 13247 Austin, TX 78711 T: 512/424-6517 F: 512/424-6587 E-mail: [email protected] Internet address: www.hhsc.tx.us/medicaid/index.html

UTAH Governor Honorable Michael O. Leavitt 210 State Capitol 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. Rod Betit, 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.hlunix.hl.state.ut.us Medicaid Director Mr. Michael Deily, Director Department of Health Division of Health Care Financing P.O. Box 14301 Salt Lake City, UT 84114-1000 T: 801/538-6406 F: 801/538-6099 E-mail: [email protected] Internet address: www.hlunix. Ex.state.ut.us/medicaid



VERMONT 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 Single State Agency Director Mr. Charles 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. Paul Wallace-Brodeur, Medicaid Director Department of Prevention, Transition, and Health Access 103 South Main Street Waterbury, VT 05676 T: 802/241-3985 F: 802/241-2897 E-mail: [email protected] Internet address: www.dsw.state.vt.us

VIRGINIA 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 Single State Agency Director Ms. Jane H. Woods, Secretary Health and Human Resources Secretariat Ninth Street Office Building 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] 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: 804/225-4512 E-mail: [email protected] Internet address: www.dms.state.va.us

VIRGIN ISLANDS 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 Mavis Matthew, M.D. 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. Priscilla Berry-Quetel, Executive Director Bureau of Health Insurance and Medical Assistance Department of Health 210-3A Altona, Suite 302 Frostco Center Charlotte Amalie St. Thomas, VI 00802 T: 340/774-4624 F: 340/774-4918 E-mail: [email protected]



WASHINGTON Governor Honorable Gary Locke 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.govemail.htm Single State Agency Director Mr. Dennis Braddock, 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: braddd.dshs.wa.gov Internet address: www.wa.gov/dshs Medicaid Director Mr. Doug Porter, Assistant Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080 T: 360/902-1863 F: 360/902-7855 E-mail: [email protected] Internet address: www.fortress.wa.gov/dshs/maa

WEST VIRGINIA Governor Honorable Bob Wise 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 Single State Agency Director Mr. Paul Nusbaum, 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 25304 T: 304/558-1700 F: 304/926-1833 E-mail: [email protected] Internet address: www.wvdhhr.org/bms

WISCONSIN 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. 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, Room 350 Madison, WI 53701-0309 T: 608/266-2522 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us



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 Internet address: 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



CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) REGIONAL OFFICES

ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID Region I Boston Regional Office

Vacant John F. Kennedy Federal Bldg. Government Center, Room 2325 Boston, MA 02203-0003 617/565-1223

Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Region II New York Regional Office

Sue Kelly 26 Federal Plaza Room 3811 New York, NY 10278-0063 212/264-2058

New Jersey, New York, Puerto Rico, Virgin Islands

Region III Philadelphia Regional Office

Mary McSorley Suite 216, The Public Ledger Building 150 South Independence Mall West Philadelphia, PA 19106 215/861-4261

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

Region IV Atlanta Regional Office

Rhonda Cottrell Atlanta Federal Center 61 Forsyth Street, S.W., Suite 4T20 Atlanta, GA 30303-8909 404/562-7175

Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, Tennessee

Region V Chicago Regional Office

Cheryl Harris 233 North Michigan Avenue Suite 600 Chicago, IL 60601-5519 312/353-2702

Illinois, Indiana, Michigan, Minnesota, Ohio, Wisconsin

Region VI Dallas Regional Office

Andrew Fredrickson 1301 Young Street, Room 714 Dallas, TX 75202 214/767-6385

Arkansas, Louisiana, New Mexico, Oklahoma, Texas

Region VII Kansas City Regional Office

Tom Lenz Richard Bolling Federal Building 601 East 12th Street, Room 235 Kansas City, MO 64106-2808 816/426-5925

Iowa, Kansas, Missouri, Nebraska

Region VIII Denver Regional Office

Mark Gilbert Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 303/844-7055

Colorado, Montana, North Dakota, South Dakota, Utah, Wyoming

Region IX San Francisco Regional Office

Linda Minamoto 75 Hawthorne Street, 4th & 5th Floors San Francisco, CA 94105-3901 415/744-3568

Arizona, California, Hawaii, Guam Nevada, and Pacific Islands

Region X Seattle Regional Office

Karen O’Connor 2201 6th Avenue Mail Stop RX-40 Seattle, WA 98121-2500 206/615-2330

Alaska, Idaho, Oregon, Washington

Source: CMS, Regional Office Contacts, February 2003.



CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) NATIONAL ACCOUNT REPRESENTATIVES

STATE CENTRAL OFFICE REGIONAL OFFICE

Alabama Bill Lasowski Director Division of Financial Management Finance, Systems and Quality Group 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]

Jay Gavens Financial Analyst Atlanta Federal Center 61 Forsyth Street, SW 4th Floor, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7430 E-mail: [email protected]

Alaska Richard Strauss Deputy Director Division of Financial Management Finance, Systems and Quality 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 Sixth Avenue MS/RX-40 Seattle, WA 98121 T: 206/615-2400 E-mail: [email protected]

American Samoa Linda Murphy Health Insurance Specialist Division of Quality System Management Finance, Systems and Quality 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 Rhonda Rhodes Deputy Director Division of Integrated Health Services 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: 410/786-1848 E-mail: [email protected]

Ronald Reepen Health Insurance Specialist 75 Hawthorne Street 4th Floor, Rom 408 San Francisco, CA 94105-3901 T: 415/744-3601 E-mail: [email protected]



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 Medicaid Fraud & Abuse Liaison Medicaid Alliance for Program Safeguards 1301 Young Street, RM 714 Dallas, TX 75202 T: 214/767-26284461 E-mail: [email protected]

California Richard Chambers Director 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: 410/786-5647 E-mail: [email protected]

Pat Daley Health Insurance Specialist 75 Hawthorne Street 4th Floor, Room 408 San Francisco, CA 94105 T: 415/744-3592 E-mail: [email protected]

Colorado Todd Lawson Budget Staff Director Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5366 E-mail: [email protected]

Penny Finnegan State Program Coordinator Office of the Regional Administrator Colorado State Bank Bldg. 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7117 E-mail: [email protected]

Connecticut 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]

Elena Nicolella Health Insurance Specialist JFK Federal Building RM 2325 Boston, MA 02203-0003 T: 617/565-1243 E-mail: [email protected]



Delaware Mike Goldman Chief Nursing Homes Branch Section II Division of Nursing Homes and Continuing Care Services Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6813 E-mail: [email protected]

Elizabeth Wheeler Health Insurance Specialist The Public Ledger Building 150 S. Independence Mall West, Suite 116 Philadelphia, PA 19106 T: 215/861-4190 E-mail: [email protected]

District of Columbia

Rick Fenton Deputy Director Family & 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 150 S. Independence Mall West, Suite 116 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]

Eugene Grasser, ARA Division of Medicaid and State Operations Atlanta Federal Center, 4th Floor 61Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7401 E-mail: [email protected]

Georgia

Linda Strumsky Deputy Director Private Health Insurance Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3255 E-mail: [email protected]

Hugh Webster, Chief Medicaid Financial Management Branch Atlanta Federal Center 61 Forsyth Street, SW 4th Floor, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7432 E-mail: [email protected]



Guam Maria Friedman Technical Director Division of Quality Improvement and Training Finance, Systems and Quality Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 202/401-3561 E-mail: [email protected]

Eddie Martin Accountant 75 Hawthorne Street 4th Floor, Room 408 San Francisco, CA 94105-3901 T: 415/744-3567 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 4th Floor, Room 408 San Francisco, CA 94105-3901 T: 415/744-3599 E-mail: [email protected]

Idaho Georgia Johnson Technical Director Continuing Care Providers Branch 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 Sixth Avenue MS/RX 40 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]

Vera Drivalas 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/886-0792 E-mail: [email protected]



Indiana Regina Fletcher Special Assistant 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: 410/786-3293 E-mail: [email protected]

Jean Hall 233 N. Michigan Avenue Suite 600 Chicago, IL 6061 T: 312/352-3746 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]

Brenda Jackson Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3307 E-mail: [email protected]

Kansas Frank Sokolik 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: 410/786-7089 E-mail: [email protected]

Jackie Glaze Health Insurance Speicalist Richard Bolling Federal Building 601 East 12th Street Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3318 E-mail: [email protected]

Kentucky Jack Williams Director, Division of National Systems Finance Systems and Quality Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6743 E-mail: [email protected]

Renard Murray Atlanta Federal Center 61 Forsyth Street, SW 4th Floor, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7417 E-mail: [email protected]



Louisiana Wayne Smith Deputy Director Finance, Systems and Quality Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-2583 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]

Maine Roger Buchanan Director Division of Informational Analysis and Technical Assistance Finance, Systems and Quality 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]

Irvin Rich JFK Federal Building Room 2325 Boston, MA 02203-0003 T: 617/565-1247 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 150 S. Independence Mall West, Suite 216 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]

Patricia Hitz McKnight Health Insurance specialist Division of Medicaid and State Operations JFK Federal Building Room 2275 Boston, MA 02203-0003 T: 617/565-1268 E-mail: [email protected]



Michigan Lillian Gibbons Senior Advisor Children’s Health Programs and Policies 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 Michigan/Minnesota/Wisconsin Branch Division of Medicaid and Children's Oversight 233 N. Michigan Avenue, Suite 600 Chicago, IL 60601 T: 312/353-9843 E-mail: [email protected]

Mississippi Pam Vocke Director Division of Quality Improvement and Training Finance, Systems and Quality Group Finance, Systems and Quality 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]

Selwyn White Atlanta Federal Center 4th Floor, Suite 4T20 61 Forsyth Street, SW Atlanta, GA 30303-8909 T: 404/562-7427 E-mail: [email protected]

Missouri

Steven Pelovits Director Survey and Certification Group Finance, Systems and Quality Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3160 E-mail: [email protected]

Judith Flynn Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3308 E-Mail: [email protected]



Montana Helene Fredeking Technical Director Division of Nursing Homes and Continuing 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: 410/786-7304 E-mail: [email protected]

Robert Lyon Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7114 E-mail: [email protected]

Nebraska Dave Witt Technical 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: 410/786-5600 E-mail: [email protected]

Sharon Taggart Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3320 E-mail: [email protected]

Nevada Judy Yost Director Div. of Laboratories and 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: 410/786-3407 E-mail: [email protected]

Lee Netzer Health Insurance Specialist 75th Hawthorne Street 4th Floor, Room 408 San Francisco, CA 94105-3901 T: 415/744-3595 E-mail: [email protected]

New Hampshire Jan Tarantino 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: 410/786-0905 E-mail: [email protected]

Harold Finn JFK Federal Building Boston, MA 02203-0003 T: 617/565-1225 E-mail: [email protected]



New Jersey Fred Gladden Chief Nursing Homes Branch Section I Division of Nursing Homes and Continuing 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: 410/786-3033 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 Susan Cuerdon Policy Advisor Office of the Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1146 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 Charlene Brown 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 4th Floor, suite 4T20 61 Forsyth Street, SW Atlanta, GA 30303-8909 T: 404/562-7406 E-mail: [email protected]



North Dakota James Merrill Life Safety Code Specialist Nursing Homes Branch Section 1 Division of Nursing Homes and Continuing Care Services 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

Randy Graydon Deputy 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: 410/786-1357 E-mail: [email protected]

H. Stephen Deering Deputy Regional Administrator 75 Hawthorne Street 4th Floor, 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 Quality 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 Chief Continuing Care Providers Branch Division of Nursing Homes and Continuing 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: 410/786-6568 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]



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]

Randy Poulsen Health Insurance Specialist Medicaid Branch, Region X 2201 Sixth Avenue MS/RX -43 Seattle, WA 98121 T: 206/615-2390 E-mail: [email protected]

Pennsylvania Cheryl Austein-Casnoff 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: 410/786-4196 E-mail: [email protected]

Michael Cruse Health Insurance Specialist The Public Ledger Building 150 S. Independence Mall West, Suite 216 Philadelphia, PA 19106 T: 215/861-4216 E-mail: [email protected]

Puerto Rico Cindy Melanson Health Program Evaluator 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 Quality 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]

Richard Pecorella JFK Federal Build9ng Boston, MA 02203-0003 T: 617/565-1244 E-mail: [email protected]



South Carolina Helaine Jeffers Accreditation Staff Director Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5648 E-mail: [email protected]

Jessie Spillers 61 Forsyth Street, SW 4th Floor, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7418 E-mail: [email protected]

South Dakota David Eddinger Technical Director Division of Laboratories and 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: 410/786-3429 E-mail: [email protected]

Cynthia Myers State Program Coordinator Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7116 E-mail: [email protected]

Tennessee Mike Fiore Director Division of integrated Health Systems 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: 410/786-0623 E-mail: [email protected]

Dorothy Smith Health Insurance Specialist Atlanta Federal Center 4th Floor, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7159 E-mail: [email protected]

Texas

Dave McNally Deputy Director Finance, Systems and Quality Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3292 E-mail: [email protected]

Shirley Glaspie Health Insurance Specialist 1301 Young Street Room 714 Dallas, TX 75202 T: 214/767-6407 E-mail: [email protected]



Utah Aaron Blight 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: 410/786-5239 E-mail: [email protected]

Tilly Rollin Utah State Program Coordinator CMS 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]

Allen P. Bryan Health Insurance Specialist Room 2275 Boston, MA 02203-0003 T: 617/565-1246 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 150 S. Independence Mall West Suite 216 Philadelphia, PA 19106 T: 215/861-4181 E-mail: [email protected]

Virgin Islands Cindy Granunke Acting Director Division of Nursing Homes and Continuing 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: 410/786-6782 E-mail: [email protected]

Ricardo Holligan 26 Federal Plaza Room 3811 New York, NY 10278-0063 T: 212/264-3978 E-mail: [email protected]



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 Sixth Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2515 E-mail: [email protected]

West Virginia Joan Simmons Deputy Director Division of Laboratories and 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: 410/786-3409 E-mail: [email protected]

Ted Gallagher Health Insurance Specialist The Public Ledger Building 150 S. Independence Mall West Suite 216 Philadelphia, PA 19106 T: 215/861-4275 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

Marjorie Eddinger Technical Director Division of Laboratories and 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: 410/786-0375 E-mail: [email protected]

Robert Tonsberg Epidemiologist, Sr. Health Services Office Manager Office of the Regional Administrator, CMS Colorado State Bank Bldg. 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-1981 E-mail: [email protected]

Source: CMS website, http://www.cms.hhs.gov/states/natreps.pdf. Accessed on December 31, 2002.



CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) CENTER FOR MEDICAID AND STATE OPERATIONS

CENTRAL OFFICE STAFF 7500 Security Boulevard

Baltimore, MD 21244-1850 410/786-3000

Director Dennis Smith 410/786-3870

Deputy Director Charlene Brown 410/786-3870

Financial Advisor Bill Lasowski 410/786-3870

Appeals and Grievances Tim Roe (Managed Care)

410/786-2006 Bob Tomlinson (Fee for Service)

410/786-4463

Assignment of Rights to Benefits Cheryl Camillo 410/786-1068

Budget Information for State Agencies

Miles McDermott 410/786-3722

Children’s Health Insurance

Cheryl Austein Casnoff 410/786-6614

Coordination of Benefits

Ginni Hain (Disabled & Elderly) 410/786-6036

Marty Svolos (Families & Children)

Data Inquiries Marilyn McMillan

410/786-4623

Department Appeals Board Decisions Ed Davis

410/786-3280

Disabled/Elderly 1915(b) Waivers; 1115 Demonstrations; And PACE Program

Terri Pratt 410/786-5831

Drug Rebate Agreement/Data

Judy Allison 410/786-3330

Source: CMS Central Office, CMSO, February 2003.

Drug Utilization Review Christina Lyon 410/786-3332 Carl Tepper

410/786-2137

Eligibility Marty Svolos (Families & Children)

410/786-4582 Roy Trudel (Disabled/Elderly)

410/786-3417

Family/Children 1915(b) Waivers; 1115 Demonstrations; And the Health Insurance Flexibility & Accountability

Initiative (HIFA) Mike Fiore

410/786-0623

HCFA 2082 Statistical Report Cindy Foltz

410/786-0253

Home and Community Based Waiver Program Reviews; Independence Plus Initiative

Mary Jean Duckett 410/786-3294

Investigational/Experimental Drugs

Tami Bruce 410/786-1519

Managed Care Enrollment Report

Carolyn Lawson 410/786-0704

Medicaid Statistical Information System (MSIS)

Ron North 410/786-5651 rmacy Issues

(Coverage, Payment & Rebate Program)

Larry Reed 410/786-3325 Dierde Duzor 410/786-4626




National Pharmaceutical Council B-1

Appendix B: Medicaid Program Statistics -- CMS MSIS Tables


B-2 National Pharmaceutical Council



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 for all states is for FY 2000, too old for inclusion in the main body of this year’s Compilation. Hence in many sections of this year’s Compilation, we have used data from other, more current sources. MSIS data for FY 2001 have been released for some states, and partial data are included in this Appendix where appropriate. Please note these data are preliminary and subject to change.

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 1999 and FY 2000. 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. Partial tables with the incomplete FY 2001 data are also included for the state-by-state data where appropriate. Additionally, there are three partial tables at the end of the Appendix that correspond to FY 2000 tables presented in Section 2.





Total U.S. Medical Assistance Recipients By Type of Service

Service FY 1999** Percent of Total* FY 2000*** Percent of Total* Percent Change 1999-2000Capitated Payment Services 20,686,648 51.5% 21,261,218 49.7% 2.8%Pharmaceuticals 19,854,953 49.4% 20,516,882 48.0% 3.3%Physicians 18,373,483 45.7% 19,103,558 44.7% 4.0%Hospital Outpatient 12,417,078 30.9% 13,226,305 30.9% 6.5%Lab/X-ray 10,194,096 25.4% 11,395,712 26.6% 11.8%Other Care 8,571,677 21.3% 9,036,596 21.1% 5.4%Clinic 6,746,062 16.8% 7,666,977 17.9% 13.7%Dental 5,621,824 14.0% 5,891,733 13.8% 4.8%PCCM Services 3,890,455 9.7% 5,560,441 13.0% 42.9%Hospital Inpatient 4,497,189 11.2% 4,933,277 11.5% 10.0%Other Practitioners 3,985,501 9.9% 4,735,427 11.1% 18.8%Personal Support Services 4,076,883 10.1% 4,549,488 10.6% 11.6%Nursing Facility 1,616,663 4.0% 1,702,885 4.0% 5.3%Home Health Care 813,631 2.0% 994,801 2.3% 22.3%ICF-Mentally Retarded 122,082 0.3% 118,171 0.3% -3.2%Mental Health Facility 97,146 0.2% 99,342 0.2% 2.3%

Total Unduplicated Recipients* 40,184,407 42,763,233 6.4% *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. **New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting. ***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals. Source: CMS, MSIS Report, FY 1999 and FY 2000.



Total U.S. Medical Assistance Payments By Type of Service

Service FY 1999** Percent of Total* FY 2000*** Percent of Total* Percent Change 1999-2000Nursing Facility $33,113,405,994 21.7% $34,432,018,376 20.5% 4.0%Capitated Payment Services $21,114,777,944 13.8% $24,412,582,129 14.5% 15.6%Hospital Inpatient $22,182,314,066 14.5% $24,265,794,997 14.4% 9.4%Pharmaceuticals $16,566,787,283 10.9% $20,013,770,558 11.9% 20.8%Other Care $13,088,047,530 8.6% $14,808,103,169 8.8% 13.1%Personal Support Services $10,498,771,251 6.9% $11,567,367,970 6.9% 10.2%ICF-Mentally Retarded $9,326,234,901 6.1% $9,374,506,773 5.6% 0.5%Hospital Outpatient $6,060,585,731 4.0% $7,053,041,842 4.2% 16.4%Physicians $6,496,562,916 4.3% $6,805,694,595 4.0% 4.8%Clinic $5,777,756,292 3.8% $6,174,164,021 3.7% 6.9%Home Health Care $2,898,409,629 1.9% $3,118,966,203 1.9% 7.6%Mental Health Facility $1,757,605,519 1.2% $1,768,270,710 1.1% 0.6%Dental $1,202,573,063 0.8% $1,404,498,611 0.8% 16.8%Lab/X-Ray $1,146,792,397 0.8% $1,288,213,313 0.8% 12.3%Unknown $468,963,299 0.3% $997,460,227 0.6% 112.7%Other Practitioners $466,810,030 0.3% $658,455,027 0.4% 41.1%PCCM Services $463,066,148 0.3% $164,562,061 0.1% -64.5%

Total Payments $152,629,463,993 $168,307,398,582 10.3% *Percentages may not add to 100% due to rounding. Puerto Rico and the U.S. Territories are not included in these national totals. **New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting. ***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals. Source: CMS, MSIS Report, FY 1999 and FY 2000.



2000 Baseline Data

State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of TotalNational Total* $168,307,231,426 $20,013,770,558 42,763,233 20,516,882 11.9%Alabama $2,391,194,897 $331,574,388 619,480 438,529 13.9%Alaska $470,249,823 $51,196,685 96,432 60,273 10.9%Arizona $2,111,769,849 $1,952,231 681,258 7,034 0.1%Arkansas $1,510,079,842 $209,933,612 489,325 290,749 13.9%California $17,060,494,184 $2,316,135,493 7,915,450 2,487,875 13.6%Colorado $1,808,569,210 $152,478,786 380,964 160,264 8.4%Connecticut $2,839,310,317 $264,641,409 419,890 113,089 9.3%Delaware $528,339,689 $66,263,771 115,267 78,167 12.5%District of Columbia $792,584,432 $55,092,178 138,677 38,129 7.0%Florida $7,350,363,024 $1,366,193,807 2,360,417 1,072,082 18.6%Georgia $3,577,903,288 $580,612,920 1,289,795 847,730 16.2%Hawaii** $535,162,729 $44,849,664 203,763 35,687 8.4%Idaho $593,750,993 $83,525,730 131,077 92,776 14.1%Illinois $7,807,447,335 $847,001,431 1,516,082 1,013,254 10.8%Indiana $2,976,177,145 $464,982,829 704,624 420,041 15.6%Iowa $1,476,340,040 $193,832,443 313,648 212,178 13.1%Kansas $1,226,210,559 $167,216,488 262,557 158,334 13.6%Kentucky $2,912,792,289 $465,178,958 770,536 427,514 16.0%Louisiana $2,630,563,430 $476,400,908 761,248 581,356 18.1%Maine $1,306,809,473 $175,938,952 191,624 148,049 13.5%Maryland $3,585,781,047 $374,121,433 664,576 409,511 10.4%Massachusetts $5,397,153,356 $682,519,910 1,047,440 666,627 12.6%Michigan $4,880,769,009 $374,334,359 1,351,650 435,654 7.7%Minnesota $3,277,014,103 $221,682,000 559,463 180,104 6.8%Mississippi $1,807,391,891 $370,355,016 605,077 415,925 20.5%Missouri $3,270,152,458 $600,484,118 890,318 447,062 18.4%Montana $433,207,577 $58,634,278 103,821 58,899 13.5%Nebraska $958,490,235 $135,355,734 229,038 165,891 14.1%Nevada $515,444,377 $51,682,326 138,069 51,169 10.0%New Hampshire $650,594,289 $80,562,181 96,935 73,313 12.4%New Jersey $4,706,928,703 $584,533,211 822,369 298,450 12.4%New Mexico $1,248,764,305 $57,502,713 375,585 67,238 4.6%New York $26,147,613,087 $2,366,900,006 3,419,893 2,173,791 9.1%North Carolina $4,830,025,832 $794,550,074 1,208,789 827,039 16.5%North Dakota $356,184,829 $38,076,519 60,864 38,957 10.7%Ohio $7,090,395,763 $882,579,749 1,304,886 777,632 12.4%Oklahoma $1,603,788,998 $178,254,361 507,059 221,984 11.1%Oregon $1,700,408,573 $163,263,562 542,392 191,901 9.6%Pennsylvania $6,365,806,031 $533,527,373 1,492,352 416,498 8.4%Rhode Island $1,069,994,225 $89,482,143 178,859 49,809 8.4%South Carolina $2,672,145,530 $334,740,332 685,104 474,465 12.5%South Dakota $401,175,221 $44,650,518 101,951 53,666 11.1%Tennessee $3,490,956,581 $0 1,568,318 0 0.0%Texas $9,075,305,586 $1,125,238,856 2,602,616 1,852,801 12.4%Utah $959,100,396 $100,794,076 224,268 133,164 10.5%Vermont $479,258,616 $91,724,918 138,862 103,228 19.1%Virginia $2,483,930,711 $382,471,744 627,214 347,251 15.4%Washington $2,432,050,117 $387,877,281 895,279 339,440 15.9%West Virginia $1,391,731,163 $216,077,217 335,014 261,544 15.5%Wisconsin $2,905,598,526 $349,558,072 576,636 267,417 12.0%Wyoming $213,957,743 $27,233,795 46,422 33,342 12.7% * Puerto Rico and the U.S. Territories are not included in the national totals. ** Hawaii data is for FY1999 Source: CMS, MSIS Report, FY 2000.



2001 Baseline Data*

State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of TotalNational Total Alabama Alaska $557,398,672 $64,923,574 105,464 65,278 11.6%Arizona $2,453,184,175 $4,254,191 763,422 9,761 0.2%Arkansas $1,684,717,766 $248,392,084 531,533 321,920 14.7%California $19,824,989,448 $2,808,298,437 8,596,862 2,486,910 14.2%Colorado $1,952,708,545 $177,115,553 393,195 143,169 9.1%Connecticut $2,962,088,094 $304,470,534 684,717 116,755 10.3%Delaware $601,182,212 $81,623,058 122,948 85,351 13.6%District of Columbia $830,258,078 $62,292,004 140,720 35,324 7.5%Florida $8,398,159,525 $1,487,935,645 2,458,609 1,159,155 17.7%Georgia $3,815,267,274 $655,515,772 1,256,990 856,797 17.2%Hawaii Idaho $713,433,025 $105,473,425 157,121 112,357 14.8%Illinois $14,838,487,574 $975,308,665 1,655,837 1,068,512 6.6%Indiana $3,355,995,714 $562,120,344 771,785 464,879 16.7%Iowa $1,660,864,098 $230,430,967 319,741 221,691 13.9%Kansas $1,370,248,183 $189,290,260 272,783 158,515 13.8%Kentucky $3,235,072,953 $598,093,343 807,435 475,365 18.5%Louisiana $2,779,206,115 $547,731,897 740,730 594,364 19.7%Maine Maryland $3,855,002,531 $417,080,496 634,273 413,755 10.8%Massachusetts $5,765,107,723 $795,309,302 1,039,979 664,891 13.8%Michigan $5,316,248,739 $604,759,491 1,352,418 551,593 11.4%Minnesota $3,766,604,923 $265,240,353 609,314 188,566 7.0%Mississippi $2,180,662,071 $494,805,247 707,899 478,404 22.7%Missouri $3,626,212,602 $680,574,899 978,546 472,624 18.8%Montana $482,543,436 $69,552,397 107,708 63,338 14.4%Nebraska $1,089,787,848 $161,577,499 242,901 178,365 14.8%Nevada $565,299,853 $62,849,319 133,103 55,580 11.1%New Hampshire $691,195,787 $90,927,579 97,062 73,489 13.2%New Jersey $5,011,794,888 $649,274,352 898,685 307,798 13.0%New Mexico $1,476,537,827 $70,147,344 379,207 75,669 4.8%New York $27,497,918,486 $2,779,026,904 3,039,436 2,283,293 10.1%North Carolina $5,499,093,501 $971,066,103 1,304,684 907,413 17.7%North Dakota Ohio $7,772,738,205 $1,087,552,923 1,413,925 904,380 14.0%Oklahoma $2,004,799,211 $215,717,760 570,671 249,678 10.8%Oregon Pennsylvania Rhode Island South Carolina $3,096,853,528 $438,498,935 760,797 542,764 14.2%South Dakota $426,633,598 $52,608,524 109,461 58,203 12.3%Tennessee $4,059,332,053 $0 1,602,027 - 0.0%Texas $9,644,600,358 $1,327,222,456 2,659,682 1,917,351 13.8%Utah $1,059,729,740 $117,101,302 232,520 136,682 11.1%Vermont $541,283,084 $105,673,417 149,262 109,328 19.5%Virginia $2,715,962,318 $419,133,293 618,395 333,880 15.4%Washington West Virginia $1,565,008,585 $256,395,319 349,229 269,174 16.4%Wisconsin $3,029,722,940 $389,373,521 633,463 262,238 12.9%Wyoming $241,187,030 $31,881,860 51,068 36,704 13.2% *2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Source: CMS, MSIS Report, FY 2001.



Medicaid Payments and Recipients, 2000

State Total Payments Total Recipients Payments Per Recipient National Total* $168,307,231,426 42,763,233 $3,936 Alabama $2,391,194,897 619,480 $3,860 Alaska $470,249,823 96,432 $4,876 Arizona $2,111,769,849 681,258 $3,100 Arkansas $1,510,079,842 489,325 $3,086 California $17,060,494,184 7,915,450 $2,155 Colorado $1,808,569,210 380,964 $4,747 Connecticut $2,839,310,317 419,890 $6,762 Delaware $528,339,689 115,267 $4,584 District of Columbia $792,584,432 138,677 $5,715 Florida $7,350,363,024 2,360,417 $3,114 Georgia $3,577,903,288 1,289,795 $2,774 Hawaii** $535,162,729 203,763 $2,626 Idaho $593,750,993 131,077 $4,530 Illinois $7,807,447,335 1,516,082 $5,150 Indiana $2,976,177,145 704,624 $4,224 Iowa $1,476,340,040 313,648 $4,707 Kansas $1,226,210,559 262,557 $4,670 Kentucky $2,912,792,289 770,536 $3,780 Louisiana $2,630,563,430 761,248 $3,456 Maine $1,306,809,473 191,624 $6,820 Maryland $3,585,781,047 664,576 $5,396 Massachusetts $5,397,153,356 1,047,440 $5,153 Michigan $4,880,769,009 1,351,650 $3,611 Minnesota $3,277,014,103 559,463 $5,857 Mississippi $1,807,391,891 605,077 $2,987 Missouri $3,270,152,458 890,318 $3,673 Montana $433,207,577 103,821 $4,173 Nebraska $958,490,235 229,038 $4,185 Nevada $515,444,377 138,069 $3,733 New Hampshire $650,594,289 96,935 $6,712 New Jersey $4,706,928,703 822,369 $5,724 New Mexico $1,248,764,305 375,585 $3,325 New York $26,147,613,087 3,419,893 $7,646 North Carolina $4,830,025,832 1,208,789 $3,996 North Dakota $356,184,829 60,864 $5,852 Ohio $7,090,395,763 1,304,886 $5,434 Oklahoma $1,603,788,998 507,059 $3,163 Oregon $1,700,408,573 542,392 $3,135 Pennsylvania $6,365,806,031 1,492,352 $4,266 Rhode Island $1,069,994,225 178,859 $5,982 South Carolina $2,672,145,530 685,104 $3,900 South Dakota $401,175,221 101,951 $3,935 Tennessee $3,490,956,581 1,568,318 $2,226 Texas $9,075,305,586 2,602,616 $3,487 Utah $959,100,396 224,268 $4,277 Vermont $479,258,616 138,862 $3,451 Virginia $2,483,930,711 627,214 $3,960 Washington $2,432,050,117 895,279 $2,717 West Virginia $1,391,731,163 335,014 $4,154 Wisconsin $2,905,598,526 576,636 $5,039 Wyoming $213,957,743 46,422 $4,609 *Puerto Rico and the U.S. Territories are not included in the national totals. ** Hawaii data is for FY1999 Source: CMS, MSIS Report, FY 2000.



Medicaid Payments and Recipients, 2001*

State Total Payments Total Recipients Payments Per Recipient National Total Alabama Alaska $557,398,672 105,464 $5,285 Arizona $2,453,184,175 763,422 $3,213 Arkansas $1,684,717,766 531,533 $3,170 California $19,824,989,448 8,596,862 $2,306 Colorado $1,952,708,545 393,195 $4,966 Connecticut $2,962,088,094 684,717 $4,326 Delaware $601,182,212 122,948 $4,890 District of Columbia $830,258,078 140,720 $5,900 Florida $8,398,159,525 2,458,609 $3,416 Georgia $3,815,267,274 1,256,990 $3,035 Hawaii Idaho $713,433,025 157,121 $4,541 Illinois $14,838,487,574 1,655,837 $8,961 Indiana $3,355,995,714 771,785 $4,348 Iowa $1,660,864,098 319,741 $5,194 Kansas $1,370,248,183 272,783 $5,023 Kentucky $3,235,072,953 807,435 $4,007 Louisiana $2,779,206,115 740,730 $3,752 Maine Maryland $3,855,002,531 634,273 $6,078 Massachusetts $5,765,107,723 1,039,979 $5,543 Michigan $5,316,248,739 1,352,418 $3,931 Minnesota $3,766,604,923 609,314 $6,182 Mississippi $2,180,662,071 707,899 $3,080 Missouri $3,626,212,602 978,546 $3,706 Montana $482,543,436 107,708 $4,480 Nebraska $1,089,787,848 242,901 $4,487 Nevada $565,299,853 133,103 $4,247 New Hampshire $691,195,787 97,062 $7,121 New Jersey $5,011,794,888 898,685 $5,577 New Mexico $1,476,537,827 379,207 $3,894 New York $27,497,918,486 3,039,436 $9,047 North Carolina $5,499,093,501 1,304,684 $4,215 North Dakota Ohio $7,772,738,205 1,413,925 $5,497 Oklahoma $2,004,799,211 570,671 $3,513 Oregon Pennsylvania Rhode Island South Carolina $3,096,853,528 760,797 $4,071 South Dakota $426,633,598 109,461 $3,898 Tennessee $4,059,332,053 1,602,027 $2,534 Texas $9,644,600,358 2,659,682 $3,626 Utah $1,059,729,740 232,520 $4,558 Vermont $541,283,084 149,262 $3,626 Virginia $2,715,962,318 618,395 $4,392 Washington West Virginia $1,565,008,585 349,229 $4,481 Wisconsin $3,029,722,940 633,463 $4,783 Wyoming $241,187,030 51,068 $4,723 *2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Source: CMS, MSIS Report, FY 2001.



Drug Payments and Recipients, 2000

*Puerto Rico and the U.S. Territories are not included in the national totals. ** Hawaii data is for FY1999 Source: CMS, MSIS Report, FY 2000.

State Total Drug Payments Total Drug Recipients Drug Payments per Recipient National Total* $20,013,770,558 20,516,882 $975 Alabama $331,574,388 438,529 $756 Alaska $51,196,685 60,273 $849 Arizona $1,952,231 7,034 $278 Arkansas $209,933,612 290,749 $722 California $2,316,135,493 2,487,875 $931 Colorado $152,478,786 160,264 $951 Connecticut $264,641,409 113,089 $2,340 Delaware $66,263,771 78,167 $848 District of Columbia $55,092,178 38,129 $1,445 Florida $1,366,193,807 1,072,082 $1,274 Georgia $580,612,920 847,730 $685 Hawaii** $44,849,664 35,687 $1,257 Idaho $83,525,730 92,776 $900 Illinois $847,001,431 1,013,254 $836 Indiana $464,982,829 420,041 $1,107 Iowa $193,832,443 212,178 $914 Kansas $167,216,488 158,334 $1,056 Kentucky $465,178,958 427,514 $1,088 Louisiana $476,400,908 581,356 $819 Maine $175,938,952 148,049 $1,188 Maryland $374,121,433 409,511 $914 Massachusetts $682,519,910 666,627 $1,024 Michigan $374,334,359 435,654 $859 Minnesota $221,682,000 180,104 $1,231 Mississippi $370,355,016 415,925 $890 Missouri $600,484,118 447,062 $1,343 Montana $58,634,278 58,899 $996 Nebraska $135,355,734 165,891 $816 Nevada $51,682,326 51,169 $1,010 New Hampshire $80,562,181 73,313 $1,099 New Jersey $584,533,211 298,450 $1,959 New Mexico $57,502,713 67,238 $855 New York $2,366,900,006 2,173,791 $1,089 North Carolina $794,550,074 827,039 $961 North Dakota $38,076,519 38,957 $977 Ohio $882,579,749 777,632 $1,135 Oklahoma $178,254,361 221,984 $803 Oregon $163,263,562 191,901 $851 Pennsylvania $533,527,373 416,498 $1,281 Rhode Island $89,482,143 49,809 $1,797 South Carolina $334,740,332 474,465 $706 South Dakota $44,650,518 53,666 $832 Tennessee $0 0 $0 Texas $1,125,238,856 1,852,801 $607 Utah $100,794,076 133,164 $757 Vermont $91,724,918 103,228 $889 Virginia $382,471,744 347,251 $1,101 Washington $387,877,281 339,440 $1,143 West Virginia $216,077,217 261,544 $826 Wisconsin $349,558,072 267,417 $1,307 Wyoming $27,233,795 33,342 $817



Drug Payments and Recipients, 2001*

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Source: CMS, MSIS Report, FY 2001.

State Total Drug Payments Total Drug Recipients Drug Payments per Recipient National Total Alabama Alaska $64,923,574 65,278 $995 Arizona $4,254,191 9,761 $436 Arkansas $248,392,084 321,920 $772 California $2,808,298,437 2,486,910 $1,129 Colorado $177,115,553 143,169 $1,237 Connecticut $304,470,534 116,755 $2,608 Delaware $81,623,058 85,351 $956 District of Columbia $62,292,004 35,324 $1,763 Florida $1,487,935,645 1,159,155 $1,284 Georgia $655,515,772 856,797 $765 Hawaii Idaho $105,473,425 112,357 $939 Illinois $975,308,665 1,068,512 $913 Indiana $562,120,344 464,879 $1,209 Iowa $230,430,967 221,691 $1,039 Kansas $189,290,260 158,515 $1,194 Kentucky $598,093,343 475,365 $1,258 Louisiana $547,731,897 594,364 $922 Maine Maryland $417,080,496 413,755 $1,008 Massachusetts $795,309,302 664,891 $1,196 Michigan $604,759,491 551,593 $1,096 Minnesota $265,240,353 188,566 $1,407 Mississippi $494,805,247 478,404 $1,034 Missouri $680,574,899 472,624 $1,440 Montana $69,552,397 63,338 $1,098 Nebraska $161,577,499 178,365 $906 Nevada $62,849,319 55,580 $1,131 New Hampshire $90,927,579 73,489 $1,237 New Jersey $649,274,352 307,798 $2,109 New Mexico $70,147,344 75,669 $927 New York $2,779,026,904 2,283,293 $1,217 North Carolina $971,066,103 907,413 $1,070 North Dakota Ohio $1,087,552,923 904,380 $1,203 Oklahoma $215,717,760 249,678 $864 Oregon Pennsylvania Rhode Island South Carolina $438,498,935 542,764 $808 South Dakota $52,608,524 58,203 $904 Tennessee $0 0 $0 Texas $1,327,222,456 1,917,351 $692 Utah $117,101,302 136,682 $857 Vermont $105,673,417 109,328 $967 Virginia $419,133,293 333,880 $1,255 Washington West Virginia $256,395,319 269,174 $953 Wisconsin $389,373,521 262,238 $1,485 Wyoming $31,881,860 36,704 $869



Drug Payment Trends, Percent Change 1999-2000

State 1999 2000 Percent Change National Total* $16,566,787,283 $20,013,770,558 20.8% Alabama $281,017,085 $331,574,388 18.0% Alaska $39,414,646 $51,196,685 29.9% Arizona $1,458,590 $1,952,231 33.8% Arkansas $182,862,001 $209,933,612 14.8% California $1,883,865,448 $2,316,135,493 22.9% Colorado $130,546,904 $152,478,786 16.8% Connecticut $220,556,702 $264,641,409 20.0% Delaware $53,443,101 $66,263,771 24.0% District of Columbia $44,963,481 $55,092,178 22.5% Florida $1,092,855,918 $1,366,193,807 25.0% Georgia $462,992,436 $580,612,920 25.4% Hawaii** $44,849,664 - Idaho $68,618,868 $83,525,730 21.7% Illinois $670,336,480 $847,001,431 26.4% Indiana $375,534,082 $464,982,829 23.8% Iowa $169,142,312 $193,832,443 14.6% Kansas $139,664,907 $167,216,488 19.7% Kentucky $359,671,170 $465,178,958 29.3% Louisiana $405,754,264 $476,400,908 17.4% Maine $145,653,294 $175,938,952 20.8% Maryland $291,435,049 $374,121,433 28.4% Massachusetts $594,321,506 $682,519,910 14.8% Michigan $320,544,345 $374,334,359 16.8% Minnesota $184,423,517 $221,682,000 20.2% Mississippi $274,594,293 $370,355,016 34.9% Missouri $482,087,676 $600,484,118 24.6% Montana $47,841,127 $58,634,278 22.6% Nebraska $115,303,037 $135,355,734 17.4% Nevada $40,265,800 $51,682,326 28.4% New Hampshire $64,895,522 $80,562,181 24.1% New Jersey $491,431,380 $584,533,211 18.9% New Mexico $46,998,841 $57,502,713 22.3% New York*** $1,972,517,591 $2,366,900,006 20.0% North Carolina $611,309,477 $794,550,074 30.0% North Dakota $31,584,648 $38,076,519 20.6% Ohio $761,987,389 $882,579,749 15.8% Oklahoma $167,704,485 $178,254,361 6.3% Oregon $123,806,352 $163,263,562 31.9% Pennsylvania $605,729,789 $533,527,373 -11.9% Rhode Island $75,139,107 $89,482,143 19.1% South Carolina $268,317,914 $334,740,332 24.8% South Dakota $37,044,912 $44,650,518 20.5% Tennessee $0 $0 0.0% Texas $952,419,862 $1,125,238,856 18.1% Utah $83,321,189 $100,794,076 21.0% Vermont $66,833,720 $91,724,918 37.2% Virginia $327,518,802 $382,471,744 16.8% Washington $303,391,865 $387,877,281 27.8% West Virginia $195,644,951 $216,077,217 10.4% Wisconsin $277,770,270 $349,558,072 25.8% Wyoming $22,251,178 $27,233,795 22.4%

* Puerto Rico and the U.S. Trust Territories are not included in the national totals. ** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report. *** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting. Source: CMS, MSIS Report, FY 1999 and 2000.



Drug Payment Trends, Percent Change 2000-2001*

State 2000 2001 Percent Change National Total** $20,013,770,558 Alabama $331,574,388 Alaska $51,196,685 $64,923,574 26.81% Arizona $1,952,231 $4,254,191 117.91% Arkansas $209,933,612 $248,392,084 18.32% California $2,316,135,493 $2,808,298,437 21.25% Colorado $152,478,786 $177,115,553 16.16% Connecticut $264,641,409 $304,470,534 15.05% Delaware $66,263,771 $81,623,058 23.18% District of Columbia $55,092,178 $62,292,004 13.07% Florida $1,366,193,807 $1,487,935,645 8.91% Georgia $580,612,920 $655,515,772 12.90% Hawaii Idaho $83,525,730 $105,473,425 26.28% Illinois $847,001,431 $975,308,665 15.15% Indiana $464,982,829 $562,120,344 20.89% Iowa $193,832,443 $230,430,967 18.88% Kansas $167,216,488 $189,290,260 13.20% Kentucky $465,178,958 $598,093,343 28.57% Louisiana $476,400,908 $547,731,897 14.97% Maine $175,938,952 Maryland $374,121,433 $417,080,496 11.48% Massachusetts $682,519,910 $795,309,302 16.53% Michigan $374,334,359 $604,759,491 61.56% Minnesota $221,682,000 $265,240,353 19.65% Mississippi $370,355,016 $494,805,247 33.60% Missouri $600,484,118 $680,574,899 13.34% Montana $58,634,278 $69,552,397 18.62% Nebraska $135,355,734 $161,577,499 19.37% Nevada $51,682,326 $62,849,319 21.61% New Hampshire $80,562,181 $90,927,579 12.87% New Jersey $584,533,211 $649,274,352 11.08% New Mexico $57,502,713 $70,147,344 21.99% New York $2,366,900,006 $2,779,026,904 17.41% North Carolina $794,550,074 $971,066,103 22.22% North Dakota $38,076,519 Ohio $882,579,749 $1,087,552,923 23.22% Oklahoma $178,254,361 $215,717,760 21.02% Oregon $163,263,562 Pennsylvania $533,527,373 Rhode Island $89,482,143 South Carolina $334,740,332 $438,498,935 31.00% South Dakota $44,650,518 $52,608,524 17.82% Tennessee $0 $0 0.00% Texas $1,125,238,856 $1,327,222,456 17.95% Utah $100,794,076 $117,101,302 16.18% Vermont $91,724,918 $105,673,417 15.21% Virginia $382,471,744 $419,133,293 9.59% Washington $387,877,281 West Virginia $216,077,217 $256,395,319 18.66% Wisconsin $349,558,072 $389,373,521 11.39% Wyoming $27,233,795 $31,881,860 17.07%

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. ** Puerto Rico and the U.S. Trust Territories are not included in the national totals. Source: CMS, MSIS Report, FY 2000 and 2001.



Rankings Based on Drug Payments

State 2000 Payments 2000 Ranking

% of 2000 Total Medicaid Drug Payments

1999 Payments 1999 Ranking

New York*** $2,366,900,006 1 11.83% $1,972,517,591 1 California $2,316,135,493 2 11.57% $1,883,865,448 2 Florida $1,366,193,807 3 6.83% $1,092,855,918 3 Texas $1,125,238,856 4 5.62% $952,419,862 4 Ohio $882,579,749 5 4.41% $761,987,389 5 Illinois $847,001,431 6 4.23% $670,336,480 6 North Carolina $794,550,074 7 3.97% $611,309,477 7 Massachusetts $682,519,910 8 3.41% $594,321,506 9 Missouri $600,484,118 9 3.00% $482,087,676 11 New Jersey $584,533,211 10 2.92% $491,431,380 10 Georgia $580,612,920 11 2.90% $462,992,436 12 Pennsylvania $533,527,373 12 2.67% $605,729,789 8 Louisiana $476,400,908 13 2.38% $405,754,264 13 Kentucky $465,178,958 14 2.32% $359,671,170 15 Indiana $464,982,829 15 2.32% $375,534,082 14 Washington $387,877,281 16 1.94% $303,391,865 18 Virginia $382,471,744 17 1.91% $327,518,802 16 Michigan $374,334,359 18 1.87% $320,544,345 17 Maryland $374,121,433 19 1.87% $291,435,049 19 Mississippi $370,355,016 20 1.85% $274,594,293 22 Wisconsin $349,558,072 21 1.75% $277,770,270 21 South Carolina $334,740,332 22 1.67% $268,317,914 23 Alabama $331,574,388 23 1.66% $281,017,085 20 Connecticut $264,641,409 24 1.32% $220,556,702 24 Minnesota $221,682,000 25 1.11% $184,423,517 26 West Virginia $216,077,217 26 1.08% $195,644,951 25 Arkansas $209,933,612 27 1.05% $182,862,001 27 Iowa $193,832,443 28 0.97% $169,142,312 28 Oklahoma $178,254,361 29 0.89% 167704485 29 Maine $175,938,952 30 0.88% $145,653,294 30 Kansas $167,216,488 31 0.84% $139,664,907 31 Oregon $163,263,562 32 0.82% $123,806,352 33 Colorado $152,478,786 33 0.76% $130,546,904 32 Nebraska $135,355,734 34 0.68% $115,303,037 34 Utah $100,794,076 35 0.50% $83,321,189 35 Vermont $91,724,918 36 0.46% $66,833,720 38 Rhode Island $89,482,143 37 0.45% $75,139,107 36 Idaho $83,525,730 38 0.42% $68,618,868 37 New Hampshire $80,562,181 39 0.40% $64,895,522 39 Delaware $66,263,771 40 0.33% $53,443,101 40 Montana $58,634,278 41 0.29% $47,841,127 41 New Mexico $57,502,713 42 0.29% $46,998,841 42 District of Columbia $55,092,178 43 0.28% $44,963,481 43 Nevada $51,682,326 44 0.26% $40,265,800 44 Alaska $51,196,685 45 0.26% $39,414,646 45 Hawaii** $44,849,664 46 0.22% - - South Dakota $44,650,518 47 0.22% $37,044,912 46 North Dakota $38,076,519 48 0.19% $31,584,648 47 Wyoming $27,233,795 49 0.14% $22,251,178 48 Arizona $1,952,231 50 0.01% $1,458,590 49 Tennessee $0 51 - $0 50

** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report. *** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting. Source: CMS, MSIS Report, FY 1999 and 2000.



Drugs as a Percentage of Total Payments, 2000

State Drug Payments Total Payments Percent of Total Payments National Total* $20,013,770,558 $168,307,231,426 11.9% Alabama $331,574,388 $2,391,194,897 13.9% Alaska $51,196,685 $470,249,823 10.9% Arizona $1,952,231 $2,111,769,849 0.1% Arkansas $209,933,612 $1,510,079,842 13.9% California $2,316,135,493 $17,060,494,184 13.6% Colorado $152,478,786 $1,808,569,210 8.4% Connecticut $264,641,409 $2,839,310,317 9.3% Delaware $66,263,771 $528,339,689 12.5% District of Columbia $55,092,178 $792,584,432 7.0% Florida $1,366,193,807 $7,350,363,024 18.6% Georgia $580,612,920 $3,577,903,288 16.2% Hawaii** $44,849,664 $535,162,729 8.4% Idaho $83,525,730 $593,750,993 14.1% Illinois $847,001,431 $7,807,447,335 10.8% Indiana $464,982,829 $2,976,177,145 15.6% Iowa $193,832,443 $1,476,340,040 13.1% Kansas $167,216,488 $1,226,210,559 13.6% Kentucky $465,178,958 $2,912,792,289 16.0% Louisiana $476,400,908 $2,630,563,430 18.1% Maine $175,938,952 $1,306,809,473 13.5% Maryland $374,121,433 $3,585,781,047 10.4% Massachusetts $682,519,910 $5,397,153,356 12.6% Michigan $374,334,359 $4,880,769,009 7.7% Minnesota $221,682,000 $3,277,014,103 6.8% Mississippi $370,355,016 $1,807,391,891 20.5% Missouri $600,484,118 $3,270,152,458 18.4% Montana $58,634,278 $433,207,577 13.5% Nebraska $135,355,734 $958,490,235 14.1% Nevada $51,682,326 $515,444,377 10.0% New Hampshire $80,562,181 $650,594,289 12.4% New Jersey $584,533,211 $4,706,928,703 12.4% New Mexico $57,502,713 $1,248,764,305 4.6% New York $2,366,900,006 $26,147,613,087 9.1% North Carolina $794,550,074 $4,830,025,832 16.5% North Dakota $38,076,519 $356,184,829 10.7% Ohio $882,579,749 $7,090,395,763 12.4% Oklahoma $178,254,361 $1,603,788,998 11.1% Oregon $163,263,562 $1,700,408,573 9.6% Pennsylvania $533,527,373 $6,365,806,031 8.4% Rhode Island $89,482,143 $1,069,994,225 8.4% South Carolina $334,740,332 $2,672,145,530 12.5% South Dakota $44,650,518 $401,175,221 11.1% Tennessee $0 $3,490,956,581 - Texas $1,125,238,856 $9,075,305,586 12.4% Utah $100,794,076 $959,100,396 10.5% Vermont $91,724,918 $479,258,616 19.1% Virginia $382,471,744 $2,483,930,711 15.4% Washington $387,877,281 $2,432,050,117 15.9% West Virginia $216,077,217 $1,391,731,163 15.5% Wisconsin $349,558,072 $2,905,598,526 12.0% Wyoming $27,233,795 $213,957,743 12.7%

*Puerto Rico and the U.S. Territories are not included in the national totals. **Hawaii data is for FY 1999. Source: CMS, MSIS Report, FY 2000



Drugs as a Percentage of Total Payments, 2001*

State Drug Payments Total Payments Percent of Total Payments National Total Alabama Alaska $64,923,574 $557,398,672 11.6% Arizona $4,254,191 $2,453,184,175 0.2% Arkansas $248,392,084 $1,684,717,766 14.7% California $2,808,298,437 $19,824,989,448 14.2% Colorado $177,115,553 $1,952,708,545 9.1% Connecticut $304,470,534 $2,962,088,094 10.3% Delaware $81,623,058 $601,182,212 13.6% District of Columbia $62,292,004 $830,258,078 7.5% Florida $1,487,935,645 $8,398,159,525 17.7% Georgia $655,515,772 $3,815,267,274 17.2% Hawaii Idaho $105,473,425 $713,433,025 14.8% Illinois $975,308,665 $14,838,487,574 6.6% Indiana $562,120,344 $3,355,995,714 16.7% Iowa $230,430,967 $1,660,864,098 13.9% Kansas $189,290,260 $1,370,248,183 13.8% Kentucky $598,093,343 $3,235,072,953 18.5% Louisiana $547,731,897 $2,779,206,115 19.7% Maine Maryland $417,080,496 $3,855,002,531 10.8% Massachusetts $795,309,302 $5,765,107,723 13.8% Michigan $604,759,491 $5,316,248,739 11.4% Minnesota $265,240,353 $3,766,604,923 7.0% Mississippi $494,805,247 $2,180,662,071 22.7% Missouri $680,574,899 $3,626,212,602 18.8% Montana $69,552,397 $482,543,436 14.4% Nebraska $161,577,499 $1,089,787,848 14.8% Nevada $62,849,319 $565,299,853 11.1% New Hampshire $90,927,579 $691,195,787 13.2% New Jersey $649,274,352 $5,011,794,888 13.0% New Mexico $70,147,344 $1,476,537,827 4.8% New York $2,779,026,904 $27,497,918,486 10.1% North Carolina $971,066,103 $5,499,093,501 17.7% North Dakota Ohio $1,087,552,923 $7,772,738,205 14.0% Oklahoma $215,717,760 $2,004,799,211 10.8% Oregon Pennsylvania Rhode Island South Carolina $438,498,935 $3,096,853,528 14.2% South Dakota $52,608,524 $426,633,598 12.3% Tennessee $0 $4,059,332,053 0.0% Texas $1,327,222,456 $9,644,600,358 13.8% Utah $117,101,302 $1,059,729,740 11.1% Vermont $105,673,417 $541,283,084 19.5% Virginia $419,133,293 $2,715,962,318 15.4% Washington West Virginia $256,395,319 $1,565,008,585 16.4% Wisconsin $389,373,521 $3,029,722,940 12.9% Wyoming $31,881,860 $241,187,030 13.2%

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Source: CMS, MSIS Report, FY 2001



Drugs as a Percentage of Total Payments, 1996 - 2001

State 1996 1997 1998 1999 2000 2001* National Total** 8.8% 9.7% 9.5% 10.9% 11.9% Alabama 13.9% 14.4% 12.4% 16.6% 13.9% Alaska 7.8% 8.8% 10.0% 9.9% 10.9% 11.6% Arizona 1.2% 0.8% 0.1% 0.1% 0.1% 0.2% Arkansas 9.4% 10.4% 11.0% 13.4% 13.9% 14.7% California 11.0% 11.7% 10.9% 12.2% 13.6% 14.2% Colorado 8.0% 8.6% 7.7% 8.0% 8.4% 9.1% Connecticut 7.2% 8.3% 7.7% 8.3% 9.3% 10.3% Delaware 9.0% 12.6% 9.9% 11.6% 12.5% 13.6% District of Columbia 4.6% 5.4% 5.6% 5.9% 7.0% 7.5% Florida 14.1% 15.8% 16.4% 17.0% 18.6% 17.7% Georgia 10.3% 11.0% 12.3% 14.3% 16.2% 17.2% Hawaii*** 10.1% - 7.8% - 8.4% Idaho 10.1% 10.4% 12.9% 13.2% 14.1% 14.8% Illinois 8.3% 9.1% 9.4% 10.6% 10.8% 6.6% Indiana 11.0% 12.3% 12.7% 13.7% 15.6% 16.7% Iowa 10.2% 11.4% 11.4% 12.4% 13.1% 13.9% Kansas 10.5% 11.4% 13.0% 12.7% 13.6% 13.8% Kentucky 14.1% 13.9% 13.2% 13.8% 16.0% 18.5% Louisiana 12.1% 13.5% 14.8% 16.0% 18.1% 19.7% Maine 11.6% 13.2% 16.3% 12.1% 13.5% Maryland 7.6% 7.8% 6.0% 9.6% 10.4% 10.8% Massachusetts 8.0% 10.3% 10.8% 12.0% 12.6% 13.8% Michigan 10.5% 10.2% 8.6% 6.8% 7.7% 11.4% Minnesota 6.2% 6.6% 5.9% 6.1% 6.8% 7.0% Mississippi 13.2% 14.6% 16.1% 17.2% 20.5% 22.7% Missouri 14.0% 15.3% 14.9% 17.2% 18.4% 18.8% Montana 9.3% 11.2% 11.7% 13.1% 13.5% 14.4% Nebraska 10.5% 11.5% 12.3% 13.2% 14.1% 14.8% Nevada 6.7% 7.1% 7.5% 8.8% 10.0% 11.1% New Hampshire 7.7% 8.2% 9.1% 12.3% 12.4% 13.2% New Jersey 10.0% 10.4% 10.1% 11.2% 12.4% 13.0% New Mexico 7.0% 7.7% 4.8% 4.2% 4.6% 4.8% New York**** 4.1% 5.1% 5.6% 7.8% 9.1% 10.1% North Carolina 9.4% 10.7% 11.6% 14.3% 16.5% 17.7% North Dakota 7.0% 7.7% 8.1% 9.1% 10.7% Ohio 9.4% 9.9% 10.5% 12.0% 12.4% 14.0% Oklahoma***** 9.6% 10.7% - 11.7% 11.1% 10.8% Oregon 5.1% 5.0% 6.4% 7.8% 9.6% Pennsylvania 11.5% 11.8% 8.6% 9.9% 8.4% Rhode Island 6.7% 7.1% 6.7% 8.5% 8.4% South Carolina 9.4% 9.9% 11.1% 10.9% 12.5% 14.2% South Dakota 7.6% 8.7% 8.7% 10.0% 11.1% 12.3% Tennessee 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Texas 9.7% 10.2% 11.5% 11.7% 12.4% 13.8% Utah 11.4% 12.0% 11.1% 10.5% 10.5% 11.1% Vermont 12.1% 14.4% 12.4% 15.9% 19.1% 19.5% Virginia 12.5% 13.4% 13.4% 14.8% 15.4% 15.4% Washington 12.4% 14.7% 12.0% 11.8% 15.9% West Virginia 11.1% 10.6% 12.0% 14.6% 15.5% 16.4% Wisconsin 10.8% 10.9% 10.5% 12.4% 12.0% 12.9% Wyoming 7.5% 8.1% 8.9% 11.2% 12.7% 13.2%

* FY 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. **Puerto Rico and the U.S. Territories are not included in the national totals. ***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. ****New York did not provide Quarter 1 MSIS data for FY 1999 and was included based on totals estimated from State hard-copy reporting. *****Oklahoma did not report for FY 1998 and was excluded from the national total for that year. Source: CMS, HCFA-2082 Reports, FY 1996-FY 1998 and MSIS Reports, FY 1999-2001.



Total Drug Recipients ‡

State 1996 1997 1998 1999 2000 2001*National Total** 22,575,656 20,943,872 19,324,605 19,854,953 20,516,082 Alabama 412,511 412,739 395,290 405,338 438,529 Alaska 40,839 42,174 43,734 52,086 60,273 65,278 Arizona 63,103 80,450 56,796 5,545 7,034 9,761 Arkansas 255,211 254,079 262,907 280,573 290,749 321,920 California 3,565,667 3,158,386 2,644,430 2,264,942 2,487,875 2,486,910 Colorado 173,707 156,631 147,033 151,581 160,264 143,169 Connecticut 209,557 120,522 108,331 108,753 113,089 116,755 Delaware 61,380 68,672 69,027 73,093 78,167 85,351 District of Columbia 66,349 64,494 57,733 37,862 38,129 35,324 Florida 1,079,467 1,024,555 1,014,372 1,079,997 1,072,082 1,159,155 Georgia 891,335 846,963 805,923 841,024 847,730 856,797 Hawaii*** 29,657 - 32,222 35,687 35,687 Idaho 84,553 79,961 86,775 81,943 92,776 112,357 Illinois 1,028,753 1,008,740 959,472 965,747 1,013,254 1,068,512 Indiana 401,042 352,814 323,811 361,784 420,041 464,879 Iowa 230,749 221,061 215,173 213,161 212,178 221,691 Kansas 179,653 170,167 155,875 153,117 158,334 158,515 Kentucky 497,251 494,293 429,102 372,254 427,514 475,365 Louisiana 593,415 563,864 552,481 549,296 581,356 594,364 Maine 138,360 139,524 137,816 142,043 148,049 Maryland 268,440 256,423 176,403 345,740 409,511 413,755 Massachusetts 527,114 559,215 613,186 664,528 666,627 664,891 Michigan 763,232 688,882 589,818 436,652 435,654 551,593 Minnesota 294,589 227,027 203,220 184,947 180,104 188,566 Mississippi 404,263 391,328 368,609 375,585 415,925 478,404 Missouri 469,821 395,478 353,902 411,959 447,062 472,624 Montana 66,465 62,092 58,641 59,204 58,899 63,338 Nebraska 138,322 151,973 145,408 155,169 165,891 178,365 Nevada 60,274 55,876 50,903 48,535 51,169 55,580 New Hampshire 75,701 71,692 70,339 71,037 73,313 73,489 New Jersey 518,833 347,105 309,849 302,687 298,450 307,798 New Mexico 197,565 184,502 96,637 55,020 67,238 75,669 New York 1,737,372 1,667,927 1,803,428 2,193,515 2,173,791 2,283,293 North Carolina 764,482 779,229 764,886 797,903 827,039 907,413 North Dakota 40,062 39,654 37,675 38,191 38,957 Ohio 902,211 786,322 702,143 796,720 777,632 904,380 Oklahoma**** 245,075 207,441 - 224,742 221,984 249,678 Oregon 154,801 149,461 148,258 171,997 191,101 Pennsylvania 857,818 763,255 580,749 520,251 416,498 Rhode Island 52,239 46,817 44,852 49,285 49,809 South Carolina 365,409 359,910 401,611 446,938 474,465 542,764 South Dakota 49,056 47,845 46,588 50,783 53,666 58,203 Tennessee^ 18 3 1 0 0 0 Texas 2,058,903 1,986,178 1,894,447 1,853,536 1,852,801 1,917,351 Utah 114,321 105,676 126,953 128,297 133,164 136,682 Vermont 78,376 83,057 58,037 88,322 103,228 109,328 Virginia 417,580 396,719 383,880 373,491 347,251 333,880 Washington 305,791 292,733 274,463 301,753 339,440 West Virginia 299,967 280,550 267,398 274,842 261,544 269,174 Wisconsin 309,582 265,987 221,508 224,213 267,417 262,238 Wyoming 35,415 33,426 32,510 33,285 33,342 36,704

‡ Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. * FY 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. **Puerto Rico and the U.S. Territories are not included in the national totals. ***Hawaii did not report on time for FY 1997. They are excluded from the national total for that year. Hawaii also did not report for FY 2000. Their FY 1999 data is included in the FY 2000 Total. ****Oklahoma did not report for FY 1998. They are excluded from the national total for that year. ^Tennessee does not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these plans.



Source: CMS, HCFA-2082 Report, FY 1996-FY1998 and MSIS Report, FY 1999-2001.



Total Medicaid Eligibles by Basis of Eligibility, 2001*

State Total Eligibles

Age 65And Older

Blind/Disabled Children Adults

Foster Care/Children

BOEUnknown

National Total Alabama Alaska 115,996 6,403 11,443 70,446 25,920 1,772 12Arizona 808,386 37,102 102,909 430,749 229,944 7,682 0Arkansas 550,668 52,240 104,421 267,241 120,840 5,913 13California 8,495,030 626,550 959,584 3,169,960 3,598,569 140,366 1Colorado 410,611 46,708 65,407 202,166 79,337 16,878 115Connecticut 446,326 59,510 58,579 234,953 84,401 8,862 21Delaware 133,079 9,613 16,500 59,452 45,580 1,934 0District of Columbia 152,597 9,957 31,334 71,667 35,007 4,632 0Florida 2,462,171 248,466 478,847 1,190,510 503,789 40,545 14Georgia 1,328,379 109,245 229,725 717,007 253,525 18,877 0Hawaii Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0Illinois 1,796,814 112,122 282,418 952,300 367,676 82,235 63Indiana 825,556 78,267 113,799 484,090 137,344 12,056 0Iowa 331,025 41,128 57,426 157,333 65,498 9,640 0Kansas 291,837 31,659 52,513 150,022 44,424 13,219 0Kentucky 762,871 70,730 207,524 374,318 101,494 8,805 0Louisiana 886,518 101,002 173,725 499,771 102,480 9,540 0Maine Maryland 704,628 54,654 114,951 386,346 132,309 16,367 1Massachusetts 1,125,607 112,994 235,157 453,373 323,473 610 0Michigan 1,430,246 100,156 288,790 744,902 255,755 40,564 79Minnesota 609,856 64,108 83,579 309,972 142,313 9,884 0Mississippi 681,161 74,018 159,306 369,654 74,943 3,224 16Missouri 1,032,047 95,603 140,938 538,423 233,282 23,801 0Montana 101,966 9,952 17,757 50,954 19,335 3,947 21Nebraska 249,079 23,026 28,877 138,980 47,826 10,121 249Nevada 167,247 17,920 29,993 79,283 35,217 4,834 0New Hampshire 108,562 12,833 13,507 63,942 15,675 2,605 0New Jersey 923,697 106,976 164,564 436,335 195,988 19,834 0New Mexico 423,543 22,605 50,326 268,391 78,634 3,587 0New York 3,548,630 385,586 684,658 1,573,767 825,201 79,418 0North Carolina 1,397,486 180,515 234,304 685,285 281,193 16,189 0North Dakota Ohio 1,660,463 145,324 263,878 861,621 348,936 40,533 171Oklahoma 631,996 62,350 76,638 397,586 88,507 6,915 0Oregon Pennsylvania Rhode Island South Carolina 871,675 78,673 120,088 444,607 220,606 7,692 9South Dakota 106,154 9,894 16,042 61,743 16,704 1,771 0Tennessee 1,601,406 88,350 324,191 682,755 493,266 12,822 22Texas 2,729,660 362,522 351,509 1,526,365 458,079 31,185 0Utah 214,597 11,855 26,386 119,196 50,579 6,581 0Vermont 154,991 19,534 18,529 67,666 46,876 2,382 4Virginia 700,715 97,093 137,282 359,463 92,543 14,334 0Washington West Virginia 351,489 31,183 86,566 168,367 58,889 6,484 0Wisconsin 673,538 61,165 133,983 299,529 160,354 18,505 2Wyoming 58,013 4,984 8,476 32,076 10,638 1,839 0

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. Source: CMS, MSIS Report, FY 2001.



Total Medicaid Eligibles Per 1000 Population, 2001*

State


Total Eligibles

Eligibles per1000 Populations

National Total 285,317,559 Alabama 4,468,912 Alaska 633,630 115,996 183.1Arizona 5,306,966 808,386 152.3Arkansas 2,694,698 550,668 204.4California 34,600,463 8,495,030 245.5Colorado 4,430,989 410,611 92.7Connecticut 3,434,602 446,326 129.9Delaware 796,599 133,079 167.1District of Columbia 573,822 152,597 265.9Florida 16,373,330 2,462,171 150.4Georgia 8,405,677 1,328,379 158.0Hawaii 1,227,024 Idaho 1,320,585 172,348 130.5Illinois 12,520,227 1,796,814 143.5Indiana 6,126,743 825,556 134.7Iowa 2,931,967 331,025 112.9Kansas 2,702,125 291,837 108.0Kentucky 4,068,816 762,871 187.5Louisiana 4,470,368 886,518 198.3Maine 1,284,470 Maryland 5,386,079 704,628 130.8Massachusetts 6,401,164 1,125,607 175.8Michigan 10,006,266 1,430,246 142.9Minnesota 4,984,535 609,856 122.3Mississippi 2,859,733 681,161 238.2Missouri 5,637,309 1,032,047 183.1Montana 905,382 101,966 112.6Nebraska 1,720,039 249,079 144.8Nevada 2,097,722 167,247 79.7New Hampshire 1,259,359 108,562 86.2New Jersey 8,511,116 923,697 108.5New Mexico 1,830,935 423,543 231.3New York 19,084,350 3,548,630 185.9North Carolina 8,206,105 1,397,486 170.3North Dakota 636,550 Ohio 11,389,785 1,660,463 145.8Oklahoma 3,469,577 631,996 182.2Oregon 3,473,441 Pennsylvania 12,303,104 Rhode Island 1,059,659 South Carolina 4,062,125 871,675 214.6South Dakota 758,324 106,154 140.0Tennessee 5,749,398 1,601,406 278.5Texas 21,370,983 2,729,660 127.7Utah 2,278,712 214,597 94.2Vermont 612,978 154,991 252.8Virginia 7,196,750 700,715 97.4Washington 5,993,390 West Virginia 1,800,975 351,489 195.2Wisconsin 5,405,947 673,538 124.6Wyoming 493,754 58,013 117.5

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. 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, State Population Estimates; CMS, MSIS, FY 2001.



Medicaid Total Net Expenditures and Eligibles, 2001*

State


Total Eligibles

AveragePer Eligible

National Total $215,809,899,631 Alabama $2,875,372,953 Alaska $576,586,201 115,996 $4,971 Arizona $2,665,261,328 808,386 $3,297 Arkansas $1,852,176,546 550,668 $3,364 California $23,870,521,004 8,495,030 $2,810 Colorado $2,142,029,851 410,611 $5,217 Connecticut $3,213,848,086 446,326 $7,201 Delaware $591,974,246 133,079 $4,448 District of Columbia $979,941,105 152,597 $6,422 Florida $8,557,796,303 2,462,171 $3,476 Georgia $5,037,084,881 1,328,379 $3,792 Hawaii $634,781,970 Idaho $693,205,598 172,348 $4,022 Illinois $7,764,611,352 1,796,814 $4,321 Indiana $4,008,812,857 825,556 $4,856 Iowa $1,666,923,701 331,025 $5,036 Kansas $1,686,410,544 291,837 $5,779 Kentucky $3,304,053,663 762,871 $4,331 Louisiana $4,201,982,590 886,518 $4,740 Maine $1,315,523,163 Maryland $3,256,576,882 704,628 $4,622 Massachusetts $6,619,524,971 1,125,607 $5,881 Michigan $7,218,697,113 1,430,246 $5,047 Minnesota $3,835,870,579 609,856 $6,290 Mississippi $2,438,979,981 681,161 $3,581 Missouri $4,744,963,426 1,032,047 $4,598 Montana $482,357,404 101,966 $4,731 Nebraska $1,187,237,577 249,079 $4,767 Nevada $674,337,888 167,247 $4,032 New Hampshire $873,248,831 108,562 $8,044 New Jersey $7,123,653,988 923,697 $7,712 New Mexico $1,467,417,736 423,543 $3,465 New York $31,367,464,639 3,548,630 $8,839 North Carolina $6,150,681,587 1,397,486 $4,401 North Dakota $406,418,593 Ohio $8,433,412,161 1,660,463 $5,079 Oklahoma $2,021,033,069 631,996 $3,198 Oregon $2,658,358,391 Pennsylvania $10,908,343,146 Rhode Island $1,187,880,819 South Carolina $3,019,387,228 871,675 $3,464 South Dakota $464,455,469 106,154 $4,375 Tennessee $5,501,312,153 1,601,406 $3,435 Texas $11,583,679,558 2,729,660 $4,244 Utah $833,720,115 214,597 $3,885 Vermont $601,467,093 154,991 $3,881 Virginia $3,036,846,387 700,715 $4,334 Washington $4,305,724,247 West Virginia $1,548,398,817 351,489 $4,405 Wisconsin $3,976,142,914 673,538 $5,903 Wyoming $243,408,927 58,013 $4,196

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and Washington. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, 2001.


National Pharmaceutical Council C-1

Appendix C: Medicaid Rebate Law


C-2 National Pharmaceutical Council



TITLE 42 - THE PUBLIC HEALTH AND WELFARE CHAPTER 7 - SOCIAL SECURITY SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Sec. 1396r-8. Payment for covered outpatient drugs* (a) Requirement for rebate agreement (1) In general In order for payment to be available under section 1396b(a) of this title for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after November 4,1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be retroactively calculated as if the agreement between the manufacturer and the State had been entered into on January 1,1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an agreement, subsequently entered into, shall 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 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.



*This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.

(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 after November 4, 1992) and would have entered into an agreement under such section (as such section was in effect at such time), but for a legislative change in such section after November 4, 1992.



(b) Terms of rebate agreement (1) Periodic rebates

(A) In general A rebate agreement under this subsection shall require the manufacturer to provide, to each State plan approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for which payment was made under the State plan for such period. Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2) for the period involved. (B) Offset against medical assistance Amounts received by a State under this section (or under an agreement authorized by the Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) in any quarter shall be considered to be a reduction in the amount expended under the State plan in the quarter for medical assistance for purposes of section 1396b(a)(1) of this title.

(2) State provision of information

(A) State responsibility Each State agency under this subchapter shall report to each manufacturer not later than 60 days after the end of each rebate period and in a form consistent with a standard reporting format established by the Secretary, information on the total number of units of each dosage form and strength and package size of each covered outpatient drug dispensed after December 31, 1990, for which payment was made under the plan during the period, and shall promptly transmit a copy of such report to the Secretary. (B) Audits A manufacturer may audit the information provided (or required to be provided) under subparagraph (A). Adjustments to rebates shall be made to the extent that information indicates that utilization was greater or less than the amount previously specified.

(3) Manufacturer provision of price information

(A) In general Each manufacturer with an agreement in effect under this section shall report to the Secretary - (i) not later than 30 days after the last day of each rebate period under the agreement (beginning on or after January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the agreement, and (ii) not later than 30 days after the date of entering into an agreement under this section on the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 for each of the manufacturer’s covered outpatient drugs. (B) Verification surveys of average manufacturer price The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices reported under subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drug refuses a request for information about charges or prices by the Secretary in connection with a survey under this subparagraph or knowingly provides false information. The provisions of section 1320a-7a of this title (other than subsections (a) (with respect to amounts of penalties or additional assessments) and (b)) shall



apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title. (C) Penalties (i) Failure to provide timely information In the case of a manufacturer with an agreement under this section that fails to provide information required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by $10,000 for each day in which such information has not been provided and such amount shall be paid to the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the agreement shall be suspended for services furnished after the end of such 90-day period and until the date such information is reported (but in no case shall such suspension be for a period of less than 30 days). (ii) False information Any manufacturer with an agreement under this section that knowingly provides false information is subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions of section 1320a-7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title. (D) Confidentiality of information Notwithstanding any other provision of law, information disclosed by manufacturers or wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section is confidential and shall not be disclosed by the Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of a specific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler, except- (i) as the Secretary determines to be necessary to carry out this section, (ii) to permit the Comptroller General to review the information provided, and (iii) to permit the Director of the Congressional Budget Office to review the information provided.

(4) Length of agreement

(A) In general A rebate agreement shall be effective for an initial period of not less than 1 year and shall be automatically renewed for a period of not less than one year unless terminated under subparagraph (B). (B) Termination (i) By the Secretary The Secretary may provide for termination of a rebate agreement for violation of the requirements of the agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a hearing concerning such a termination, but such hearing shall not delay the effective date of the termination. (ii) By a manufacturer A manufacturer may terminate a rebate agreement under this section for any reason. Any such termination shall not be effective until the calendar quarter beginning at least 60 days after the date the manufacturer provides notice to the Secretary. (iii) Effectiveness of termination Any termination under this subparagraph shall not affect rebates due under the agreement before the effective date of its termination. (iv) Notice to States



In the case of a termination under this subparagraph, the Secretary shall provide notice of such termination to the States within not less than 30 days before the effective date of such termination. (v) Application to terminations of other agreements The provisions of this subparagraph shall apply to the terminations of agreements described in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title 38. (C) Delay before reentry

(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 - (i) the total number of units of each dosage form and strength paid for under the State plan in the rebate period (as reported by the State); and (ii) subject to subparagraph (B)(ii), the greater of -

(I) the difference between the average manufacturer price and the best price (as defined in subparagraph (C)) for the dosage form and strength of the drug, or (II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer price, for the rebate period.

(B) Range of rebates required (i) Minimum rebate percentage For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate periods beginning -

(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent; (II) after September 30, 1992, and before January 1, 1994, is 15.7 percent; (III) after December 31, 1993, and before January 1, 1995, is 15.4 percent; (IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and (V) after December 31, 1995, is 15.1 percent.

(ii) Temporary limitation on maximum rebate amount In no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning -

(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or (II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the average manufacturer price.

(C) “Best price” defined For purposes of this section - (i) In general The term “best price” means, with respect to a single source drug or innovator multiple source drug of a manufacturer, the lowest price available from the manufacturer during the rebate period to any wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity within the United States, excluding -

(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department of Veterans Affairs, a State home receiving funds under section 1741 of title 38, the Department of Defense, the Public Health Service, or a covered entity described in subsection (a)(5)(B) of this section;



(II) any prices charged under the Federal Supply Schedule of the General Services Administration; (III) any prices used under a State pharmaceutical assistance program; and (IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of the Federal Government.

(ii) Special rules The term “best price” -

(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement, volume discounts, and rebates (other than rebates under this section); (II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form or product or package; and (III) shall not take into account prices that are merely nominal in amount.

(2) Additional rebate for single source and innovator multiple source drugs

(A) In general The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount equal to the product of - (i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State plan for the rebate period; and (ii) the amount (if any) by which -

(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds (II) the average manufacturer price for such dosage form and strength for the calendar quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an entity, including a division or subsidiary of the manufacturer, after the first day of such quarter), increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index for September 1990

. (B) Treatment of subsequently approved drugs In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter after the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and “the month prior to the first month of the first full calendar quarter after the day on which the drug was first marketed” for “September 1990”.

(3) Rebate for other drugs

(A) In general The amount of the rebate paid to a State for a rebate period with respect to each dosage form and strength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs) shall be equal to the product of - (i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the dosage form and strength for the rebate period, and (ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State plan for the rebate period. (B) “Applicable percentage” defined For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning - (i) before January 1, 1994, is 10 percent, and (ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs



(1) Permissible restrictions

(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of paragraph (5). (B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if - (i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this section); (ii) the drug is contained in the list referred to in paragraph (2); (iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection (a)(4) of this section; or (iv) the State has excluded coverage of the drug from its formulary established in accordance with paragraph (4).

(2) List of drugs subject to restriction The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:

(A) Agents when used for anorexia, weight loss, or weight gain. (B) Agents when used to promote fertility. (C) Agents when used for cosmetic purposes or hair growth. (D) Agents when used for the symptomatic relief of cough and colds. (E) Agents when used to promote smoking cessation. (F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. (G) Nonprescription drugs. (H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. (I) Barbiturates. (J) Benzodiazepines.

(3) Update of drug listings The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by surveillance and utilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriate use. (4) Requirements for formularies A State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s drug use review board established under subsection (g)(3) of this section). (B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any manufacturer which has entered into and complies with an agreement under subsection (a) of this section (other than any drug excluded from coverage or otherwise restricted under paragraph (2)). (C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate compendia described in subsection (k)(6) of this section), the excluded drug does not have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such



treatment for such population over other drugs included in the formulary and there is a written explanation (available to the public) of the basis for the exclusion. (D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that is consistent with paragraph (5). (E) The formulary meets such other requirements as the Secretary may impose in order to achieve program savings consistent with protecting the health of program beneficiaries. A prior authorization program established by a State under paragraph (5) is not a formulary subject to the requirements of this paragraph.

(5) Requirements of prior authorization programs A State plan under this subchapter may require, as a condition of coverage or payment for a covered outpatient drug for which Federal financial participation is available in accordance with this section, with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a request for prior authorization; and (B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by the Secretary).

(6) Other permissible restrictions A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or maximum quantities per prescription or on the number of refills, if such limitations are necessary to discourage waste, and may address instances of fraud or abuse by individuals in any manner authorized under this chapter. (e) Treatment of pharmacy reimbursement limits (1) In general During the period beginning on January 1, 1991, and ending on December 31, 1994 –

(A) a State may not reduce the payment limits established by regulation under this subchapter or any limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1, 1991, and (B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph (A).

(2) Special rule If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not apply to such State until such State is in compliance with such regulations. (3) Effect on State maximum allowable cost limitations This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31, 1994, relating to any maximum allowable cost limitation established by a State for payment by the State for covered outpatient drugs, and rebates shall be made under this section without regard to whether or not payment by the State for such drugs is subject to such a limitation or the amount of such a limitation.



(4) Establishment of upper payment limits HCFA shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA has rated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all such additional formulations are rated as such and shall use only such formulations when determining any such upper limit. (f) Repealed and redesignated (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; (III) the DRUGDex information System; (IV) American Medical Association Drug Evaluations; and

(ii) the peer-reviewed medical literature. (C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each State an amount equal to 75 per centum of so much of the sums expended by the State plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug use review program which conforms to the requirements of this subsection. (D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to residents of nursing facilities which are in compliance with the drug regimen review procedures prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.

(2) Description of program Each drug use review program shall meet the following requirements for covered outpatient drugs:

(A) Prospective drug review (i) The State plan shall provide for a review of drug therapy before each prescription is filled or delivered to an individual receiving benefits under this subchapter, typically at the point-of-sale or point of distribution. The review shall include screening for potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literature referred to in paragraph (1)(B) as its source of standards for such review.



(ii) As part of the State’s prospective drug use review program under this subparagraph applicable State law shall establish standards for counseling of individuals receiving benefits under this subchapter by pharmacists which includes at least the following:

(I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapter or caregiver of such individual (in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which in the exercise of the pharmacist’s professional judgment (consistent with State law respecting the provision of such information), the pharmacist deems significant including the following:

(aa) The name and description of the medication. (bb) The route, dosage form, dosage, route of administration, and duration of drug therapy. (cc) Special directions and precautions for preparation, administration and use by the patient. (dd) Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur. (ee) Techniques for self-monitoring drug therapy. (ff) Proper storage. (gg) Prescription refill information. (hh) Action to be taken in the event of a missed dose.

(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the following information regarding individuals receiving benefits under this subchapter:

(aa) Name, address, telephone number, date of birth (or age) and gender. (bb) Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices. (cc) Pharmacist comments relevant to the 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 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 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; (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 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 The term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis, or (B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.

(6) Medically accepted indication The term “medically accepted indication” means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i) of this section. (7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug

(A) Defined (i) Multiple source drug The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or more drug products which -

(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”), (II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and (III) are sold or marketed in the State during the period.

(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source drug that was originally marketed under an original new drug application approved by the Food and Drug Administration. (iii) Noninnovator multiple source drug



The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator multiple source drug. (iv) Single source drug The term “single source drug” means a covered outpatient drug which is produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributers 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 - (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.




National Pharmaceutical Council D-1

Appendix D: Federal Upper Limits for Multiple Source Products


D-2 National Pharmaceutical Council


SOURCE: B = Blue Book; M = Medi-Span; R = Red Book


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 May 11, 2003. 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 May 11, 2003.

Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride Eq 200 mg base, Capsule, Oral 100 $0.4612 B Eq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Codeine Phosphate 300 mg; 15 mg, Tablet, Oral 100 0.1500 R 300 mg; 30 mg, Tablet, Oral 100 0.2137 B 300 mg; 60 mg, Tablet, Oral 100 0.2812 B

Acetaminophen; Hydrocodone Bitartrate 500 mg; 5 mg, Capsule, Oral 100 0.1943 B 500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral 473 ml 0.1014 R 500 mg; 5 mg, Tablet, Oral 100 0.1153 B 500 mg; 7.5 mg, Tablet, Oral 100 0.1913 B 500 mg; 10 mg, Tablet, Oral 100 0.4603 B 650 mg; 7.5 mg, Tablet, Oral 100 0.1550 B 650 mg; 10 mg, Tablet, Oral 100 0.1852 R 660 mg; 10 mg, Tablet, Oral 100 0.5284 B 750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R

Acetaminophen; Oxycodone Hydrochloride 500 mg; 5 mg, Capsule, Oral 100 0.2137 B 325 mg; 5 mg, Tablet, Oral 100 0.1192 B

Acetaminophen; Propoxyphene Hydrochloride

650 mg; 65 mg, Tablet, Oral 100 0.1688 B




Generic Name Upper Limit per Unit (Source) Acetaminophen; Propoxyphene Napsylate

650 mg; 100 mg, Tablet, Oral 100 0.2250 B Acetazolamide

250 mg, Tablet, Oral 100 0.2454 R Acetylcysteine

10%, Solution, Inhalation; Oral 10 ml 0.7634 B 20%, Solution, Inhalation; Oral 10 ml 0.9285 B

Acyclovir

200 mg, Capsule, Oral 100 0.3525 B 400 mg, Tablet, Oral 100 0.7048 R 800 mg, Tablet, Oral 100 1.2160 B

Albuterol 0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B

Albuterol Sulfate Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B

Allopurinol

100 mg, Tablet, Oral 100 0.0784 B 300 mg, Tablet, Oral 100 0.1671 B

Alprazolam

0.25 mg, Tablet, Oral 100 0.0614 R 0.5 mg, Tablet, Oral 100 0.0698 B 1 mg, Tablet, Oral 100 0.0885 B 2 mg, Tablet, Oral 100 0.1745 R

Amantadine Hydrochloride

50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M

Amiloride Hydrochloride; Hydrochlorothiazide Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 B

Aminophylline

100 mg, Tablet, Oral 100 0.0278 B 200 mg, Tablet, Oral 100 0.0390 R

Amiodarone Hydrochloride

200 mg, Tablet, Oral 60 1.6875 B




Generic Name Upper Limit per Unit (Source) Amitriptyline Hydrochloride

10 mg, Tablet, Oral 100 0.0608 B 25 mg, Tablet, Oral 100 0.0653 B 50 mg, Tablet, Oral 100 0.0666 B 75 mg, Tablet, Oral 100 0.1425 B 100 mg, Tablet, Oral 100 0.1500 R 150 mg, Tablet, Oral 100 0.2430 B

Amitriptyline Hydrochloride; Perphenazine

10 mg; 2 mg, Tablet, Oral 100 0.0704 B 25 mg; 2 mg, Tablet, Oral 100 0.0869 B

Amoxapine 50 mg, Tablet, Oral 100 0.5425 R

Amoxicillin

250 mg, Capsule, Oral 100 0.0636 B 500 mg, Capsule, Oral 100 0.1272 B 125 mg/5 ml, Powder for reconstitution, Oral 150 0.0201 B 250 mg, Tablet, Chewable, Oral 100 0.1595 B

Ampicillin/Ampicillin Trihydrate 250 mg, Capsule, Oral, 100 0.1295 R 500 mg, Capsule, Oral, 100 0.2171 B Aspirin; Carisoprodol

325 mg; 200 mg, Tablet, Oral 100 0.3522 B Atenolol

25 mg, Tablet, Oral 100 0.1595 B 50 mg, Tablet, Oral 100 0.0885 B 100 mg, Tablet, Oral 100 0.1650 B

Atenolol; Chlorthalidone


Atropine Sulfate; Diphenoxylate Hydrochloride

0.025 mg; 2.5 mg, Tablet, Oral 100 0.3743 R

Benzonatate 100 mg, Capsule, Oral 100 0.4387 B

Benztropine Mesylate

0.5 mg, Tablet, Oral 100 0.1227 B 1 mg, Tablet, Oral 100 0.1502 B 2 mg, Tablet, Oral 100 0.1930 B




Generic Name Upper Limit per Unit (Source) Betamethasone Dipropionate

Eq 0.05% base, Cream, Topical 15 gm 0.2330 B Eq 0.05% base, Lotion, Topical 60 ml 0.1437 B

Betamethasone Valerate Eq 0.1% base, Cream, Topical 45 gm 0.1197 B Eq 0.1% base, Lotion, Topical 60 ml 0.1087 B

Bisoprolol Fumarate; Hydrochlorothiazide

2.5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B 5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B 10 mg; 6.25 mg, Tablet, Oral 100 0.8250 B

Bumetanide


Buspirone Hydrochloride 5 mg, Tablet, Oral 100 0.2964 B 10 mg, Tablet, Oral 100 0.3942 B 15 mg, Tablet, Oral 60 0.4470 B

Captopril 12.5 mg, Tablet, Oral 100 0.0398 B 100 mg, Tablet, Oral 100 0.1867 B

Captopril; Hydrochlorothiazide 25 mg; 15 mg, Tablet, Oral 100 0.2359 B 25 mg; 25 mg, Tablet, Oral 100 0.2360 B 50 mg; 15 mg, Tablet, Oral 100 0.3702 B 50 mg; 25 mg, Tablet, Oral 100 0.3702 B

Carbamazepine

200 mg, Tablet, Oral 100 0.1388 R

Carbidopa; Levodopa 10 mg; 100 mg, Tablet, Oral 100 0.3644 B 25 mg; 100 mg, Tablet, Oral 100 0.3915 B 25 mg; 250 mg, Tablet, Oral 100 0.4657 B

Carisoprodol

350 mg, Tablet, Oral 100 0.3743 B

Carteolol Hydrochloride 1%, Solution/Drops, Ophthalmic 10 ml 3.6775 R




Generic Name Upper Limit per Unit (Source) Cefaclor

Eq 250 mg base, Capsule, Oral 100 0.6600 B Eq 500 mg base, Capsule, Oral 100 1.2900 B Eq 125 mg base/5 ml,

Powder for reconstitution, Oral 150 0.1107 B Eq 187 mg base/5 ml,



Powder for reconstitution, Oral 100 0.4492 B Cefadroxil/Cefadroxil Hemihydrate

Eq 500 mg base, Capsule, Oral 50 2.4837 B

Cephalexin Eq 250 mg base, Capsule, Oral 100 0.2513 B Eq 500 mg base, Capsule, Oral 100 0.4446 B

Chlordiazepoxide Hydrochloride

5 mg, Capsule, Oral 100 0.1140 B 10 mg, Capsule, Oral 100 0.0877 B

Chlorhexidine Gluconate 0.12%, Solution, Dental 480 ml 0.0146 B

Chlorpheniramine Maleate

4 mg, Tablet, Oral 100 0.0171 M

Chlorpropamide 100 mg, Tablet, Oral 100 0.1837 B 250 mg, Tablet, Oral 100 0.3885 B

Chlorthalidone


Chlorzoxazone 500 mg, Tablet, Oral 100 0.1085 B

Cholestyramine

Eq 4 gm Resin/Packet, Powder, Oral 60 1.2767 B

Cimetidine 200 mg, Tablet, Oral 100 0.1238 B 300 mg, Tablet, Oral 100 0.1313 B 400 mg, Tablet, Oral 100 0.1537 B 800 mg, Tablet, Oral 100 0.2775 B




Generic Name Upper Limit per Unit (Source) Cimetidine Hydrochloride

Eq 300 mg bases/ 5 ml solution, Oral 240 ml 0.1139 B

Clindamycin Hydrochloride Eq 150 mg base, Capsule, Oral 100 0.9180 R

Clindamycin Phosphate

Eq 1% base, Solution, Topical 60 ml 0.2060 R

Clobetasol Propionate 0.05%, Cream, Topical 30 gm 0.8315 B

Clomipramine Hydrochloride

25 mg, Capsule, Oral 100 0.3322 R 50 mg, Capsule, Oral 100 0.5138 B 75 mg, Capsule, Oral 100 0.5772 B

Clonazepam


Clonidine Hydrochloride

0.1 mg, Tablet, Oral 100 0.0968 B 0.2 mg, Tablet, Oral 100 0.1350 B 0.3 mg, Tablet, Oral 100 0.1794 B

Clorazepate Dipotassium

3.75 mg, Tablet, Oral 100 0.8350 B 7.5 mg, Tablet, Oral 100 1.0388 B 15 mg, Tablet, Oral 100 1.4094 B

Cromolyn Sodium 4%, Solution/ Drops, Ophthalmic 10 ml 3.3750 B

Cyclobenzaprine Hydrochloride


Desonide 0.05%, Ointment, Topical 60 gm 0.4077 B

Desoximetasone

0.25%, Cream, Topical 60 gm 0.6180 B

Dexamethasone 0.5 mg/5 ml, Elixir, Oral 240 ml 0.0625 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




Generic Name Upper Limit per Unit (Source Diazepam


Diclofenac Potassiuim

50 mg, Tablet, Oral 100 0.8625 B Diclofenac Sodium

50 mg, Tablet, Delayed Release, Oral 100 0.4748 R 75 mg, Tablet, Delayed Release, Oral 100 0.5850 R

Dicyclomine Hydrochloride 10 mg, Capsule, Oral 100 0.1222 B 20 mg, Tablet, Oral 100 0.1185 B

Diflunisal


Diltiazem Hydrochloride 30 mg, Tablet, Oral 100 0.1019 B 60 mg, Tablet, Oral 100 0.1114 B 90 mg, Tablet, Oral 100 0.2312 B 120 mg, Tablet, Oral 100 0.2331 B

Diphenhydramine Hydrochloride

12.5 mg/5 ml, Elixir, Oral 120 ml 0.0137 B

Dipivefrin Hydrochloride 0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B

Doxazosin Mesylate

1 mg, Tablet, Oral 100 0.5918 B 2 mg, Tablet, Oral 100 0.5918 B 4 mg, Tablet, Oral 100 0.6210 B 8 mg, Tablet, Oral 100 0.6518 B

Doxepin Hydrochloride

Eq 10 mg base, Capsule, Oral 100 0.0891 R Eq 25 mg base, Capsule, Oral 100 0.1822 B Eq 50 mg base, Capsule, Oral 100 0.1447 R Eq 75 mg base, Capsule, Oral 100 0.2052 R Eq 100 mg base, Capsule, Oral 100 0.4174 B Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1145 R




Generic Name Upper Limit per Unit (Source) Doxycycline Hyclate

Eq 50 mg base, Capsule, Oral 50 0.0915 B Eq 100 mg base, Capsule, Oral 50 0.1050 B Eq 100 mg base, Tablet, Oral 50 0.1287 B

Erythromycin

250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1889 B 2%, Solution, Topical 60 ml 0.0687 B

Estazolam

1 mg, Tablet, Oral 100 0.5925 R 2 mg, Tablet, Oral 100 0.6449 R

Estradiol


Estropipate

0.75 mg, Tablet, Oral 100 0.2754 B 1.5 mg, Tablet, Oral 100 0.3450 B 3 mg, Tablet, Oral 100 0.8622 B

Etodolac

200 mg, Capsule, Oral 100 0.4800 B 400 mg, Tablet, Oral 100 0.3600 R 500 mg, Tablet, Oral 100 1.0032 R

Famotidine 20 mg, Tablet, Oral 100 0.6210 B 40 mg, Tablet, Oral 100 1.2000 B

Fenoprofen Calcium Eq 600 mg base, Tablet, Oral 100 0.2400 R

Fluocinolone Acetonide

0.01%, Solution, Topical 60 ml 0.1172 B

Fluocinonide 0.05%, Cream, Topical 60 gm 0.1789 B 0.05%, Gel, Topical 60 gm 0.4965 R 0.05%, Solution, Topical 60 ml 0.2483 R

Fluorometholone

0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 B





Fluoxetine Hydrochloride 10 mg, Capsule, Oral 100 0.5850 B 20 mg, Capsule, Oral 100 0.6000 B 40 mg Capsule, Oral 30 4.0125 B 20 mg/5ml, Solution, Oral 120 ml 0.7500 R 10 mg, Tablets, Oral 30 0.6000 B

Fluphenazine Hydrochloride 1 mg, Tablet, Oral 100 0.2273 B 2.5 mg, Tablet, Oral 100 0.2775 B 5 mg, Tablet, Oral 100 0.3546 B 10 mg, Tablet, Oral 100 0.5099 R

Flurazepam Hydrochloride

15 mg, Capsule, Oral 100 0.0750 R 30 mg, Capsule, Oral 100 0.0922 R

Flurbiprofen

100 mg, Tablet, Oral 100 0.3600 B

Flurbiprofen Sodium 0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 B

Folic Acid

1 mg, Tablet, Oral 100 0.0456 B Furosemide

10 mg/ml, Solution, Oral 60 ml 0.1300 B 20 mg, Tablet, Oral 100 0.0563 B 40 mg, Tablet, Oral 100 0.0599 B 80 mg, Tablet, Oral 100 0.1043 B

Gemfibrozil 600 mg, Tablet, Oral 500 0.3058 B

Gentamicin Sulfate

Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.6540 B

Glipizide 5 mg, Tablet, Oral 100 0.0699 B 10 mg, Tablet, Oral 100 0.0944 B

Glyburide

1.25 mg, Tablet, Oral, 100 0.1244 B 1.5 mg, Tablet, Oral 100 0.2549 R 2.5 mg, Tablet, Oral, 100 0.1893 B 3 mg, Tablet, Oral 100 0.3202 R 5 mg, Tablet, Oral, 100 0.2831 B




Generic Name Upper Limit per Unit (Source) 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 2.2185 B

Guanfacine Hydrochloride

Eq 1 mg base, Tablet, Oral 100 0.5250 B Eq 2 mg base, Tablet, Oral 100 0.7200 B

Haloperidol Lactate Eq 2 mg base/ml, Concentrate, Oral 120 ml 0.1500 B

Homatropine Methylbromide; Hydrocodone Bitartrate

1.5 mg/5 ml; 5mg/5 ml, Syrup, Oral 480 ml 0.0280 R

Hydralazine Hydrochloride 10 mg, Tablet, Oral 100 0.0354 B 25 mg, Tablet, Oral 100 0.0450 B

Hydrochlorothiazide; Propranolol Hydrochloride


Hydrochlorothiazide; Spironolactone

25 mg; 25 mg, Tablet, Oral 100 0.3463 B

Hydrochlorothiazide; Triamterene 25 mg; 37.5 mg, Capsule, Oral 100 0.3177 B 25 mg; 37.5 mg, Tablet, Oral 100 0.1932 B 50 mg; 75 mg, Tablet, Oral 100 0.0488 B

Hydrocortisone

0.5%, Cream, Topical, 30 gm 0.0375 B 1%, Cream, Topical 30 gm 0.0585 B 2.5%, Cream, Topical 30 gm 0.1820 B 1%, Lotion, Topical 120 ml 0.0572 B 2.5%, Lotion, Topical 59 ml 0.6814 B

Hydroxychloroquine Sulfate

200 mg, Tablet, Oral 100 0.8535 B Hydroxyzine Hydrochloride

10 mg/5 ml, Syrup, Oral 480 ml 0.0307 B

Hydroxyzine Pamoate Eq 25 mg HCL, Capsule, Oral 100 0.0892 B Eq 50 mg HCL, Capsule, Oral 100 0.1013 B




Generic Name Upper Limit per Unit (Source) Ibuprofen


Imipramine Hydrochloride

10 mg, Tablet, Oral 100 0.3210 B 25 mg, Tablet, Oral 100 0.4275 R 50 mg, Tablet, Oral 100 0.5615 B

Indapamide

1.25 mg, Tablet, Oral 100 0.1035 B 2.5 mg, Tablet, Oral 100 0.1125 B

Isoniazid

300 mg, Tablet, Oral 100 0.0890 B Isosorbide Dinitrate

10 mg, Tablet, Oral 100 0.0281 R 20 mg, Tablet, Oral 100 0.0291 B 2.5 mg, Tablet, Sublingual 100 0.0488 B 5 mg, Tablet, Sublingual 100 0.0456 B

Isosorbide Mononitrate

10 mg, Tablet, Oral 100 0.6110 R 20 mg, Tablet, Oral 100 0.4950 B 60 mg, Tablet, Extended Release, Oral 100 0.7492 B

Ketoconazole

200 mg, Tablet, Oral 100 2.7750 B Ketoprofen


Ketorolac Tromethamine

10 mg, Tablet, Oral 100 0.6773 M

Labetalol Hydrochloride 100 mg, Tablet, Oral 100 0.2157 B 200 mg, Tablet, Oral 100 0.3582 B 300 mg, Tablet, Oral 100 0.5363 B

Lactulose

10 gm/15 ml, Solution, Oral 480 ml 0.0219 B




Generic Name Upper Limit per Unit (Source) Levobunolol Hydrochloride

0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B 0.5%, Solution/Drops, Ophthalmic 10 ml 1.4925 B

Lidocaine Hydrochloride 2%, Solution, Oral 100 ml 0.0278 M

Lisinopril 2.5 mg, Tablet, Oral, 100 0.3855 B 5 mg, Tablet, Oral, 100 0.5783 B 10 mg, Tablet, Oral, 100 0.5970 B 20 mg, Tablet, Oral, 100 0.6390 B 30 mg, Tablet, Oral, 100 0.9038 B 40 mg, Tablet, Oral, 100 0.9345 B Lisinopril ; Hydrochlorothiazide 10 mg ; 12.5 mg, Tablet, Oral, 100 0.6450 B 20 mg ; 12.5 mg, Tablet, Oral, 100 0.6983 B 20 mg ; 25 mg, Tablet, Oral, 100 0.7065 B Lorazepam


Lovastatin 10 mg, Tablet, Oral 60 0.7487 B 20 mg, Tablet, Oral 60 1.2488 B 40 mg, Tablet, Oral 60 2.2738 B

Meclizine Hydrochloride 12.5 mg, Tablet, Oral 100 0.0599 B 25 mg, Tablet, Oral 100 0.0717 B

Medroxyprogesterone Acetate


Megestrol Acetate


Meperidine Hydrochloride





Generic Name Upper Limit per Unit (Source) Methazolamide

25 mg, Tablet, Oral 100 0.3150 R 50 mg, Tablet, Oral 100 0.4650 R

Methenamine Mandelate 1 gm, Tablet, Oral 100 0.2923 B

Methocarbamol

500 mg, Tablet, Oral 100 0.1943 B

Methotrexate Sodium Eq 2.5 mg base, Tablet, Oral 100 1.2637 B

Methylphenidate Hydrochloride


Methylprednisolone 4 mg, Tablet, Oral 100 0.2849 B

Metoclopramide

10 mg, Tablet, Oral 100 0.1095 B Metoclopramide Hydrochloride

Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B Eq 5 mg base, Tablet, Oral 100 0.1842 B Eq 10 mg base, Tablet, Oral 100 0.1089 B

Metoprolol Tartrate


Metronidazole


Mexiletine Hydrochloride

200 mg, Capsule, Oral 100 0.9712 R

Minocycline Hydrochloride Eq 50 mg base, Capsule, Oral 100 0.9000 B Eq 100 mg base, Capsule, Oral 50 1.8000 B

Minoxidil 2.5 mg, Tablet, Oral 100 0.3170 B 10 mg, Tablet, Oral 100 0.6965 B




Generic Name Upper Limit per Unit (Source) Nadolol


Naltrexone Sodium 50 mg, Tablet, Oral 100 4.0400 B

Naphazoline Hydrochloride 0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R

Naproxen

250 mg, Tablet, Oral 100 0.1044 R 375 mg, Tablet, Oral 100 0.1383 R 500 mg, Tablet, Oral 100 0.1805 B 375 mg, Tablet, Delayed Release, Oral 100 0.6750 B

Niacin 500 mg, Tablet, Oral 100 0.0390 B

Nicardipine Hydrochloride


Nifedipine

10 mg, Capsule, Oral 100 0.1237 B Nizatidine 150 mg, Capsule, Oral, 60 1.8307 B 300 mg, Capsule, Oral, 30 3.6615 B Nortriptyline Hydrochloride

Eq 10 mg base, Capsule, Oral 100 0.1019 B Eq 25 mg base, Capsule, Oral 100 0.1406 B Eq 50 mg base, Capsule, Oral 100 0.1722 B Eq 75 mg base, Capsule, Oral 100 0.2203 B

Nystatin

100,000 units/gm, Cream, Topical 30 gm 0.0755 B 100,000 units/gm, Ointment, Topical 15 gm 0.1019 B 100,000 units/ml, Suspension, Oral 60 ml 0.1757 B

Nystatin; Triamcinolone Acetonide 100,000 units/gm; 0.1%, Cream, Topical 30 gm 0.0975 B

Orphenadrine Citrate

100 mg, Tablet, Extended Release, Oral 100 1.8225 B





Oxaprozin 620 mg, Tablet, Oral 100 0.6758 B

Oxazepam

10 mg, Capsule, Oral 100 0.5363 B 15 mg, Capsule, Oral 100 0.7624 B 30 mg, Capsule, Oral 100 1.2337 R

Oxybutynin Chloride

5 mg, Tablet, Oral 100 0.1260 R

Penicillin V Potassium Eq 250 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0165 B

Pentoxifylline 400 mg, Tablet, Extended Release, Oral 100 0.3147 B

Perphenazine

2 mg, Tablet, Oral 100 0.2801 R 4 mg, Tablet, Oral 100 0.3448 B 16 mg, Tablet, Oral 100 0.6377 R

Pindolol


Piroxicam


Polymyxin B Sulfate; Trimethoprim Sulfate 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 0.0772 B

Prednisolone 15 mg/5 ml, Syrup, Oral 480 ml 0.2081 B

Prednisolone Acetate

1%, Suspension/Drops, Ophthalmic 10 ml 1.6950 B Prednisone





Generic Name Upper Limit per Unit (Source) Primidone

250 mg, Tablet, Oral 100 0.6405 B

Probenecid 500 mg, Tablet, Oral 100 0.7059 B

Prochlorperazine Maleate

Eq 5 mg base, Tablet, Oral 100 0.3986 B Eq 10 mg base, Tablet, Oral 100 0.5766 B

Promethazine Hydrochloride

6.25 mg/5 ml, Syrup, Oral 120 ml 0.0264 B

Propranolol Hydrochloride 10 mg, Tablet, Oral 100 0.0585 B 20 mg, Tablet, Oral 100 0.0705 B 40 mg, Tablet, Oral 100 0.0848 B 80 mg, Tablet, Oral 100 0.1140 B

Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride 60 mg; 2.5 mg, Tablet, Oral 100 0.0336 B

Quinidine Gluconate

324 mg, Tablet, Extended Release, Oral 100 0.4500 B

Ranitidine Hydrochloride Eq 150 mg base, Tablet, Oral, 100 0.3411 R Eq 300 mg base, Tablet, Oral 100 0.3180 B

Selegiline Hydrochloride

5 mg, Tablet, Oral 60 0.7658 R

Selenium Sulfide 2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B

Spironolactone


Sucralfate 1 gm, Tablet, Oral 100 0.3690 B

Sulfacetamide Sodium 10%, Solution/Drops, Opthalmic 15 ml 0.1530 B

Sulfamethoxazole; Trimethoprim





Generic Name Upper Limit per Unit (Source) Sulfasalazine

500 mg, Tablet, Oral 100 0.1757 B

Sulindac 150 mg, Tablet, Oral 100 0.3317 B 200 mg, Tablet, Oral 100 0.4289 B

Temazepam


Terazosin Hydrochloride Eq 1 mg base, Capsule, Oral 100 1.5413 B Eq 2 mg base, Capsule, Oral 100 1.5413 B Eq 5 mg base, Capsule, Oral 100 1.5413 B Eq 10 mg base, Capsule, Oral 100 1.5413 B

Tetracycline Hydrochloride

500 mg, Capsule, Oral 100 0.0975 B

Theophylline 100 mg, Tablet, Extended Release, Oral 100 0.1184 B 200 mg, Tablet, Extended Release, Oral 100 0.1607 B 300 mg, Tablet, Extended Release, Oral 100 0.1593 B

Thioridazine Hydrochloride 10 mg, Tablet, Oral 100 0.2190 B 25 mg, Tablet, Oral 100 0.3030 B 50 mg, Tablet, Oral 100 0.3885 R 100 mg, Tablet, Oral 100 0.5025 B

Thiothixene

1 mg, Capsule, Oral 100 0.1388 B 2 mg, Capsule, Oral 100 0.1860 B 5 mg, Capsule, Oral 100 0.2963 B 10 mg, Capsule, Oral 100 0.4065 B

Ticlopidine Hydrochloride 250 mg, Tablet, Oral 60 1.5119 B

Timolol Maleate

Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.6975 B Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 0.9000 B

Tizanidine Hydrochloride 2 mg, Tablet, Oral, 150 0.8071 B 4 mg, Tablet, Oral, 150 0.9560 B




Generic Name Upper Limit per Unit (Source) Tobramycin

0.3%, Solution/Drops, Ophthalmic 5 ml 1.1850 M

Tolazamide 250 mg, Tablet, Oral 100 0.4005 B

Tramadol Hydrochloride 50 mg, Tablet, Oral, 100 0.3068 B Trazodone Hydrochloride

50 mg, Tablet, Oral 100 0.0684 R 100 mg, Tablet, Oral 100 0.0952 B 150 mg, Tablet, Oral 100 0.3113 B

Triamcinolone Acetonide 0.025%, Cream, Topical 80 gm 0.0364 B 0.1%, Cream, Topical 80 gm 0.0448 B 0.5%, Cream, Topical 15 gm 0.1889 B 0.1%, Lotion, Topical 60 ml 0.1215 B 0.1%, Ointment, Topical 80 gm 0.0502 B 0.1%, Paste, Dental 5 gm 0.8280 B

Triazolam

0.125 mg, Tablet, Oral 100 0.4041 B

Trifluoperazine Hydrochloride Eq 1 mg base, Tablet, Oral 100 0.2433 B Eq 2 mg base, Tablet, Oral 100 0.3552 B Eq 5 mg base, Tablet, Oral 100 0.4271 B Eq 10 mg base, Tablet, Oral 100 0.5403 B

Trihexyphenidyl Hydrochloride 2 mg, Tablet, Oral 100 0.1275 B 5 mg, Tablet, Oral 100 0.2580 B

Tropicamide

0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B 1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B

Valproic Acid

250 mg, Capsule, Oral 100 0.3488 B 250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M




Generic Name Upper Limit per Unit (Source) Verapamil Hydrochloride

120 mg, Capsule, Extended Release, Oral 100 0.8250 B 180 mg, Capsule, Extended Release, Oral 100 0.8700 B 240 mg, Capsule, Extended Release, Oral 100 0.4350 B 40 mg, Tablet, Oral 100 0.1963 R 80 mg, Tablet, Oral 100 0.0735 B 120 mg, Tablet, Oral 100 0.1110 B 180 mg, Tablet, Extended Release, Oral 100 0.4350 B 240 mg, Tablet, Extended Release, Oral 100 0.3683 B





National Pharmaceutical Council E-1

Appendix E: Glossary


E-2 National Pharmaceutical Council



GLOSSARY OF MEDICAL, MEDICAID, AND MANAGED CARE TERMS

Term Definition

Access A patient’s ability to obtain medical care. The ease of access is determined by components such as the availability of medical services and their acceptability to the patient, the location of health care facilities, transportation, hours of operation and affordability of care.

Actual Acquisition Cost (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.



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 healthcare by funding healthcare services research, conducting health technology assessments and outcomes studies, and developing and disseminating clinical practice guidelines.

Aid to Families with Dependent Children (AFDC)

A State-based Federal cash assistance program for low-income families. In all States, AFDC recipiency may be used to establish Medicaid eligibility. Now known as Temporary Assistance 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.



Term Definition

Ancillary Services Hospital services other than room, board, and professional services. They may include X-rays, lab tests, or anesthesia.

Antitrust A legal term encompassing a variety of efforts on the part of government to assure that sellers do not conspire to restrain trade or fix prices for their goods or services in the market.

Any Willing Provider A requirement that a health insurance plan or a health maintenance organization (HMO) must sign a contract for the delivery of healthcare services with any provider in the area that would like to provide such services to the plan’s or HMO’s enrollees, and can meet the terms of a contract.

Assignee The person to whom the rights to a health insurance policy are assigned, either in part or in whole, by the original policyholder.

Assignment of Benefits A method under which a claimant requests that his/her benefits under a claim be paid to some designated person or institution, usually a physician or hospital.

At-Risk Accepting prepayment as full coverage for a predetermined healthcare benefit and assuming financial liability for any loss that occurs when premiums paid are less than the cost of services provided.

Authorization As it applies to managed care, authorization is the approval of care, such as hospitalization.

Average Cost Per Claim The average dollar amount of administrative and/or medical services rendered for the unit of measure within each expenditure category. The calculation is $amount / #of units.

Average Manufacturer Price (AMP) The average price paid by wholesalers for products distributed to the retail class of trade.

Average Wholesale Price (AWP) The published suggested wholesale price of a drug. It is often used by pharmacies as a cost basis for pricing prescriptions.

Barriers To Access Barriers to access can be financial (insufficient monetary resources), geographic (distance to providers), organizational (lack of available providers) and sociological (e.g., discrimination, language barriers). Efforts to improve access often focus on providing/improving health coverage.

Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse disorders.

Beneficiary An individual who receives benefits from or is covered by an insurance policy or other health care financing program. Also known as a "member," "enrollee," "subscriber," or "insured."

Benefit A service provided under an insurance policy or prepayment plan.

Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs during a benefit period.

Benefit Package Services an insurer, government agency, or health plan offers to a group or individual under the terms of a contract.



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 healthcare, and (3) with whom, other than in an emergency, a patient must consult to obtain a referral to a specialist provider in order to obtain the highest level of benefits available under a health plan. Care coordinators are sometimes called “gatekeepers.”

Carve Out A decision to purchase separately a service that is typically a part of an indemnity or HMO plan. Example: an HMO may “carve out” the behavioral health benefits and select a specialized vendor to supply these services on a stand-alone basis.



Term Definition

Case Management (1) A process whereby covered persons with specific health care needs are identified and a plan designed to efficiently utilize healthcare resources is formulated and implemented to achieve the optimum patient outcome in the most cost-effective manner. (2) A utilization management program that assists the patient in determining the most appropriate and cost-effective treatment plan. It is used for patients who have prolonged expensive or chronic conditions, helps determine the treatment location (hospital, or other institution, or home), and authorizes payment for such care if it is not covered under the patient’s benefit agreement.

Case Manager An experienced professional (e.g., nurse, doctor or social worker) who works with patients, providers and insurers to coordinate all services deemed necessary to provide the patient with a plan of medically necessary and appropriate health care.

Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabled individuals or families and children who meet financial eligibility requirements for TANF, Supplemental Security Income, or an optional State supplement.

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.

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.



Term Definition

Claims Administration A carrier function involving the review of health insurance claims submitted for payment, by individual claim or in the aggregate. Claims administration, as it relates to professional review programs, is an identification procedure, screening treatment or charge pattern, for subsequent peer review and adjudication.

Claims Clearinghouse System A system which allows electronic claims submission through a single source.

Claims Review The method by which an enrollee’s health care service claims are reviewed before reimbursement is made. The purpose of this monitoring system is to validate the medical appropriateness of the provided services and to be sure the cost of the service is not excessive.

Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several third-party payers.

Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable outcomes and to explain or prevent undesirable outcomes.

Clinical Outcome The status of the patient’s health, especially after receipt of medical care services. Assessment of outcomes may be dependent upon targeted goals, clinical markers, and the ability to provide objective measurements.

Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified health conditions.

Closed-Panel HMO Generally offers the services of a relatively limited number of healthcare providers, e.g., physicians employed by the HMO. Staff- and group-model HMOs are usually referred to as being in this category.

CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic source of state-reported eligibility and claims data on the Medicaid population, their characteristics, utilization, and payments. Through FY 1998, the HCFA-2082 was an annual State submitted report designed to collect aggregate statistical data on Medicaid eligibles, recipients, services, and expenditures during each federal fiscal year. States summarized and reported the data processed through their own Medicaid claims processing and payment systems unless they opted to participate in The Medicaid Statistical Information System (MSIS) where the 2082 Report was produced by CMS. State-by-State national summary tables were developed based on the 2082 Reports. As a result of legislation enacted by The Balanced Budget Act of 1997, States, beginning in FY 1999, are required to submit all of their eligibility and claims data on a quarterly basis through MSIS. The State requirement for completing the HCFA-2082 Report has been eliminated.

CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system. It is a statement of expenditures for The Medicaid program that states submit to CMS 30 days after each quarter. The Report is an accounting statement of actual expenditures made by the States for which they are entitled to receive federal reimbursement under Title XIX for that quarter. Along with The CMS MSIS Report, it is one of the primary sources for Medicaid statistical data.

Coinsurance The portion of covered healthcare costs for which the covered person has a financial responsibility, usually according to a fixed percentage. Often coinsurance applies after first meeting a deductible requirement.



Term Definition

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.

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.



Term Definition

Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified charge for a specified service, such as $10 for an office visit. The covered person is usually responsible for payment at the time the healthcare is rendered. Typical copayments are fixed or variable flat amounts for physician office visits, prescriptions or hospital services. Some copayments are referred to as coinsurance, with the distinguishing characteristics that copayments are flat or variable dollar amounts and coinsurance is a defined percentage of the charges for services rendered.

Cosmetic Procedures Those procedures which involve physical appearance, but which do not correct or materially improve a physiological function and are not deemed medically necessary.

Cost Sharing Any provision of a health insurance policy that requires the insured to pay some portion of medical expenses. The general term includes deductibles, copayments, and coinsurance.

Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs when one payer obtains a discount on provider services, and the providers increase costs to another payer to make up the difference.

Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost to the provider of delivering services.

Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure, for example, relates the cost of that drug or procedure to the health benefits resulting from it. In health terms, it is often expressed as the cost per year per life saved.

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.

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.



Term Definition

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.

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.



Term Definition

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.

Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

The EPSDT program covers screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care and other measures to correct or ameliorate any defects and chronic conditions discovered.

Electronic Data Interchange (EDI) The computer-to-computer exchange of business or other information. The data may be in either a standardized or priority format.

Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees at their place of work. The employer typically picks up all or part of the cost of these benefits.

Employee Retirement Income Security Act of 1974, Public Law 93-406 (ERISA)

A Federal act passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from State insurance laws.

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.



Term Definition

Estimated Acquisition Cost (EAC) An estimate of the price generally, and currently, paid by providers for a drug marketed or sold by a particular manufacturer or labeler in the package size most frequently purchased by providers.

Exclusions Specific conditions or circumstances listed in the contract or employee benefit plan for which the policy or plan will not provide benefit payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with more than one health maintenance organization or preferred provider organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State agency for the covered medical expenses of eligible participants.

Experience Rating The process of setting rates based partially or in whole on previous claims experience and projected required revenues for a future policy year for a specific group or pool of groups.

Experimental, Investigational or Unproven Procedures

Medical, surgical, psychiatric, substance abuse or other healthcare services, supplies, treatments, procedures, drug therapies or devices that are determined by the health plan (at the time it makes a determination regarding coverage in a particular case) to be either: not generally accepted by informed healthcare professionals in the U.S. as effective in treating the condition, illness or diagnosis for which their use is proposed; or not proven by scientific evidence to be effective in treating the condition, illness or diagnosis for which their use is proposed.

Extended Care Long-term care, ranging from routine assistance for daily activities to sophisticated medical and nursing care for those needing it. The care, covered under certain insurance policies, can be provided in homes, day-care centers or other facilities.

Family Planning Services Any medically approved means, including diagnosis, treatment, drugs, supplies and devices, and related counseling which are furnished or prescribed by or under the supervision of a physician for individuals of childbearing age for purposes of enabling such individuals freely to determine the number or spacing of their children.

Favorable Selection A tendency for utilization of health services in a population group to be lower than expected or estimated.

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.



Term Definition

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.

Fee Maximum The maximum amount a participating provider may be paid for a specific healthcare service provided to a covered person under a specific contract. Sometimes called “fee max.”

Fee Schedule A listing of codes and related services with pre-established payment amounts that could be percentages of billed charges, flat rates or maximum allowable amounts.

Fee-for-Service Reimbursement The traditional healthcare payment system, under which physicians and other providers receive a payment that does not exceed their billed charge for each unit of service provided. Fees are paid as care is rendered.

First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon enrollment, without a deductible charge.

Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid agency.

Fiscal Intermediary The agent that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers’ records.

Fiscal Year Any predetermined set of 12 months for which annual accounts are kept. The Federal Government’s fiscal year extends from Oct. 1 to the following Sept. 30.

Fixed Fee An established “fee” schedule for pharmacy services allowed by certain government and private third-party programs in lieu of cost-of-doing business markups.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to choose providers whether or not they connect with the plans (often coupled with any willing provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”



Term Definition

Generic Drug A chemically equivalent copy of a brand name drug whose patent has expired. Drug formulations must be of identical composition with respect to the active ingredient (i.e., meet official standards of identity, purity, and quality of active ingredient). Also called generic equivalent or non-innovator multiple source drug.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand-name medication.

Global Target A financing method identical to a global budget except that no enforcement mechanism is used to keep providers and hospitals within budget (i.e., providers and hospitals will receive additional funding if their costs exceed their budgeted payments).

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 non-physician services such as ambulance, physical therapy and durable medical equipment. The local codes are developed by local Medicare carriers in order to supplement the national codes. HCPCS codes are 5-digit codes, the first digit a letter followed by four numbers. HCPCS codes beginning with A through V are national; those beginning with W through Z are local.

Health Care Financing Administration (HCFA)

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 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.



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 healthcare or otherwise assuring healthcare delivery in a geographic area, (b) An agreed upon set of basic and supplemental health maintenance and treatment services, and (c) A voluntary enrolled group of people.

Health Plan An organization that provides a defined set of benefits; this term usually refers to an HMO-like entity, as opposed to an indemnity insurer.

Health Plan Employer Data and Information Set (HEDIS)

A core set of performance measures to assist employers and other health purchasers in understanding the value of healthcare purchases and evaluating health plan performance. HEDIS 2003 is currently used and distributed by NCQA (National Committee for Quality Assurance).

HMO - Group Model A healthcare model involving contracts with physicians organized as a partnership, professional corporation, or other association. The health plan compensates the medical group for contracted services at a negotiated rate, and that group is responsible for compensating its physicians and contracting with hospitals for care of their patients.

HMO - Individual Practice Association (IPA)

A healthcare model that contracts with physicians and other community healthcare providers, to provide services in return for a negotiated fee. Physicians continue in their existing individual or group practices and are compensated on a per capita, fee schedule, or fee-for-service basis.

HMO - Network Model An HMO type in which the HMO contracts with more than one physician group, and may contract with single- and multi-specialty groups. The physician works out of his/her own office. The physician may share in utilization savings, but does not necessarily provide care exclusively for HMO members.

HMO - Staff Model A healthcare model that employs physicians to provide healthcare to its members. All premiums and other revenues accrue to the HMO, which compensates physicians by salary and incentive programs.

Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant to State and Federal laws to provide healthcare services in the home.

Home Health Services Services and items furnished to an individual who is under the care of a physician by a home health agency or by others under arrangements made by such agency. Services are furnished under a plan established and periodically reviewed by a physician. They are provided on a visiting basis in an individual’s home and include: nursing, physical therapy, dietary, counseling, and social services; part-time or intermittent skilled nursing care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances (other than drugs and biologicals); home health aide services; and services of interns and residents.



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 physician-hospital organization, group practice without walls, integrated provider organization and medical foundation.

Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician for individuals with serious medical conditions and delivered with the guidance of a registered nurse.

Intermediate Care Facility (ICF) An institution that is licensed under State law to provide on a regular basis, health-related care and services to individuals who do not require the degree of care or treatment which a hospital or skilled nursing facility is designed to provide. Public institutions for care of the mentally retarded or people with related conditions are also included in the definition. The distinction between "health-related care and services" and "room and board" has often proven difficult to make but is important because ICFs are subject to quite different regulations and coverage requirements than institutions which do not provide health-related care and services.

International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM)

A listing of diagnoses and identifying codes used by physicians for reporting diagnoses of health plan enrollees. The coding and terminology provide a uniform language that can accurately designate primary and secondary diagnoses and provide for reliable, consistent communications on claim forms.

Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are considered experimental and, therefore, may not be covered by insurance plans. The definition of experimental currently varies from plan to plan.



Term Definition

Laboratory and Radiological Services Professional and technical laboratory and radiological services ordered by a licensed practitioner, provided in an office or similar facility (other than a hospital outpatient department or clinic) or by a qualified lab.

Legend Drug A drug that, by law, can be obtained only by prescription and bears the label, “Caution: Federal law prohibits dispensing without a prescription.” See “Prescription Medication.”

Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by an insurer. This amount serves as a cap on contractual liability and can be exceeded only in rare and unusual circumstances.

Long Term Care A set of health care, personal care and social services required by persons who have lost, or never acquired, some degree of functional capacity (e.g., the chronically ill, aged, disabled, or retarded) in an institution or at home, on a long-term basis. The term is often used more narrowly to refer only to long-term institutional care such as that provided in nursing homes, homes for the retarded and mental hospitals. Ambulatory services such home health care, which can also be provided on a long-term basis, are seen as alternatives to long-term institutional care.

Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using magnetic fields to produce comprehensive pictures of the anatomy.

Managed Care (1) A system of healthcare delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to high quality, cost-effective healthcare; (2) A systemized approach which seeks to ensure the provision of the right healthcare at the right time, place and cost.

Managed Care Organization (MCO) Broad term that encompasses various types of health plans, including Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Point-of-Service plans (POSs) and Provider-Sponsored Organizations (PSOs). Often used to refer to a health plan that is similar to an HMO but which does not have an HMO license and serves only Medicaid beneficiaries.

Mandated Benefits Those benefits which health plans are required by State or Federal law to provide to policyholders and eligible dependents.

Maximum Allowable Cost, or “Reasonable Cost Range”

A maximum cost is fixed for which the pharmacist can be reimbursed for selected products, as identified in a “formulary.”

Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a benefit contract.

Medicaid A Federally aided State-operated and administered program that provides medical benefits for certain indigent or low-income persons in need of health and medical care. The program, authorized by Title XIX of the Social Security Act, is basically for the poor. It does not cover all of the poor, however, but only persons who meet specified eligibility criteria. Subject to broad Federal guidelines, States determine the benefits covered, program eligibility, rates of payment for providers, and methods of administering the program. Also referred to as State Medical Assistance Programs.



Term Definition

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 Necessity The evaluation of healthcare services to determine if they are: medically appropriate and required to meet basic health needs; consistent with the diagnosis or condition and rendered in a cost-effective manner; and consistent with national medical practice guidelines regarding type, frequency and duration of treatment.

Medical Savings Account (MSA) A non-taxable savings account used to cover medical expenses. Based loosely on the idea of individual retirement accounts.

Medically Needy Under Medicaid, medically needy cases are aged, blind, or disabled individuals or families and children who are not otherwise eligible for Medicaid, and whose income resources are above the limits for eligibility as categorically needy (TANF or SSI) but are within limits set under the Medicaid State plan.

Medicare (Part A/Part B) A U.S. health insurance program for people aged 65 and over, for persons eligible for social security disability payments for two years or longer, and for certain workers and their dependents who need kidney transplantation or dialysis. Monies from payroll taxes and premiums from beneficiaries are deposited in special trust funds for use in meeting the expenses incurred by the insured. It consists of two separate but coordinated programs: hospital insurance (Part A) and supplementary medical insurance (Part B).

Medicare Beneficiary A person designated by the Social Security Administration as entitled to receive Medicare benefits.

Medicare Payment Advisory Commission (MedPAC)

A Federal commission established under the Balanced Budget Act of 1997 to advise and assist Congress and the Department of Health and Human Services in maintaining and updating the Medicare prospective payment system. MedPAC replaces and assumes the responsibilities of the Physician Payment Review Commission (PPRC) and the Prospective Payment Assessment Commission (ProPAC).

Medicare Supplemental Insurance A policy guaranteeing that a health plan will pay a policyholder’s coinsurance, deductible and copayments and will provide additional health plan or 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.”



Term Definition

Medigap (Medicare Supplemental Insurance)

See “Medicare Supplemental Insurance.”

Members A participant in a health plan (member or eligible dependent). Also used to describe an individual specified within a subscriber contract that may receive health care services according to the terms of the subscriber policy. Also known as "beneficiary," "enrollee," "subscriber," or "insured."

Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain fee maximums for each procedure.

Most Favored Nations Discount or Clause

A contractual agreement that stipulates that a vendor must provide to a particular payor the lowest prices that would be available to any purchaser. The Federal government often invokes most favored nation clauses for healthcare contracts.

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).

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.

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.”

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.



Term Definition

Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for him/herself and/or dependents: i.e., deductibles, copays and coinsurance - as defined per the contract. Once this limit is reached, benefits will increase to 100% for health services received during the rest of that calendar year. Some out-of-pocket costs (e.g., mental health, penalties for non-precertification, etc.) are not eligible for out-of-pocket limits.

Outcome Measures Assessments which gauge the effect or results of treatment for a particular disease or condition. Outcome measures include such parameters as: the patient’s perception of restoration of function, quality of life and functional status, as well as objective measures of mortality, morbidity and health status.

Outcomes Management Systematically improving healthcare results, typically by modifying practices in response to data gleaned through outcomes measurement, then remeasuring and remodifying - often in a formal program of continuous quality improvement.

Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or medical technology on health or costs.

Outlier An observation in a distribution that is outside a certain range, often defined as two or three standard deviations from the mean or exceeding a specific percentile. Frequently refers to a case or hospital stay that is unusually long or expensive for its type, or to a physician practice that uses an abnormally high or low volume of resources.

Outpatient Services Outpatient services are medical and other services provided on a non-resident basis (patients are not admitted to the facility) by a hospital or other qualified facility, such as a mental health clinic, rural health clinic, mobile X-ray unit, or freestanding dialysis unit. Such services include outpatient physical therapy services, diagnostic X-ray and laboratory tests, and X-ray and other radiation therapy.

Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State law.

Participating Provider A provider who has contracted with the health plan to provide medical services to covered persons. The provider may be a hospital, pharmacy, other facility or a physician who has contractually accepted the terms and conditions as set forth by the health plan.

Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their health. Questions may be general and address overall health status with regard to a specific condition (e.g., an arthritic patient’s ability to make a fist or an asthmatic patient’s ability to climb a flight of stairs).

Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients have regarding how a health plan meets their medical needs and how the delivery of care is handled, (e.g., waiting time, access to treatments).

Payer A general term indicating the responsible party for the payment of medical care service expenses. Payers may be patients, insurance companies, government agencies, or a combination of these.

Peer Review The evaluation of quality of total healthcare provided, by medical staff with equivalent training.



Term Definition

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 compromises the official organizational line of communication between the medical and pharmacy components of the health plan. A major function of such a committee is to develop, manage and administer a drug formulary.

Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly licensed and qualified under the law of jurisdiction in which treatment is received.

Physician-Hospital Organization (PHO)

A legal entity formed by a hospital and a group of physicians to further mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices and agree to accept managed care patients according to the terms of a professional service agreement with the PHO. The PHO serves as a collective negotiating and contracting unit. It is typically owned and governed jointly by a hospital and shareholder physicians.

Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with different benefit levels associated with the use of participating providers. POS can be provided in several ways: an HMO may allow members to obtain limited services from non-participating providers; an HMO may provide non-participating benefits through a supplemental major medical policy; a PPO may be used to provide both participating and non-participating levels of coverage and access; or various combinations of the above may be used.

Portability Requirement that health plans guarantee continuous coverage without waiting periods for persons moving between plans.

Practice Guideline Systematically developed statements on medical practice that assist a practitioner and a patient in making decisions about appropriate healthcare for specific medical conditions. Managed care organizations frequently use these guidelines to evaluate appropriateness and medical necessity of care. Terms used synonymously include practice parameters, standard treatment protocols and clinical practice guidelines.

Practice Parameters See “Practice Guidelines.”



Term Definition

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if the provider’s care is significantly different from others with similar practices. If there is a significant difference, the practitioner’s practice is analyzed to determine the reasons for the variation and whether that practitioner’s practice patterns should be modified.

Pre-Certification Review See “Utilization Review.”

Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person’s effective date of coverage under the master group contract.

Preferred Provider Organization (PPO)

A program in which contracts are established with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits (fewer copayments) for services received from preferred providers, thus encouraging covered persons to use these providers. Covered persons are generally allowed benefits for non-participating providers’ services, usually on an indemnity basis with significantly higher copayments. A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee-for-service basis.

Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriate specialties, as well as other professional and subprofessional personnel, who, for regular compensation, undertake to provide comprehensive care to an enrolled population for premium payments that are made in advance by the consumer and/or their employers.

Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity provides comprehensive services on a non-risk basis.

Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescription of a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed practitioner to his own patients. This item does not include a practitioner’s drug charges that are not separable from his other charges, or drugs covered by a hospital bill.

Prescription Medication A drug which has been approved by the Food and Drug Administration and which can, under Federal and State law, be dispensed only pursuant to a prescription order from a duly licensed prescriber, usually a physician.

Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunization and well person care.

Primary Care Basic or general healthcare traditionally provided by family practice, pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case Management (PCCM)

Managed care arrangements where primary care providers receive a per capita management fee to coordinate a patient's care in addition to reimbursement (fee-for-service or capitation) for the medical services they provide.



Term Definition

Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner, pediatrician, and in some cases, OB/Gyn) in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non-routine services. See Care Coordinator.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Prospective Financing Financing for health care services based on prices or budgets determined prior to the delivery of service. Payments can be per unit of service, per member, or per time period. In all its forms prospective financing differs from cost-based reimbursement, under which a provider is paid for costs incurred.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or any individual or group of individuals that provides a healthcare service.

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.

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.



Term Definition

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.

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.”



Term Definition

Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and Human Services broad authority to waive certain laws relating to Medicaid for the purpose of conducting pilot, experimental or demonstration projects. Section 1115 demonstration waivers allow States to change provisions of their Medicaid programs, including: eligibility requirements, the scope of services available, the freedom to choose a provider, a provider’s choice to participate in a plan, the method of reimbursing providers, and the statewide application of the program. Projects typically run three to five years.

Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section 1915(b) freedom-of-choice waivers allowed States to require Medicaid recipients to enroll in HMOs or other managed care plans in an effort to control costs. The waivers allowed States to: implement a primary care case-management system; require Medicaid recipients to choose from a number of competing health plans; provide additional benefits in exchange for savings resulting from recipients’ use of cost-effective providers; and limit the providers from which beneficiaries can receive non-emergency treatment. Under the BBA, States can enroll recipients into managed care without applying for 1915(b) waivers.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a designated health service (e.g., pharmacies, clinical laboratories, and outpatient surgery) in which the provider or the provider’s immediate family member has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such as tobacco and alcohol.

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.

Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital.

Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified skilled nursing facility that meets standards set by Secretary of DHHS.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income (after medical expenses) meets Medicaid financial requirements.

State Buy-In The term given to the process by which a State may provide Supplementary Medical Insurance coverage for its needy eligible persons through an agreement with the Federal government under which the State pays the premiums for them.

State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health services (e.g., in vitro fertilization) or services provided by certain health care providers (e.g., audiologists). Self-insureds are exempt from these requirements. There are over 800 mandates nationwide.



Term Definition

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 The Medicaid State Plan is a comprehensive written commitment by a Medicaid agency to administer or supervise the administration of a Medicaid program in accordance with Federal requirements.

Stop Loss That point at which a third party has reinsurance to protect against the overly large single claim or the excessively high aggregate claim during a given period of time. Large employers, who are self-insured, may also purchase “reinsurance” for stop-loss purposes.

Supplemental Security Income (SSI) A Federal cash assistance program for low-income aged, blind and disabled individuals established by Title XVI of the Social Security Act. States may use SSI income limits to establish Medicaid eligibility.

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.”



Term Definition

Universal Coverage The guaranteed provision of at least basic health care services to every United States citizen or legal resident. See “Universal Access.”

Usual, Customary and Reasonable Charges

A term used to refer to the commonly charged or prevailing fees for health services within a geographic area. A fee is considered to be reasonable if it falls within the parameters of the average or commonly charged fee for the particular service within that specific community.

Utilization The extent to which the members of a covered group use a program or obtain a particular service, or category of procedures, over a given period of time. Usually expressed as the number of services used per year or per 100 or 1,000 persons eligible for the service.

Utilization Management (UM) A process of integrating review and case management of services in a cooperative effort with other parties, including patients, providers, and payers.

Utilization Review A formal assessment of the medical necessity, efficiency, and/or appropriateness of healthcare services and treatment plans on a prospective, concurrent or retrospective basis.

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 plan modification.

Withhold “At-risk” portion of a claim deducted and withheld by the health plan before payment is made to a participating physician as an incentive for appropriate utilization and quality of care. This amount – for example, 20% of the claim – remains within the plan and is credited to the doctor’s account. Can be used where the plan needs additional funds to pay for claims. The withhold may be returned to the physician in varying levels which are determined based on analysis of his/her performance or productivity compared against his/her peers. Also called “physician contingency reserve (PCR).”



ACRONYMS

AABD Aid to Aged, Blind, and Disabled AAC Actual Acquisition Cost AB Aid to the Blind AFDC Aid to Families with Dependent Children AHRQ Agency for Health Research and Quality AIDS Acquired Immune Deficiency Syndrome AMP Average Manufacturer Price ANSI American National Standards Institute APTD Aid to the Permanently and Totally Disabled ARF Area Resource File ASO Administrative Services Only AWP Any Willing Provider OR Average Wholesale Price BBA Balanced Budget Act of 1997 BIPA Benefits Improvement and Protection Act BLS Bureau of Labor Statistics 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 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 HIO Health Insuring Organizations HIPAA Health Insurance Portability and Accountability Act HMO Health Maintenance Organization HRSA Health Resources and Services Administration ICF Intermediate Care Facility ICF-MR Intermediate Care Facility for the Mentally Retarded IPA Individual Practice Association MAC Maximum Allowable Cost MAIC Maximum Allowable Ingredient Cost MCAID-MCO Medicaid-only Managed Care Organization MCO Managed Care Organization MMIS Medicaid Management Information System MNAB Medically Needy Aid to the Blind MNAFDC Medically Needy Aid to Families with Dependent Children MNAPTD Medically Needy Aid to the Permanently and Totally Disabled MNOAA Medically Needy Old Age Assistance MQC Medicaid Quality Control MSA Medical Savings Account MSIS Medicaid Statistical Information System NDC National Drug Code NP Nurse Practitioner OAA Old Age Assistance OACT Office of the Actuary



OASDI Old Age, Survivors, and Disability Insurance OBRA Omnibus Budget Reconciliation Act OHS Outpatient Hospital Services 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 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 SNF Skilled Nursing Facility SSA Social Security Administration SSI Supplemental Security Income SSP State Supplemental Payments TANF Temporary Assistance for Needy Families TDOC Total Days of Care TEFRA Tax Equity & Fiscal Responsibility Act 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 UR Utilization Review WAC Weighted Average Cost OR Wholesale Acquisition Cost



Documents

Pharmaceutical Benefits Under State Medical Assistance Programs, 2002