Pharmaceutical Benefits Under State Medical Assistance Programs, 2003

National Pharmaceutical Council Pharmaceutical Benefits 2003

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TABLE OF CONTENTS

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

SECTION 1: THE MEDICARE PRESCRIPTION DRUG, MODERNIZATION, AND IMPROVEMENT ACT OF 2003, DUAL ELIGIBLES, AND IMPACT ON STATES .................................................................................................. 1-1

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

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

- Total Medicaid Eligibles by Maintenance Assistance Status, 2001........................ 2-11 - Total Medicaid Eligibles by Age Group, 2001........................................................ 2-12 - Total Medicaid Eligibles by Basis of Eligibility, 2001 ........................................... 2-13 - Total Medicaid Eligibles by per 1000 Population, 2001 ........................................ 2-14 - Total Net U.S. Medical Assistance Expenditures by Type of Service ................... 2-15 - Federal Medical Assistance Percentages (FMAP), FY 2004 and FY 2005 ........... 2-16 - Medicaid Total Net Expenditures and Eligibles, 2001 ........................................... 2-17 - Total Medicaid Program Expenditures, 2002 ......................................................... 2-18 - Total SCHIP Expenditures, 2002 ........................................................................... 2-19

Medicaid Managed Care Enrollment ................................................................................... 2-21

- Medicaid Managed Care Enrollment, As of June 30, 2002..................................... 2-23 - Pharmaceutical Benefits Under Managed Care Plans ............................................ 2-24 - Medicaid Managed Care Enrollment Trends, 1998-2002 ....................................... 2-25 - Medicaid Managed Care Plan Type, As of June 30, 2002 ...................................... 2-26 - Medicaid Managed Enrollment by Plan Type, As of June 30, 2002....................... 2-27 - Medicaid Managed Care Enrollment by Payment Arrangement, As of June 30, 2002 ............................................................................................... 2-28

Medicaid Managed Care Waivers.......................................................................................... 2-29

- Section 1915(b) Waivers, As of June 30, 2002 ....................................................... 2-33 - Section 1115 Research and Demonstration Waivers, As of June 30, 2002............. 2-35 - Pharmacy Plus Demonstrations Program Status, Pharmacy Waivers

Under 115 Authority................................................................................................ 2-36

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

Sociodemographics

- Age Demographics, 2002 .......................................................................................... 3-5 - Race Demographics, 2002......................................................................................... 3-6 - Hispanic Demographics, 2002 .................................................................................. 3-7 - Insurance Status-Populations, 2002 .......................................................................... 3-8 - Insurance Status-Percentages, 2002 ........................................................................ 3-9

- Poverty Status-Populations, 2002 ........................................................................... 3-10


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- Poverty Status-Percentages, 2002............................................................................ 3-11 - Employment Status, 2003........................................................................................ 3-12

Health Care Delivery System

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

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

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

− Drug Expenditures Trends ......................................................................................... 4-5 − Ranking Based on Drug Expenditures....................................................................... 4-6 − Drugs as a Percentage of Total Net Expenditures, 2002 ........................................... 4-7 − Drugs as a Percentage of Total Net Expenditures, 2000-2002 .................................. 4-8 − Share of Drug Expenditures by Category, 2002 ........................................................ 4-9 − Share of Prescriptions Processed, 2002 ................................................................... 4-11 − Medicaid Average Cost per Prescription, 2002 ....................................................... 4-13

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

− Medicaid Drug Rebates, 2002 ................................................................................. 4-17 − Medicaid Drug Rebate Trends, 1998-2002.............................................................. 4-18 − Medicaid Drug Rebate Trends, Annual Percent Change, 1997-2002...................... 4-19 − Rebates As Percent of Drug Expenditures, 2002..................................................... 4-20

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

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

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

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


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

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

APPENDIXES

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


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INTRODUCTION

The 2003 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 38th year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest sources of information on pharmacy programs within the State Medical Assistance Programs (Title XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled team and countless contributors, the “Medicaid Compilation” has become a standard reference and invaluable resource in government offices, research libraries, consultancies, the pharmaceutical industry, numerous businesses, and policy organizations. The data used to create each edition of the Compilation are assembled from numerous sources. The Compilation incorporates information on each State pharmacy program from an annual NPC survey of State Medicaid program administrators and pharmacy consultants, statistics from the Centers for Medicare and Medicaid Services (CMS), and information from other Federal agencies and organizations. In order to give a better understanding of the content of the “Medicaid Compilation,” the information contained in this version of the book is summarized below by section:

• Section 1: Reports on the Medicare Modernization Act provisions, the dual eligibles it will affect, and the overall impact on the States.

• 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 2002. 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 2003 NPC annual survey of State pharmacy program administrators. In addition, this section provides Medicaid eligibility statistics from CMS for fiscal year 2001 and program expenditure data for fiscal years 2001 and 2002. Medicaid pharmacy programs are characterized by estimates of total expenditures, drug payments, drug benefit design, and pharmacy payment and patient cost sharing.

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

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

The book also contains a series of appendices. Appendix A features a list of State contacts, CMS regional offices and Medicaid program personnel. Appendix B provides a national level summary on total Medicaid program recipients by type of service for FY 2000 and FY 2001 and data on total number of drug recipients for each State and the nation as a whole for the period 1996-2001. Appendix C provides the current Medicaid drug rebate law. Appendix D contains the list of CMS upper limits on multiple source products. Appendix E is a glossary and list of acronyms.


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Each year, finding and compiling current, relevant information for inclusion in the Compilation presents a challenge. For example, each year CMS makes available on its website the Medical Statistical Information System (MSIS) Statistical Reports for the most recent enrollment and expenditure data available. The MSIS tables are used throughout several sections as a secondary data source. This year, CMS released MSIS reports on federal Fiscal Year 2001. However, at the time of publication, the FY 2001 information for Washington State was not yet available. FY 2000 data have been substituted in their place. Additionally, Hawaii did not report for FY 2000 and FY 2001, therefore, their FY 1999 numbers are used. In addition, updated information for the Medicaid Waivers and Managed Care statistics have not been released at this time. We believe that this remains an important aspect of State Medical Assistance Programs and have included last year’s data in its place. As we continue to update and discover data, we are able to improve the Compilation with new tables and sources that we believe enhance its overall significance to the user. These new tables and sources include:

• Eligibility and maintenance assistance status table; • Eligibility and age table; • New poverty tables including raw numbers and percentages; • Enhanced employment tables; • Additional information on the Pharmacy Plus Demonstration waivers under Section 1115

Authority; • New listing for brand name products contacts in the State Profiles and Appendix A; and • A new source for the registered nurses.

NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program officials and their staffs. With their cooperation, we were able to achieve a 90 percent response rate to the 2003 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


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Section 1: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003: Dual Eligibles and Impact on the States


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BACKGROUND AND PURPOSE The Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003 was passed by Congress and signed by the President in December 2003. MMA will have a significant impact on Medicare beneficiaries and State Medicaid programs through changes affecting those dually eligible for both Medicare and Medicaid. The purpose of this section is to:

• Provide a concise summary of the key provisions affecting those dually eligible and the States. • Provide details of the demographic and Medicaid expenditure characteristics of the dually

eligible, using data from ten states.

THE MEDICARE MODERNIZATION ACT OF 2003 The MMA1 has been described as the most significant expansion of the Medicare program since the latter was originally enacted in 1965. It affects all aspects of Medicare and related programs. MMA enacted:

• A new voluntary Medicare Prescription Drug Program, effective January 2006 [Medicare Part D].

• A new Medicare Prescription Drug Discount Card Program as a transition to the Prescription

Drug Program, available from mid-2004 through December 2005.

• Prescription drug coverage currently provided by Medicaid to individuals who are dually eligible for Medicaid and Medicare will be available only through Medicare Part D Plan beginning in 2006, but states will be required to continue contributing toward the cost of this coverage.

• Revisions to the Medicare provisions for Health Maintenance Organizations (HMOs), now

called the Medicare Advantage (MA) program [Medicare Part C]. • New payment provisions for drugs furnished by physicians [under Medicare

Part B]. • Dozens of other amendments affecting the existing Medicare program, including:

o Enhancements of services furnished in rural areas. o Coverage of additional preventive screening tests (cardiovascular screening blood

tests; diabetes screening tests; an initial preventive screening examination; payment improvements for mammography tests).

o Additional demonstration projects and studies, including a demonstration project for the coverage of certain prescription drugs and biologicals.

o Authority to replace Medicare fiscal intermediaries and carriers with regular government contractors.

1 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. Law No. 108-173 (December 8, 2003).


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o Detailed procedures for appealing Medicare coverage provisions and other administrative decisions.

o Establishment of a unified center within CMS for the coordinated administration of the Medicare HMO, drug, and beneficiary marketing and outreach programs.

• Various amendments to the Medicaid program, including exclusion of inpatient drugs

purchased by certain public hospitals and exclusion of prices negotiated under a Part D Plan, from the “best price” calculation for the Medicaid drug rebate program.

• Reforms to the Hatch-Waxman patent procedure for introducing new generic drugs.

• Establishment of Health Savings Accounts and other tax amendments.

PROVISIONS OF MMA AFFECTING DUAL ELIGIBLES AND THE STATES

The Prescription Drug Program A separate Medicare program. The prescription drug program will be a new, separate part of the Medicare program (Part D). Enrolling in the program, and paying the required premiums, will be a voluntary choice for most beneficiaries. However, a Medicare beneficiary must first be entitled to Medicare Part A or enrolled in Medicare Part B in order to be eligible to enroll in a Part D Prescription Drug Plan (PDP). A full-benefit dual eligible individual who fails to enroll in a drug plan may be enrolled by CMS into a drug plan whose monthly premium does not exceed the amount of the premium subsidy. If there is more than one such plan available, CMS will enroll the individual on a random basis among all plans in the region. However, the individual will remain free to decline or change this enrollment. A covered Part D drug is defined as a drug that may be dispensed only with a prescription and that meets the same tests for safety and efficacy under the Federal Food, Drug, and Cosmetic Act as apply under the Medicaid drug rebate program. Also covered are approved biologicals, insulin and medical supplies associated with insulin injections, and approved vaccines. However, drugs excluded from the Medicaid drug rebate program are also excluded from Medicare Part D, except for smoking cessation agents, which can be covered. Enrolling in a Drug Plan. A beneficiary currently in the traditional Medicare fee-for-service program will be able to enroll in a PDP. A beneficiary enrolled in a Medicare HMO, called a Medicare Advantage (MA) Plan, will be able to enroll only in that Plan’s drug benefits program if it qualifies under the new law (“an MA-PD Plan”); such a beneficiary will not be allowed to enroll in a fee-for-service drug Plan unless the MA-Plan lacks qualified drug coverage. CMS must ensure that there are at least two Drug Plans available in each area, offered by different entities, and at least one of the Plans must be a PDP. The other may be an MA-PD Plan.

Premium and Cost-Sharing Subsidies for Low-Income Beneficiaries The new law defines a subsidy eligible individual as an individual eligible for Medicare Part D drug benefits who is enrolled in a PDP or an MA-PD Plan; has income below 150% of the Federal poverty line; and whose resources for 2006 do not exceed three times the maximum amount of resources under the SSI program (which is $2,000 in countable resources for an individual or $3,000 for a married couple). Thus, the Part D resources limit would be $6,000 for an individual or $9,000 for a married couple. These limits will be increased each year in multiples of $10 by the percentage increase in the Consumer Price Index (“CPI”). For individuals with income below 135% of the Federal poverty level,


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the resources limit for 2006 is $10,000 for an individual, or $20,000 for a married couple, increased annually in multiples of $10 by the CPI. The new law defines a full-benefit dual eligible individual as a beneficiary who has qualified for prescription drug benefits under a Medicare PDP, and who has been determined by the State Medicaid program to be eligible for any category of full Medicaid benefits. This includes the “medically needy,” once they have “spent down” their medical expenses to meet the Medicaid income and resource levels. When a dually eligible beneficiary has access to drug coverage under both a PDP under Medicare Part C or D, and under the State’s Medicaid program, Medicare will be the primary payer and no Medicaid benefits will be available for the drugs themselves or for any cost sharing for them, such as deductibles and co-payments. However, a State Medicaid Plan may choose to continue to provide Medicaid coverage in case of a drug that is not covered under a PDP and is covered by the Medicaid Plan. CMS will notify a PDP of the exact status of each subsidy eligible individual enrolled in the Plan. The Plan will reduce the beneficiary’s premiums, deductibles, and co-payments appropriately, and CMS will periodically reimburse the Plan for such reductions. Individuals with income below 135% of the Federal poverty line will be eligible for a subsidy of 100% of the premium for basic drug coverage. They will be subject to a drug deductible of zero. Benefits will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”), subject to reduced cost sharing, but no co-insurance will be due for full benefit dual eligibles who are institutionalized. The reduced cost sharing for individuals who are not institutionalized will be $2 for a generic drug or a multiple source drug and $5 for any other drug. However, individuals with income not exceeding 100% of the Federal poverty line who are not institutionalized will be subject to a reduced co-payment of $1 for a generic drug or a preferred multiple source drug, and $3 for any other drug, increased annually in multiples of 5 cents and 10 cents, respectively, by the percentage increase in annual aggregate Part D expenditures. There will be no cost sharing for the cost of drugs that exceeds the out-of-pocket limit ($3600). Other individuals with income below 150% of the federal poverty line will be entitled to a reduced deductible of $50 for 2006, increased annually in multiples of $1 by the percentage increase in aggregate Part D expenditures. They will also be entitled to a premium subsidy based on a sliding scale ranging from 100% premium subsidy for individuals with income at or below 135% of the Federal poverty line, to a premium subsidy of 0 for individuals at or above 150% of the Federal poverty level. These individuals will also be entitled to a reduced annual deductible of $50. Benefits will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”), subject to reduced co-payment of 15% (instead of 25%).

Phased Down State Contribution The costs States now incur for drugs for dual eligibles will be shifted to Medicare, but States must continue to pay CMS a portion of those costs. The new law provides that this assumption of costs by the Federal government be phased in gradually. To accomplish this phase-in, each State must pay to CMS each month, beginning January 2006, an amount equal to the product of:

• the “Medicaid amount” for the State for that month; • the total number of full-benefit dual eligible individuals for the State for that month; and • the phase-in factor.

The “Medicaid amount” is 1/12 of the product of:


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• the base year Medicaid per capita expenditures for full benefit dual-eligibles; and • a proportion equal to 100% minus the Federal medical assistance percentage (“FMAP”) (“the

matching rate”). This product is increased each year (beginning with 2004 up to and including the year involved) by the “growth factor.” The “base year State Medicaid per capita expenditures” for covered Part D drugs for full-benefit dual eligible individuals for a State is the weighted average of:

• the gross per capita Medicaid expenditures for prescription drugs for 2003; and • the estimated actuarial value of prescription drug benefits under a capitated managed care plan

per full-benefit dual eligible individual for 2003. The “growth factor” for 2004, 2005, and 2006 is the average annual percent change from the previous year of the per capita amount of prescription drug expenditures as determined based on the most recent National Health Expenditures for the years involved. For subsequent years, the growth factor is the percentage change in aggregate annual expenditures for Part D drugs. The “phase in factor” for a month is 90% in 2006; 88 1/3% in 2007; 86 2/3% in 2008; 85% in 2009; 83 1/3% in 2010; 81 2/3% in 2011; 80% for 2012; 78 1/3% for 2013; 76 2/3% for 2014; and 75% thereafter.

MMA Medicaid Amendments Requiring State Medicaid Program Actions A State Medicaid Plan must provide that the State Medicaid program will make eligibility determinations for low-income beneficiaries who can qualify for premium and cost sharing subsidies under a PDP Plan, as well as for any Medicare cost sharing, and will offer the individual any available Medicaid benefit. The State’s administrative costs under this provision are treated as regular Medicaid administrative costs and the Federal government will match these costs at the rate for Medicaid administrative costs. The Commissioner of Social Security can also make eligibility determinations when necessary.

CHARACTERISTICS OF DUALLY ELIGIBLE BENEFICARIES The following analysis is based on detailed Medicaid Management Information System (MMIS) data from ten States, for Federal Fiscal Year 2000. Medicaid Statistical Information System (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. 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 data used in this analysis were obtained under strict confidentiality agreements with the States, which prohibits their identification. The ten States are both programmatically and geographically diverse, but comparisons of the ten States to all States using currently available data confirmed that the ten States are reasonably representative of all States for FFY 2000.

Analytic File Development Developing the analytical files involved several steps. To begin, we created a research file from the MSIS data files that would permit us to differentiate dual and non-dual Medicaid eligibles. Next, all


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claims for these beneficiaries were extracted and placed in a temporary file. A list of recipient identification numbers, which are unique to each individual, was compiled and unduplicated, creating a single file of all recipients. The final step was to extract all claims for this unduplicated list of recipients from the four claims files and the eligibility file and created a single record for each individual. This resulted in a record that contained all Medicaid expenditures for those beneficiaries. The analysis examines the demographic characteristics and expenditures patterns for dual eligibles and then contrasts the dual eligibles with those not dually eligible. The identification of dual eligibles proved challenging. The MSIS data base contains a “flag” for each person that should indicate whether that person is dual eligible or not. In the process of developing these estimates, we discovered that the flag in the Medicaid MSIS dataset that identifies dual eligible beneficiaries is not reliable across all States. Specifically, there is a significant amount of variance in the accuracy with which the flag in the eligibility dataset is coded by the States. For instance, in one medium sized Southern State, we found no dual eligibles within the dataset using this indicator. Knowing this information could not be true, we explored other ways to identify dual eligibles within the dataset. Given this problem, we analyzed the MSIS data dictionary and datasets to determine other methods to allow us to impute dual eligible status. This analysis showed that the eligibility file had no other indicator that would determine if a person was dually eligible. For example, some persons over 65 on Medicaid are not eligible for Medicare, such as those elderly who did not work 40 quarters in order to obtain Medicare eligibility. However, the claims file contains what are known as “crossover“ claims. These are claims that are filed with Medicaid for Medicare co-pay and deductible amounts. After considerable exploratory analysis. We decided that the best way to proceed was to treat all those persons that have cross over claims or have the dual eligible flag as dually eligible. This more encompassing method is what we used to identify dual eligibles.

Gender and Age Tables 1 and 2 include total patient counts and expenditures data for males versus females for both dual and non-dual eligibles.

Table 1. Population by Gender and Eligibility Status*

All

Recipients % of All

Recipients

Dual Eligible

Population % Dual Eligibles

Not Dual Eligibles

% Not Dual

Eligibles Total Medicaid Population 6,647,300 100% 1,002,400 15% 5,644,900 85% Female 3,890,401 59% 657,562 66% 3,232,839 57% Male 2,756,899 41% 344,838 34% 2,412,061 43%

*A small number of claims were missing information on gender and have been excluded from Table 1. Therefore, the column totals for number of beneficiaries may differ slightly with those in other tables.

As shown in Table 1, the dual eligible population is 66 percent female and 34 percent male. By comparison, the non-dual eligible population is 57 percent female and 43 percent male. In terms of gender. the total Medicaid population is 59 percent female and 41 percent male, very similar to the non-dual eligible population. However, even though dual eligibles constitute only 15 percent of the total Medicaid population, they account for a disproportionate share (42 percent) of Medicaid program expenditures (Table 2).


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Table 2. Medicaid Expenditures by Gender and Eligibility Status

Total Paid % of

Total Paid Dual Eligible

Paid

% Dual Eligibles

Paid Not Dual

Eligibles Paid

% Not Dual

Eligibles Paid

Total Medicaid Paid $21,942,055,818 100% $9,215,082,242 42% $12,726,973,576 58% Female $13,338,032,842 59% $6,186,874,474 67% $7,151,158,368 56% Male $8,604,022,976 41% $3,028,207,768 33% $5,575,815,208 44%

Further analysis of the data in Table 2 indicates that the male/female breakouts for expenditures are virtually identical to the demographic splits (Table 1). Within each of the eligibility categories, females account for the greatest proportions of Medicaid payments.

Table 3. Payments Per Capita by Gender

Average Per Capita by Gender

Gender Dual Eligible Medicaid Paid Dual Eligible Per Capita Not Dual Eligible

Medicaid Paid

Not Dual Eligible Per

Capita

Female $6,186,874,474 $9,409 $7,151,158,368 $2,212Male $3,028,207,768 $8,782 $5,575,815,208 $2,312Total $9,215,082,242 $9,193 $12,726,973,576 $2,255

Average Medicaid payments per capita by gender are presented in Table 3. For the dual eligible population, average expenditures per capita expenditure are 400 percent higher than for non-dual eligibles. Within each group, average per capita spending is fairly similar for males and females.

Table 4. Population Percentages by Age and Eligibility Status

All Recipients

% of All Recipients

Dual Eligible Population

% Dual Eligibles

Not Dual Eligibles

% Not Dual Eligibles

Total Medicaid Population 6,558,236 100% 1,002,432 15% 5,555,804 85% Age Group 0 to 4 1,318,346 20% 885 0% 1,317,461 23% 5 to 12 1,514,904 23% 3,831 0% 1,511,073 27% 13 to 24 1,377,283 21% 18,579 2% 1,358,704 24% 25 to 44 1,072,332 16% 163,647 16% 908,685 16% 45 to 64 566,877 9% 227,877 23% 339,000 6% Subtotal 64 5,849,742 88% 414,819 41% 5,434,923 96% 65 plus 708,494 11% 587,613 59% 120,881 2%

Table 4 shows the population distribution by age and eligibility status. For dual eligibles, 59 percent of the population is 65 years of age or older. More importantly, 41 percent of the dual eligibles are under 65 years of age. These are overwhelmingly disabled individuals. More interestingly, 17 percent (120,881 of 708,494 beneficiaries) of the Medicaid population over 65 is not dually eligible. Many individuals interested in the MMA provisions have incorrectly assumed that all Medicaid recipients over 65 are dually eligible. Therefore, even if some of these individuals are incorrectly classified by


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Medicaid programs and/or may become eligible for Part D prescription drug coverage, States will have aged beneficiaries remaining on their rolls. This occurs because many states have expanded their Medicaid eligibility criteria and/or have elected to cover optional groups whose incomes and assets exceed the criteria for dual eligibles.

Table 5. Medicaid Expenditures Percentages by Age and Eligibility Status

Total

Medicaid Paid % of

Total Paid Dual Eligible

Medicaid Paid % Dual

Eligibles Paid

Not Dual Eligibles

Medicaid Paid

% Not Dual Eligibles

Paid Total Medicaid Paid 21,353,868,898 100% 9,215,343,151 43% 12,138,525,747 57% Age Group 0 to 4 2,116,168,842 10% 6,096,559 0% 2,110,072,283 17% 5 to 12 1,669,434,562 8% 20,577,970 0% 1,648,856,592 14% 13 to 24 2,809,026,255 13% 121,273,602 1% 2,687,752,653 22% 25 to 44 4,149,276,161 19% 1,317,227,181 14% 2,832,048,980 23% 45 to 64 4,087,134,021 19% 1,885,855,392 20% 2,201,278,629 18% Subtotal 64 14,831,039,841 69% 3,351,030,704 36% 11,480,009,137 95% 65 plus 6,522,829,057 31% 5,864,312,447 64% 658,516,610 5%

Dual eligibles account for 43 percent of all Medicaid expenditures (Table 5). For dual eligibles, nearly two-thirds, 64 percent, of Medicaid expenditures are for the elderly and 36 percent are for the population under 65 years of age. By contrast, among non-dual eligibles, only 5 percent of expenditures are for beneficiaries 65 years of age and older and 95 percent are for non-elderly recipients. Of the approximately $6.5 billion in Medicaid program spending for the elderly, $659 million (10.1 percent) was spent on the population 65 and older who are not dually eligible.

Dual Eligible Expenditures by Type of Service Tables 6 and 7 summarize total patient counts and Medicaid program payments by type of service for dual and non-dual eligibles. Please note that, because an eligible beneficiary can receive more than one service, patient counts may be duplicated. However in calculating the percentages, we used the unduplicated totals (see Table 1).


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Table 6. Summary of Medicaid Data by Service Type and Eligible Status

Patient Count

Service Type Dual Eligible % Dual Eligible

Not Dual Eligible

% Not Dual Eligible

Long Term (NF/ICF/MR) 206,678 21% 54,567 1%Prescription Drug 822,235 82% 3,213,848 57%Inpatient 223,978 22% 690,048 12%Other 652,018 65% 2,318,574 41%Capitated Payments HMO/HIO 74,397 7% 1,808,451 32%Physicians 781,145 78% 3,212,998 57%Outpatient Hospital 551,116 55% 2,062,036 37%Clinic 267,253 27% 1,211,036 21%Personal Care Svcs 68,607 7% 21,769 0%Dental 125,120 12% 1,278,122 23%Home Health 42,798 4% 49,310 1%Targeted Case Mgmt 27,651 3% 184,342 3%Emergency Room 175,069 17% 1,194,406 21%Lab and X-Ray 260,823 26% 1,325,548 23%Capitated Payments for PCCM 117,297 12% 1,971,936 35%Private Duty Nursing 1072 0% 2,472 0%Members w/o Claims 28,566 3% 491,756 9%Total 1,002,400 100% 5,644,900 100%

Table 6 compares patterns of service utilization for the dual eligible and non-dual eligible populations. As shown in Table 6, the utilization rates are higher for dual eligibles for almost all of the type of service categories. The only exceptions are capitated payments, dental services, and use of emergency rooms.2 Interestingly, prescription drugs are utilized by an overwhelming 82 percent of the dual eligible population compared to just over half (57 percent) of the non-dual eligibles. Also of interest is the fact that only 3 percent of dual eligibles did not have service claims compared to 9 percent of the non-dual eligible population.

2 Please note that persons in capitation arrangements may have used other services, which are reported separately from their membership in capitation plans. The MMIS reporting system we are using requires that States collect and report managed care “encounters.” These records appear in the database but do not have the expenditure fields completed since, by definition, managed care organizations do not charge separately for each service.


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Table 7. Summary of Medicaid Expenditures by Service Type and Eligibility Status

Medicaid Paid

Service Type Dual Eligible % Dual Eligible

Not Dual Eligible

% Not Dual Eligible

Long Term (NF/ICF/MR) $4,375,191,574 47% $1,170,665,993 10%Prescription Drug $1,914,514,871 21% $1,518,678,388 13%Inpatient $335,566,759 4% $2,449,561,265 20%Other $1,035,967,616 11% $1,554,693,387 13%Capitated Payments HMO/HIO $193,803,464 2% $2,014,430,322 17%Physicians $255,046,010 3% $1,013,919,106 8%Outpatient Hospital $330,030,811 4% $908,154,113 7%Clinic $174,616,069 2% $517,907,551 4%Personal Care Svcs $334,877,197 4% $142,456,278 1%Dental $29,430,515 0% $279,049,989 2%Home Health $153,738,248 2% $100,913,904 1%Targeted Case Mgmt $33,920,739 0% $150,925,649 1%Emergency Room $19,775,428 0% $127,124,720 1%Lab and X-Ray $20,006,385 0% $89,964,175 1%Capitated Payments for PCCM $7,045,120 0% $68,025,641 1%Private Duty Nursing $1,812,345 0% $32,055,266 0%Members w/o Claims $0 0% $0 0%Total $9,215,343,151 100% $12,138,525,747 100%

Table 7 illustrates the distribution of expenditures for both dual and non-dual eligibles. For the dual eligible population, long-term care (nursing homes and ICFs/MR) and prescription drugs are the two largest expenditures categories. Long-term care, for example, accounts for 47 percent of the monies spent on dual eligibles. Prescription drugs comprise an additional 21 percent of the expenditures. By comparison long-term care is only 10 percent and prescription drugs 13 percent of total expenditures for the non-dual eligible population. These variations reflect the demographic characteristics of the dual eligible population and the fact that Medicare is paying for certain sources (i.e., inpatient care) for dual eligible beneficiaries.

Inpatient care ($2.4 billion) is the most expensive service type for non-dual eligibles. However, while it accounts for 20 percent of expenditures, only 12 percent of the non-dual eligible population had claims for inpatient care (Table 6). Conversely, for dual eligibles, 22 percent of the population had claims for inpatient care but, in terms of expenditures, inpatient care comprised only 4 percent of their total Medicaid program payments.


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Table 8. Summary of Medicaid Data by Drug Type and Dual Eligible Status

Patient Count Medicaid Paid

AHFS 2 digit Dual

Eligible

% Dual

Eligible Not Dual Eligible

% Not Dual

Eligible Dual Eligible

% Dual

Eligible Not Dual Eligible

% Not Dual

Eligible 28 - Central Nervous System Drugs 694,111 69% 1,501,358 27% $698,194,103 36% $587,625,205 39% 24 - Cardiovascular Drugs 500,805 50% 295,794 5% $289,693,604 15% $109,044,722 7% 56 - Gastrointestinal Drugs 415,094 41% 388,738 7% $231,734,451 12% $119,202,951 8% 08 - Anti-Infective Agents 544,750 54% 2,094,058 37% $122,658,237 6% $207,645,271 14% 68 - Hormones And Synthetic Substitutes 407,361 41% 717,795 13% $152,717,579 8% $121,689,014 8% 12 - Autonomic Drugs 297,568 30% 701,771 12% $81,162,590 4% $59,301,825 4% 92 - Unclassified Therapeutic Agents 120,405 12% 154,685 3% $78,521,356 4% $46,003,044 3% 20 - Blood Formation And Coagulation 139,717 14% 172,901 3% $40,782,856 2% $64,052,725 4% 40 - Electrolytic, Caloric Balance 381,513 38% 229,361 4% $58,678,234 3% $21,098,611 1% 04 - Antihistamine Drugs 235,506 23% 908,566 16% $27,477,911 1% $48,917,940 3% Other 524,159 52% 1,991,217 35% $132,893,950 7% $134,097,080 9% No Rx Claims 180,197 18% 2,341,956 41% $0 0% $0 0% Total 1,002,400 100% 5,644,900 100% $1,914,514,871 100% $1,518,678,388 100%

Table 8 summarizes drug utilization and cost data for the dual eligible and non-dual eligible populations. Analysis of these data yields some interesting results. First, across all of the categories, a significantly higher proportion of dual eligible beneficiaries compared to non-dual eligibles had drug claims and a smaller proportion of dual eligible beneficiaries had no drug claims. Furthermore, although dual eligibles comprise only 15 percent of the beneficiaries in the study, they account for more than half (56 percent) of total drug expenditures.

For almost every drug category, expenditures for dual eligibles exceed those for non-dual eligible beneficiaries, even where the actual number of dual eligible recipients is significantly smaller than the number of non-dual eligible recipients. For example, expenditures for central nervous system (CNS) drug are the highest expenditure category for both the dual and non-dual eligible population groups. However, a much higher proportion of dual eligible beneficiaries had claims for CNS drugs than did non-dual eligibles. Furthermore, despite the fact that more than twice as many non-dual eligible beneficiaries had claims for CNS drugs, total expenditures for CNS drugs were more than $110 million higher for the dual eligible group.


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Conclusion Overall, MMA will require that prudent States take a new look at their programs intended to manage prescription drug spending. Beginning in 2006, states will no longer provide and manage drug coverage for patients that currently represent, on average, about 50% of the State’s Medicaid spending for drugs. This significant shift will require that States reassess available resources and the most cost-efficient ways for employing those resources. Because of the substantial presence of the dual-eligible population in current spending patterns for drugs, the cost benefit decisions among various strategies are likely to change dramatically especially for those strategies that rely primarily on reducing drug costs. The return on investments in efforts to improve care more broadly, such as disease management, are likely to be increasingly attractive to States.


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Section 2: The Medicaid Program


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

MEDICAID ELIGIBILITY

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

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

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

• Low-income families with children;

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

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

• Qualified pregnant women;

• Newborn children of Medicaid-eligible women;

• Various categories of low-income children; and

• Certain low-income Medicare beneficiaries.

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

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

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


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For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who qualifies for Medicare Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and co-payment amounts.

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

MEDICAID SERVICES

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

• Inpatient and outpatient hospital services; • Physician services; • Medical and surgical dental services; • Laboratory and X-ray services; • Nursing facility services (for persons 21 years of age or older); • Early and periodic screening, diagnostic, and treatment (EPSDT) services for children

under age 21; • Family planning services and supplies; • Home health services for persons eligible for nursing facility services; • Rural health clinic services and any other ambulatory services offered by a rural health

clinic that are otherwise covered under the State Plan; • Nurse-midwife services (to the extent authorized under State law); • Pediatric and family nurse practitioners services; and • Federally-qualified health center 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;


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

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

CHARACTERISTICS OF BENEFITS PROVIDED

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

• The facility must be licensed or formally approved as a hospital by an officially designated authority for State standard setting;

• The facility must meet the requirements for participation in Medicare as a hospital; • The care and treatment of inpatients must be under the direction of a physician or dentist;

and • The facility must have in effect an approved utilization review plan, applicable to all

Medicaid patients, unless a waiver has been granted by the Secretary of Health and Human Services, because the State’s own utilization review procedures are adequate.

• A peer review organization (PRO) may satisfy these requirements.

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

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

• The services must be provided under the direction of a physician or dentist; • The facility must be licensed or formally approved as a hospital by an officially

designated authority for State standard setting; and • The facility must meet the requirements for participation in Medicare as a hospital.

Rural Health Clinic Services Rural health clinic (RHC) services are a mandatory service for the categorically needy. Each RHC is required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a clinic can be certified to participate in the Medicaid program only if State law permits the delivery of primary care by an NP or PA.

Services in RHCs must be provided by a physician or by a PA, NP, nurse-midwife, or other specialized nurse practitioner. Services and supplies are furnished as “incident to” the professional services of such a practitioner are also covered. Part-time or intermittent visiting nurse services and related medical supplies are provided if the RHC is located in an area which DHHS has determined


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

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

• Ordered and provided by or under the direction of a physician or other licensed practitioner of the healing arts within the scope of his or her practice, as defined by State law, or ordered and billed by a physician but provided by an independent laboratory;

• Provided in an office or similar facility other than a hospital inpatient or outpatient department or clinic; and

• Provided by a laboratory that meets the requirements for participation in Medicare. • In addition, the States can place limitations on “other laboratory and X-ray services.”

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

• Provided by a facility or a distinct part of a facility that is certified to meet the requirements for participation in the Medicaid program as a NF; and

• Ordered by and furnished under the direction of a physician.

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

Screening: • Comprehensive health and developmental history screening; • Comprehensive unclothed physical examination; • Appropriate vision testing; • Appropriate hearing testing; • Appropriate laboratory tests; • Dental screening services furnished by direct referral to a dentist for children beginning

at 3 years of age.

Diagnosis and Treatment: In addition to any diagnostic and treatment services included in the State Medicaid Plan, the State must provide to eligible EPSDT recipients the following services, the need for which is indicated by screening, even if the services are not included in the Plan:

• Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and hearing aids;

• Dental care, at as early an age as necessary, needed for relief of pain and infections, restoration of teeth and maintenance of dental health; and


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

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

Family Planning Services Federal Requirements: States are required to provide family planning services and supplies to individuals of childbearing age (including minors who can be considered to be sexually active) who are eligible under the State Medicaid Plan and who desire such services and supplies. Specifically, family planning services must be made available to categorically needy Medicaid recipients, and the State has the option of furnishing these services to the medically needy.

Defined: The term “family planning services” is not defined in the law or in regulations. However, the Senate Report accompanying the law stresses Congress’ intent of placing emphasis on the provision of services to “aid those who voluntarily choose not to risk an initial pregnancy,” as well as those families with children who desire to control family size. In keeping with Congressional intent, the State may choose to include in its definition of Medicaid family planning services only those services which either prevent or delay pregnancy, or the State may more broadly define the term to include services for the treatment of infertility. However, the Medicaid definition must be consistent with overall State policy and regulation regarding the provision of family planning services.

The State is free to determine the specific services and supplies that will be covered as Medicaid family planning services as long as those services are sufficient in amount, duration, and scope to reasonably achieve their purpose. It must also establish procedures for identifying individuals who are sexually active and eligible for family planning services.

Federal Matching Payments: Federal Financial Participation (FFP) is available at the “enhanced” rate of 90 percent for the cost of family planning services. These include counseling services and patient education, examination and treatment by medical professionals in accordance with applicable State requirements, laboratory examinations and tests, medically approved methods, procedures, pharmaceutical supplies and devices to prevent conception, and infertility services, including sterilization reversals.

FFP at the enhanced rate of 90 percent is also available for the cost of a sterilization if a properly completed sterilization informed consent form, in accordance with the requirements of 42 CFR Part 441, Subpart F, is submitted to the State prior to payment of the claim.

FFP at the 90 percent rate is not available for the cost of a hysterectomy or for the costs related to other procedures performed for medical reasons, such as removal of an intrauterine device due to infection. Only items and procedures clearly provided or performed for family planning purposes may be matched at the 90 percent rate. Transportation to a family planning service is not eligible for the 90 percent match. Transportation must be claimed as either an administrative cost or a State Plan service, in accordance with the State’s approved Medicaid State Plan.

Abortions: Abortions may not be claimed as a family planning service. For more than 20 years, Congressional restrictions have been placed on appropriated funds for DHHS programs that fund abortions. FFP is available only in expenditures for an abortion when a physician has found, and so certified in writing to the Medicaid agency, that on the basis of his/her professional judgment, the life of the mother would be endangered if the fetus were carried to term. The certification must contain the name and address of the patient. Congress has prohibited the use of Federal funds for victims of rape or incest.


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

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

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

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

• Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a home health agency. If there is no home health agency in the area, services may be provided by a registered nurse who is currently licensed to practice in the State, receives written orders from the patient’s physician, documents the care and services provided, and has had orientation to acceptable clinical and administrative record keeping from a health department nurse.

• Home Health Aide: Home health aide services provided by a home health agency. • Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are

suitable for use in the home. • Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology

Services: PT, OT, speech and hearing services provided by a home health agency or a facility licensed by the State to provide medical rehabilitation.

• Home health services are provided to categorically needy recipients age 21 and over and to those under 21 only if the State Plan provides SNF services for them.

Personal Support Services

Personal support services consist of a variety of services including personal care, targeted case management, home and community-based care for functionally disabled elderly, rehabilitative services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of some of these services are provided below:

1. Personal Care Services: Services provided to an individual who is not an inpatient or resident of a hospital, nursing facility, intermediate care facility for the mentally


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retarded, or institution for mental disease. Services are authorized by a physician in accordance with a treatment plan, are provided by a qualified individual who is not a member of the recipient’s family, and are furnished in a home or (at the State’s option) in another location.

2. Rehabilitative Services: These services include any medical or remedial service recommended by a physician or other licensed practitioner of the healing arts within the scope of State law. Services are for the maximum reduction of physical or mental disability and restoration of a recipient to their best possible functional level.

3. Hospice Services: Hospice services can be received in a hospice facility or elsewhere. Services are provided to terminally ill individuals by an authorized hospice program under a written plan established and reviewed by the attending physician, medical director or physician designee of the program, and an interdisciplinary group.

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

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

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

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

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


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

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

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

AMOUNT AND DURATION OF SERVICES Within broad Federal guidelines and certain limitations, States may determine the amount and duration of services offered under their Medicaid programs. Federal regulations require that the amount and/or duration of each type of medical and remedial care and services furnished under a State’s program must be specified in the State Plan, and that these types of care and services must be sufficient in amount, duration, and scope to “reasonably achieve” their purpose. States are required to provide Medicaid coverage for comparable amounts, duration, and scope of service to all “categorically needy” and categorically-related eligible persons.

Each State Plan must include a description of the methods that will be used to assure that the medical and remedial care and services delivered are of high quality, as well as a description of the standards established by the State to assure high quality care. The regulations also require that the fee structures developed must result in participation of a sufficient number of providers so that eligible persons can receive the medical care and services included in the Plan, at least to the extent that these are available to the general population. The law further requires that services provided under the Plan be available throughout the State. Recipients are to have freedom of choice with regard to where they receive their care, including an option to obtain their care through organizations that provide services or arrange for their availability on a prepayment basis, such as health maintenance organizations.

MEDICAID PAYMENT FOR SERVICES The Medicaid program operates on the basis of a division of responsibilities between the Federal government and the States with the Federal government paying States for a portion of State medical expenditures and administrative costs. Funding for the program is shared between the two bodies, with the Federal government matching State health care provider reimbursements at an authorized rate of between 50% and 72.96%, depending on the State’s per capita income (see the Federal Medical Assistance Percentage (FMAP) table, page 2-18).

The FMAP is based upon the State’s per capita income; if a State’s per capita income is equal to or greater than the national average, the Federal share is 50%. If a State’s per capita income is below the national average, the Federal share is increased, up to a maximum of 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.


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Total Medicaid Eligibles by Maintenance Assistance Status, 20011

State

Total Eligibles

Receiving Cash

AssistanceMedically

NeedyPoverty Related Other

1115 Demonstration

MAS Unknown

National Total 46,910,257 17,555,319 3,661,252 13,529,154 7,779,041 4,384,730 761Alabama 780,434 282,756 0 373,733 36,442 87,503 0Alaska 115,996 52,568 0 54,753 8,663 0 12Arizona 808,386 380,272 0 241,905 156,460 29,749 0Arkansas 550,668 147,990 21,122 186,090 53,291 142,162 13California 8,495,030 3,974,456 863,850 413,616 1,299,265 1,943,842 1Colorado 410,611 211,229 0 152,356 46,911 0 115Connecticut 446,326 102,886 35,997 76,751 230,671 0 21Delaware 133,079 89,121 0 11,384 15,909 16,665 0District of Columbia 152,597 91,862 27,463 25,617 7,655 0 0Florida 2,462,171 1,085,854 67,479 815,482 355,620 137,722 14Georgia 1,328,379 536,171 10,277 541,038 240,893 0 0Hawaii* 202,912 118,221 2,549 50,790 7,605 23,747 0Idaho 172,348 26,466 0 96,160 49,722 0 0Illinois 1,798,723 385,404 427,590 866,708 119,021 0 0Indiana 825,556 319,863 0 313,072 192,621 0 0Iowa 331,025 148,544 10,091 95,866 76,524 0 0Kansas 291,837 94,061 20,127 123,446 54,203 0 0Kentucky 762,871 334,192 39,893 316,906 71,880 0 0Louisiana 886,518 345,766 9,498 430,313 100,941 0 0Maine 277,843 81,088 1,360 75,760 55,759 63,876 0Maryland 704,628 206,159 83,168 365,212 50,088 0 1Massachusetts 1,125,607 324,129 22,332 422,318 119,755 237,073 0Michigan 1,430,246 447,720 125,675 476,446 380,326 0 79Minnesota 609,856 236,283 10,398 9,261 237,221 116,693 0Mississippi 681,161 293,225 0 359,329 28,591 0 16Missouri 1,032,047 390,531 0 299,010 148,868 193,638 0Montana 101,966 42,887 8,790 22,934 27,334 0 21Nebraska 249,079 59,977 40,691 117,093 31,069 0 249Nevada 167,247 62,278 0 60,921 44,048 0 0New Hampshire 108,562 24,877 10,979 48,437 24,269 0 0New Jersey 923,697 419,211 5,078 330,854 168,554 0 0New Mexico 423,543 140,380 0 206,321 67,217 9,625 0New York 3,548,630 1,395,014 1,368,735 328,866 108,099 347,916 0North Carolina 1,397,486 632,171 44,066 659,687 61,562 0 0North Dakota 65,425 28,941 16,008 9,203 11,273 0 0Ohio 1,660,463 479,253 0 329,421 851,618 0 171Oklahoma 631,996 108,432 7,887 422,073 93,604 0 0Oregon 594,679 128,859 8,302 168,341 123,016 166,152 9Pennsylvania 1,647,440 678,978 116,515 526,543 325,404 0 0Rhode Island 194,113 84,762 4,453 24,881 41,939 38,077 1South Carolina 871,675 293,556 0 362,039 216,071 0 9South Dakota 106,154 39,418 0 43,996 22,740 0 0Tennessee 1,601,406 441,875 108,363 227,155 172,886 651,105 22Texas 2,729,660 909,653 57,510 1,263,395 493,704 5,398 0Utah 214,597 47,043 5,830 122,268 39,456 0 0Vermont 154,991 32,425 12,064 47,404 14,649 48,445 4Virginia 700,715 149,660 10,067 383,725 157,263 0 0Washington** 916,838 257,453 13,421 298,026 347,937 0 1West Virginia 351,489 141,306 4,916 180,978 24,289 0 0Wisconsin 673,538 231,211 38,708 123,725 154,550 125,342 2Wyoming 58,013 18,882 0 27,546 11,585 0 0

1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. *Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. **MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table. Source: CMS, MSIS Report, FY 2000 and FY 2001.


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Total Medicaid Eligibles by Age Group, 20011

State Total Eligibles <21 Years 21-64 Years65 Years and

Older Age UnknownNational Total 46,910,257 25,798,743 15,947,857 5,060,539 103,118Alabama 780,434 419,575 249,386 111,473 0Alaska 115,996 78,373 30,761 6,862 0Arizona 808,386 487,369 271,499 49,518 0Arkansas 550,668 324,082 162,083 64,502 1California 8,495,030 4,094,864 3,647,963 752,203 0Colorado 410,611 243,120 119,729 47,761 1Connecticut 446,326 240,064 145,949 60,313 0Delaware 133,079 69,591 53,394 10,094 0District of Columbia 152,597 83,343 55,159 14,095 0Florida 2,462,171 1,375,744 765,418 321,008 1Georgia 1,328,379 815,970 377,044 135,362 3Hawaii* 202,912 97,259 85,142 20,511 0Idaho 172,348 118,848 41,602 11,898 0Illinois 1,798,723 1,111,280 535,863 151,580 0Indiana 825,556 524,690 222,095 78,771 0Iowa 331,025 182,275 107,195 41,555 0Kansas 291,837 180,124 77,305 34,408 0Kentucky 762,871 436,215 238,295 88,361 0Louisiana 886,518 566,259 219,039 101,220 0Maine 277,843 104,883 110,563 62,379 18Maryland 704,628 429,301 209,135 66,192 0Massachusetts 1,125,607 500,383 485,350 139,874 0Michigan 1,430,246 858,526 441,977 129,743 0Minnesota 609,856 330,451 212,508 66,888 9Mississippi 681,161 413,084 174,377 93,700 0Missouri 1,032,047 605,928 330,815 95,302 2Montana 101,966 57,001 34,020 10,945 0Nebraska 249,079 161,809 63,820 23,450 0Nevada 167,247 96,160 52,107 18,980 0New Hampshire 108,562 66,824 28,834 12,902 2New Jersey 923,697 497,761 285,365 140,570 1New Mexico 423,543 286,567 107,030 29,946 0New York 3,548,630 1,660,024 1,315,242 470,330 103,034North Carolina 1,397,486 766,160 449,720 181,606 0North Dakota 65,425 33,884 21,255 10,286 0Ohio 1,660,463 951,645 561,249 147,569 0Oklahoma 631,996 426,288 141,887 63,821 0Oregon 594,679 275,652 273,893 45,134 0Pennsylvania 1,647,440 882,484 557,684 207,272 0Rhode Island 194,113 99,308 71,779 23,023 3South Carolina 871,675 510,230 281,829 79,582 34South Dakota 106,154 68,539 25,816 11,799 0Tennessee 1,601,406 740,012 707,585 153,809 0Texas 2,729,660 1,743,786 632,870 353,003 1Utah 214,597 140,676 61,889 12,031 1Vermont 154,991 74,068 59,926 20,997 0Virginia 700,715 410,269 189,426 101,020 0Washington** 916,838 568,245 278,676 69,917 0West Virginia 351,489 193,628 124,482 33,379 0Wisconsin 673,538 359,417 235,553 78,568 0Wyoming 58,013 36,705 16,274 5,027 7

1 Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year. *Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. **MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table. Source: CMS, MSIS Report, FY 2000 and FY 2001.


2-13

Total Medicaid Eligibles by Basis of Eligibility, 20011

State Total Eligibles Aged

Blind/Disabled Children Adults

Foster CareChildren

BOEUnknown

National Total 46,910,257 4,400,601 7,657,411 22,438,138 11,546,609 866,692 806Alabama 780,434 89,484 182,696 377,130 125,448 5,676 0Alaska 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* 202,912 18,824 21,616 85,074 73,338 4,060 -Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0Illinois 1,798,723 112,455 282,956 952,915 368,149 82,248 0Indiana 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 277,843 56,942 74,955 91,418 51,163 3,365 0Maryland 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 65,425 10,242 9,672 29,750 14,026 1,735 0Ohio 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 594,679 43,195 64,579 234,692 237,679 14,525 9Pennsylvania 1,647,440 206,976 364,161 754,343 275,074 46,886 0Rhode Island 194,113 19,137 36,402 84,191 48,834 5,548 1South 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 92,498 14,334 45Washington** 916,838 69,054 121,662 520,323 191,871 13,927 1West 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

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


2-14

Total Medicaid Eligibles Per 1000 Population, 2001

State

Total StatePopulation

TotalEligibles*

Eligibles per1000 Populations

National Total 285,093,813 46,910,257 164.5Alabama 4,466,440 780,434 174.7Alaska 632,674 115,996 183.3Arizona 5,297,684 808,386 152.6Arkansas 2,692,041 550,668 204.6California 34,533,054 8,495,030 246.0Colorado 4,428,786 410,611 92.7Connecticut 3,432,550 446,326 130.0Delaware 795,576 133,079 167.3District of Columbia 572,716 152,597 266.4Florida 16,355,193 2,462,171 150.5Georgia 8,394,795 1,328,379 158.2Hawaii* 1,225,038 202,912 165.6Idaho 1,321,309 172,348 130.4Illinois 12,517,168 1,798,723 143.7Indiana 6,126,470 825,556 134.8Iowa 2,932,225 331,025 112.9Kansas 2,700,453 291,837 108.1Kentucky 4,067,336 762,871 187.6Louisiana 4,466,001 886,518 198.5Maine 1,284,691 277,843 216.3Maryland 5,383,377 704,628 130.9Massachusetts 6,399,869 1,125,607 175.9Michigan 10,005,218 1,430,246 143.0Minnesota 4,985,202 609,856 122.3Mississippi 2,857,716 681,161 238.4Missouri 5,636,220 1,032,047 183.1Montana 905,954 101,966 112.6Nebraska 1,719,000 249,079 144.9Nevada 2,094,633 167,247 79.8New Hampshire 1,258,974 108,562 86.2New Jersey 8,504,114 923,697 108.6New Mexico 1,829,110 423,543 231.6New York 19,074,843 3,548,630 186.0North Carolina 8,195,249 1,397,486 170.5North Dakota 636,285 65,425 102.8Ohio 11,385,833 1,660,463 145.8Oklahoma 3,467,181 631,996 182.3Oregon 3,472,629 594,679 171.2Pennsylvania 12,298,363 1,647,440 134.0Rhode Island 1,058,992 194,113 183.3South Carolina 4,059,818 871,675 214.7South Dakota 758,156 106,154 140.0Tennessee 5,745,808 1,601,406 278.7Texas 21,340,598 2,729,660 127.9Utah 2,279,590 214,597 94.1Vermont 612,923 154,991 252.9Virginia 7,192,697 700,715 97.4Washington** 5,992,760 916,838 153.0West Virginia 1,801,641 351,489 195.1Wisconsin 5,405,140 673,538 124.6Wyoming 493,720 58,013 117.5

*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. **MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table. Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 & FY 2001.


2-15

Total Net U.S. Medical Assistance Expenditures

by Type of Service, FY 2001 & FY 2002

Service FY 2002 Percent of Total FY 2001 Percent

of Total Percent Change

Nursing Facility $47,466,264,432 19.3% $43,317,811,704 20.1% +9.6%

Inpatient Acute Care Hospital $43,690,502,629 17.8% $39,586,413,122 18.3% +10.4%

Pharmaceuticals $29,339,050,970 11.9% $24,656,812,921 11.4% +19.0%

HCBS Waivers $17,169,137,673 7.0% $14,864,788,473 6.9% +15.5%

ICF-Mentally Retarded $11,205,483,449 4.6% $10,686,809,919 5.0% +4.9%

Hospital Outpatient $9,245,799,624 3.8% $7,709,540,429 3.6% +19.9%

Physicians $7,559,242,098 3.1% $6,670,379,109 3.1% +13.3%

Clinic* $7,499,886,627 3.1% $6,689,968,278 3.1% +12.1%

Inpatient Mental Health Hospital $7,446,842,170 3.0% $6,862,423,184 3.2% +8.5%

Personal Care Services $6,037,450,986 2.5% $5,251,140,806 2.4% +15.0%

Home Health Care $2,766,480,497 1.1% $2,613,356,673 1.2% +5.9%

Dental $2,630,870,620 1.1% $2,193,475,415 1.0% +19.9%

Other Practitioners $1,413,870,565 0.6% $1,141,272,064 0.5% +23.9%

EPSDT $1,007,637,056 0.4% $935,836,328 0.4% +7.7%

Lab/X-ray $781,820,930 0.3% $660,398,684 0.3% +18.3%

Other** $50,437,280,350 20.5% $41,969,472,522 19.4% +20.2%

Total Expenditures $245,697,620,676 100%‡ $215,809,899,631 100.0%‡ +13.8%‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands excluded. * Clinic includes clinics, FQHCs, and rural health clinics. ** Other includes hospice, other care services, payments to managed care organizations, etc. Source: CMS, CMS-64 Report, FY 2002 and FY 2001


2-16

Federal Medical Assistance Percentage (FMAP),

FY 2004 and FY 2005

State 2004 FMAP 2004 FMAP

(Q1-Q3)*2004 Enhanced

FMAP** 2005 FMAP 2005 Enhanced

FMAP**Alabama 70.75% 73.70% 79.53% 70.83% 79.58%Alaska*** 58.39% 61.34% 70.87% 57.58% 70.31%Arizona 67.26% 70.21% 77.08% 67.45% 77.22%Arkansas 74.67% 77.62% 82.27% 74.75% 82.33%California 50.00% 52.95% 65.00% 50.00% 65.00%Colorado 50.00% 52.95% 65.00% 50.00% 65.00%Connecticut 50.00% 52.95% 65.00% 50.00% 65.00%Delaware 50.00% 52.95% 65.00% 50.38% 65.27%District of Columbia*** 70.00% 72.95% 79.00% 70.00% 79.00%Florida 58.93% 61.88% 71.25% 58.90% 71.23%Georgia 59.58% 62.55% 71.71% 60.44% 72.31%Hawaii 58.90% 61.85% 71.23% 58.47% 70.93%Idaho 70.46% 73.91% 79.32% 70.62% 79.43%Illinois 50.00% 52.95% 65.00% 50.00% 65.00%Indiana 62.32% 65.27% 73.62% 62.78% 73.95%Iowa 63.93% 66.88% 74.75% 63.55% 74.49%Kansas 60.82% 63.77% 72.57% 61.01% 72.71%Kentucky 70.09% 73.04% 79.06% 69.60% 78.72%Louisiana 71.63% 74.58% 80.14% 71.04% 79.73%Maine 66.01% 69.17% 76.21% 64.89% 75.42%Maryland 50.00% 52.95% 65.00% 50.00% 65.00%Massachusetts 50.00% 52.95% 65.00% 50.00% 65.00%Michigan 55.89% 58.84% 69.12% 56.71% 69.70%Minnesota 50.00% 52.95% 65.00% 50.00% 65.00%Mississippi 77.08% 80.03% 83.96% 77.08% 83.96%Missouri 61.47% 64.42% 73.03% 61.15% 72.81%Montana 72.85% 75.91% 81.00% 71.90% 80.33%Nebraska 59.89% 62.84% 71.92% 59.64% 71.75%Nevada 54.93% 57.88% 68.45% 55.90% 69.13%New Hampshire 50.00% 52.95% 65.00% 50.00% 65.00%New Jersey 50.00% 52.95% 65.00% 50.00% 65.00%New Mexico 74.85% 77.80% 82.40% 74.30% 82.01%New York 50.00% 52.95% 65.00% 50.00% 65.00%North Carolina 62.85% 65.80% 74.00% 63.63% 74.54%North Dakota 68.31% 71.31% 77.82% 67.49% 77.24%Ohio 59.23% 62.18% 71.46% 59.68% 71.78%Oklahoma 70.24% 73.51% 79.17% 70.18% 79.13%Oregon 60.81% 63.76% 72.57% 61.12% 72.78%Pennsylvania 54.76% 57.71% 68.33% 53.84% 67.69%Rhode Island 56.03% 58.98% 69.22% 55.38% 68.77%South Carolina 69.86% 72.81% 78.90% 69.89% 78.92%South Dakota 65.67% 68.62% 75.97% 66.03% 76.22%Tennessee 64.40% 67.54% 75.08% 64.81% 75.37%Texas 60.22% 63.17% 72.15% 60.87% 72.61%Utah 71.72% 74.67% 80.20% 72.14% 80.50%Vermont 61.34% 65.36% 72.94% 60.11% 72.08%Virginia 50.00% 53.48% 65.00% 50.00% 65.00%Washington 50.00% 52.95% 65.00% 50.00% 65.00%West Virginia 75.19% 78.14% 82.63% 74.65% 82.26%Wisconsin 58.41% 61.38% 70.89% 58.32% 70.82%Wyoming 59.77% 64.27% 71.84% 57.90% 70.53%

* The Jobs and Growth Tax Relief and Reconciliation Act of 2003 (May 28, 2003) provides for a temporary increase in the FMAP. 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://aspe.os.DHHS.gov/health/FMAP03-04temporaryincrease.html. ** The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3). *** The values for Alaska and the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is 52.23% and for the District of Columbia is 50.00%. Source: Federal Register, November 15, 2002, Vol. 67, No. 221, pages 69223-69225; June 17, 2003, Vol. 68, No. 116, pages 35889-35890; and December 3, 2003, Vol. 68, No. 232, pages 67676-67678.


2-17

Medicaid Total Net Expenditures and Eligibles, 2001

State

Total Net MedicalAssistance Expenditures

Total Eligibles

AveragePer Eligible

National Total $215,809,899,631 46,910,257 $4,000Alabama $2,875,372,953 780,434 $3,684Alaska $576,586,201 115,996 $4,971Arizona $2,665,261,328 808,386 $3,297Arkansas $1,852,176,546 550,668 $3,364California $23,870,521,004 8,495,030 $2,810Colorado $2,142,029,851 410,611 $5,217Connecticut $3,213,848,086 446,326 $7,201Delaware $591,974,246 133,079 $4,448District of Columbia $979,941,105 152,597 $6,422Florida $8,557,796,303 2,462,171 $3,476Georgia $5,037,084,881 1,328,379 $3,792Hawaii* $634,781,970 202,912 $3,128Idaho $693,205,598 172,348 $4,022Illinois $7,764,611,352 1,798,723 $4,317Indiana $4,008,812,857 825,556 $4,856Iowa $1,666,923,701 331,025 $5,036Kansas $1,686,410,544 291,837 $5,779Kentucky $3,304,053,663 762,871 $4,331Louisiana $4,201,982,590 886,518 $4,740Maine $1,315,523,163 277,843 $4,735Maryland $3,256,576,882 704,628 $4,622Massachusetts $6,619,524,971 1,125,607 $5,881Michigan $7,218,697,113 1,430,246 $5,047Minnesota $3,835,870,579 609,856 $6,290Mississippi $2,438,979,981 681,161 $3,581Missouri $4,744,963,426 1,032,047 $4,598Montana $482,357,404 101,966 $4,731Nebraska $1,187,237,577 249,079 $4,767Nevada $674,337,888 167,247 $4,032New Hampshire $873,248,831 108,562 $8,044New Jersey $7,123,653,988 923,697 $7,712New Mexico $1,467,417,736 423,543 $3,465New York $31,367,464,639 3,548,630 $8,839North Carolina $6,150,681,587 1,397,486 $4,401North Dakota $406,418,593 65,425 $6,212Ohio $8,433,412,161 1,660,463 $5,079Oklahoma $2,021,033,069 631,996 $3,198Oregon $2,658,358,391 594,679 $4,470Pennsylvania $10,908,343,146 1,647,440 $6,621Rhode Island $1,187,880,819 194,113 $6,120South Carolina $3,019,387,228 871,675 $3,464South Dakota $464,455,469 106,154 $4,375Tennessee $5,501,312,153 1,601,406 $3,435Texas $11,583,679,558 2,729,660 $4,244Utah $833,720,115 214,597 $3,885Vermont $601,467,093 154,991 $3,881Virginia $3,036,846,387 700,715 $4,334Washington** $4,305,724,247 916,838 $4,696West Virginia $1,548,398,817 351,489 $4,405Wisconsin $3,976,142,914 673,538 $5,903Wyoming $243,408,927 58,013 $4,196

*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. **MSIS data for FY 2002 have not yet been released for Washington. FY 2000 MSIS data are used in this table. Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, FY 2000 & FY 2001.


2-18

Total Medicaid Program Expenditures, 2002

State


AdministrativeExpenditures

Total ProgramExpenditures

National Total $245,697,620,676 $11,865,503,019 $257,563,123,695Alabama $3,093,270,640 $101,262,707 $3,194,533,347Alaska $685,772,985 $53,525,999 $739,298,984Arizona $3,541,598,721 $214,483,151 $3,756,081,872Arkansas $2,237,817,554 $103,472,005 $2,341,289,559California $26,890,540,967 $2,165,421,909 $29,055,962,876Colorado $2,323,068,699 $89,593,331 $2,412,662,030Connecticut $3,456,338,545 $145,108,698 $3,601,447,243Delaware $634,046,351 $54,177,131 $688,223,482District of Columbia $1,021,772,693 $60,012,057 $1,081,784,750Florida $9,871,508,234 $528,381,789 $10,399,890,023Georgia $6,241,211,454 $302,658,380 $6,543,869,834Hawaii $740,007,314 $64,472,204 $804,479,518Idaho $773,534,776 $62,662,990 $836,197,766Illinois $8,809,060,004 $700,700,368 $9,509,760,372Indiana $4,448,318,143 $181,277,188 $4,629,595,331Iowa $2,575,146,342 $79,808,909 $2,654,955,251Kansas $1,836,717,196 $119,768,351 $1,956,485,547Kentucky $3,763,204,047 $100,440,133 $3,863,644,180Louisiana $4,885,971,853 $136,430,738 $5,022,402,591Maine $1,430,109,134 $59,837,086 $1,489,946,220Maryland $3,613,476,100 $274,488,455 $3,887,964,555Massachusetts $8,063,005,258 $317,224,866 $8,380,230,124Michigan $7,562,053,407 -$163,622,489 $7,398,430,918Minnesota $4,414,511,470 $247,714,024 $4,662,225,494Mississippi $2,877,013,521 $87,664,878 $2,964,678,399Missouri $5,360,607,640 $215,632,683 $5,576,240,323Montana $571,456,455 $26,886,645 $598,343,100Nebraska $1,339,132,070 $81,988,159 $1,421,120,229Nevada $808,198,344 $56,128,326 $864,326,670New Hampshire $1,016,094,814 $58,564,265 $1,074,659,079New Jersey $7,745,877,997 $240,847,423 $7,986,725,420New Mexico $1,776,811,688 $63,569,631 $1,840,381,319New York $36,295,107,368 $1,181,722,131 $37,476,829,499North Carolina $6,723,598,560 $302,125,603 $7,025,724,163North Dakota $461,401,546 $22,525,872 $483,927,418Ohio $9,658,040,587 $319,681,549 $9,977,722,136Oklahoma $2,260,403,490 $167,112,579 $2,427,516,069Oregon $2,571,560,664 $226,191,921 $2,797,752,585Pennsylvania $12,130,925,035 $556,891,243 $12,687,816,278Rhode Island $1,358,500,649 $62,877,169 $1,421,377,818South Carolina $3,292,901,444 $133,484,748 $3,426,386,192South Dakota $549,884,391 $15,675,093 $565,559,484Tennessee $5,787,079,096 $245,058,264 $6,032,137,360Texas $13,523,486,149 $706,759,839 $14,230,245,988Utah $984,160,785 $78,087,725 $1,062,248,510Vermont $660,731,979 $55,179,707 $715,911,686Virginia $3,812,166,436 $187,346,225 $3,999,512,661Washington $5,168,511,470 $490,873,523 $5,659,384,993West Virginia $1,584,166,286 $73,009,703 $1,657,175,989Wisconsin $4,193,175,197 $186,413,731 $4,379,588,928Wyoming $274,565,128 $23,904,404 $298,469,532

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


2-19

Total SCHIP Expenditures, 2002

State

Medicaid SCHIP Expenditures

Non-Medicaid SCHIP Expenditures Total Expenditure

National Total $1,330,657,305 $4,089,702,326 $5,420,359,631Alabama $4,628,780 $64,702,498 $69,331,278Alaska $27,348,249 $2,595,488 $29,943,737Arizona $0 $167,950,645 $167,950,645Arkansas $1,828,430 $81,548 $1,909,978California $41,021,160 $647,354,640 $688,375,800Colorado $0 $47,971,251 $47,971,251Connecticut $3,447,029 $21,426,909 $24,873,938Delaware $0 $4,015,741 $4,015,741District of Columbia $6,269,076 $654,591 $6,923,667Florida $65,139,446 $323,338,927 $388,478,373Georgia $0 $148,512,336 $148,512,336Hawaii $5,596,585 $20,389 $5,616,974Idaho $16,772,010 $1,230,699 $18,002,709Illinois $37,305,573 $18,558,488 $55,864,061Indiana $66,035,063 $16,226,253 $82,261,316Iowa $16,277,396 $22,540,225 $38,817,621Kansas $0 $49,811,709 $49,811,709Kentucky $60,261,647 $30,841,566 $91,103,213Louisiana $78,484,723 $3,679,622 $82,164,345Maine $15,623,419 $7,610,776 $23,234,195Maryland $166,152,918 $17,228,837 $183,381,755Massachusetts $72,181,353 $20,491,319 $92,672,672Michigan $25,640,047 $31,334,653 $56,974,700Minnesota $50,263 $99,462,784 $99,513,047Mississippi $5,296,814 $78,458,940 $83,755,754Missouri $83,252,095 $2,240,727 $85,492,822Montana $0 $14,935,804 $14,935,804Nebraska $16,028,217 $594,989 $16,623,206Nevada $0 $31,433,945 $31,433,945New Hampshire $276,736 $5,748,840 $6,025,576New Jersey $44,305,712 $344,167,314 $388,473,026New Mexico $16,902,487 $223,065 $17,125,552New York $11,633,119 $560,001,709 $571,634,828North Carolina $0 $117,820,812 $117,820,812North Dakota $966,615 $3,880,893 $4,847,508Ohio $175,369,794 $5,979,799 $181,349,593Oklahoma $37,014,987 $1,008,907 $38,023,894Oregon $0 $22,796,830 $22,796,830Pennsylvania $0 $152,372,663 $152,372,663Rhode Island $18,831,033 $32,810,550 $51,641,583South Carolina $47,604,923 $5,289,436 $52,894,359South Dakota $8,746,215 $2,624,039 $11,370,254Tennessee $4,877,111 $481,001 $5,358,112Texas $7,340,202 $735,462,302 $742,802,504Utah $0 $32,706,432 $32,706,432Vermont $0 $3,443,510 $3,443,510Virginia $807,958 $59,375,598 $60,183,556Washington $0 $12,319,513 $12,319,513West Virginia $2,773 $32,518,236 $32,521,009Wisconsin $34,000,865 $79,059,901 $113,060,766Wyoming $0 $4,304,677 $4,304,677

Source: CMS, CMS-21 (SCHIP) Report, 2002.


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14.4% 23.2% 29.4%40.1% 47.8% 53.6% 55.6% 55.8% 56.8% 57.6% 59.1%

85.6% 76.8% 70.6%59.9% 52.2% 46.4% 44.4% 44.2% 43.2% 42.4% 40.9%

0%

20%

40%

60%

80%

100%

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

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 ten years, managed care enrollment as a percentage of total Medicaid enrollment has increased by 310 percent (i.e., from 14.4% to 59.1%). In 2003, 59.1% of all Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30, 2003, 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, 2003. 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.


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• 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

*This table provides duplicated figures by plan type. The total number of enrollees includes 8,844,848 individuals who were enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. 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) 5 531,349

Commercial Managed Care Organization (COM-MCO) 164 9,920,954 Medicaid-only Managed Care Organization (Mcaid-MCO) 120 6,848,585

Primary Care Case Management (PCCM) 42 6,142,646 Prepaid Health Plan (PHP) 136 10,498,301

Other 44 195886 Total 511 34,107,721*


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Medicaid Managed Care Enrollment, As of June 30, 2003

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year. Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State Operations.

State Medicaid

EnrollmentMedicaid Managed

Care Enrollment Percent in

Managed Care

Rank Based on Percent in

Managed CareNational Total 42,740,719 25,262,873 59.11% Alabama 760,527 404,797 53.23% 37Alaska 95,335 0 0.00% 50Arizona 901,655 808,506 89.67% 6Arkansas 557,074 374,067 67.15% 24California 6,272,109 3,258,787 51.96% 39Colorado 330,499 262,263 79.35% 12Connecticut 405,064 294,331 72.66% 15Delaware 121,676 86,709 71.26% 17District of Columbia 128,185 85,370 66.60% 26Florida 2,214,058 1,354,025 61.16% 33Georgia 1,448,645 1,212,639 83.71% 9Hawaii 179,522 141,399 78.76% 13Idaho 156,935 101,257 64.52% 31Illinois 1,580,944 137,682 8.71% 48Indiana 707,168 502,401 71.04% 18Iowa 266,737 243,954 91.46% 5Kansas 246,186 141,119 57.32% 36Kentucky 663,002 611,878 92.29% 4Louisiana 861,846 505,434 58.65% 35Maine 249,738 148,151 59.32% 34Maryland 681,096 466,688 68.52% 21Massachusetts 915,114 572,835 62.60% 32Michigan 1,322,261 1,314,810 99.44% 2Minnesota 552,779 362,349 65.55% 28Mississippi 720,304 0 0.00% 50Missouri 950,694 425,161 44.72% 44Montana 80,378 55,372 68.89% 20Nebraska 197,378 142,377 72.13% 16Nevada 164,033 74,923 45.68% 42New Hampshire 91,261 13,407 14.69% 47New Jersey 782,309 525,864 67.22% 23New Mexico 404,497 261,015 64.53% 30New York 3,645,834 1,914,794 52.52% 38North Carolina 1,074,616 749,152 69.71% 19North Dakota 53,806 35,515 66.01% 27Ohio 1,515,712 436,146 28.77% 46Oklahoma 498,031 338,859 68.04% 22Oregon 425,627 330,874 77.74% 14Pennsylvania 1,492,095 1,192,031 79.89% 11Puerto Rico 957,298 857,310 89.56% 7Rhode Island 178,543 119,257 66.79% 25South Carolina 862,175 71,195 8.26% 49South Dakota 93,208 90,733 97.34% 3Tennessee 1,304,794 1,304,794 100.00% 1Texas 2,559,248 1,065,945 41.65% 45Utah 187,823 162,364 86.45% 8Vermont 131,051 85,751 65.43% 29Virgin Islands 16,125 0 0.00% 50Virginia 583,999 262,961 45.03% 43Washington 1,059,865 854,861 80.66% 10West Virginia 296,220 151,515 51.15% 40Wisconsin 739,431 349,246 47.23% 41Wyoming 56,209 0 0.00% 50


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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, guidelines, contractualColorado Managed Care Plan ContractualConnecticut Managed Care Plan ContractualDelaware State N/ADistrict of Columbia District of Columbia Government NoneFlorida Managed Care Plan ContractualGeorgia N/A N/AHawaii Both Guidelines Idaho N/A N/AIllinois Managed Care Plan ContractualIndiana Managed Care Plan StatutesIowa State NoneKansas Both Statutes, regulations, contractualKentucky Both ContractualLouisiana N/A N/AMaine State N/AMaryland Both RegulationsMassachusetts Managed Care Plan ContractualMichigan Managed Care Plan ContractualMinnesota Managed Care Plan ContractualMississippi State -Missouri Managed Care Plan Guidelines, 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 N/ANorth Carolina State NoneNorth Dakota State NoneOhio Managed Care Plan StatutesOklahoma Both ContractualOregon Managed Care Plan ContractualPennsylvania Managed Care Plan ContractualRhode Island Managed Care Plan RegulationsSouth Carolina Managed Care Plan ContractualSouth Dakota N/A N/ATennessee* Managed Care Plan StatutesTexas State N/AUtah State RegulationsVermont State NoneVirginia Managed Care Plan ContractualWashington Both ContractualWest Virginia State N/AWisconsin Managed Care Plan Statutes, regulations, guidelines, 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 2003 NPC Survey.


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Medicaid Managed Care Enrollment Trends, 1999-2003

State 1999 2000 2001 2002 2003National Total 17,756,603 18,786,137 20,773,813 23,117,668 25,262,873Alabama 377,952 325,059 350,485 405,090 404,797Alaska 0 0 0 0 0Arizona 363,662 442,254 527,674 697,171 808,506Arkansas 232,123 222,261 257,662 336,111 374,067California 2,540,902 2,525,406 2,870,514 3,191,168 3,258,787Colorado 216,357 254,232 247,181 278,095 262,263Connecticut 230,217 229,995 239,829 280,106 294,331Delaware 68,869 75,535 83,422 87,465 86,709District of Columbia 75,499 78,864 79,673 80,300 85,370Florida 912,045 1,016,641 1,184,506 1,267,998 1,354,025Georgia 638,082 806,009 878,140 1,043,154 1,212,639Hawaii 120,246 121,581 127,779 132,787 141,399Idaho 31,184 32,338 37,913 58,284 101,257Illinois 158,888 137,622 136,497 130,988 137,682Indiana 331,363 376,066 433,014 484,116 502,401Iowa 176,487 182,251 206,751 227,495 243,954Kansas 95,868 108,093 118,209 130,162 141,119Kentucky 324,447 464,191 489,711 500,987 611,878Louisiana 44,741 48,802 56,542 206,992 505,434Maine 23,720 57,151 96,051 110,922 148,151Maryland 347,937 385,687 421,355 451,307 466,688Massachusetts 575,186 583,324 616,241 628,832 572,835Michigan 1,130,608 1,063,557 1,023,264 1,208,803 1,314,810Minnesota 268,360 291,365 322,640 368,186 362,349Mississippi* 200,347 218,431 297,916 0 0Missouri 276,628 304,499 378,771 413,361 425,161Montana 69,738 42,312 46,995 52,209 55,372Nebraska 122,006 140,199 150,840 163,772 142,377Nevada 36,945 37,945 47,518 60,823 74,923New Hampshire 5,812 4,432 6,200 9,206 13,407New Jersey 356,956 371,641 459,087 523,904 525,864New Mexico 208,528 199,297 212,456 243,069 261,015New York 659,569 691,422 728,709 1,099,900 1,914,794North Carolina 689,104 598,852 674,133 722,089 749,152North Dakota 23,886 23,962 25,540 30,808 35,515Ohio 244,888 239,460 277,617 378,476 436,146Oklahoma 193,902 279,205 299,272 338,819 338,859Oregon 308,798 312,064 360,926 378,739 330,874Pennsylvania 1,004,601 975,211 1,037,374 1,140,211 1,192,031Puerto Rico 764,068 828,021 898,171 865,285 857,310Rhode Island 85,900 104,041 111,624 117,024 119,257South Carolina 23,149 32,149 41,716 64,272 71,195South Dakota 50,220 67,835 79,641 85,868 90,733Tennessee 1,312,969 1,323,319 1,426,622 1,430,966 1,304,794Texas 352,062 606,238 753,613 839,798 1,065,945Utah 118,601 119,200 128,898 154,784 162,364Vermont 65,692 55,605 78,181 82,261 85,751Virgin Islands 0 0 0 0 0Virginia 292,214 280,978 291,767 323,863 262,961Washington 706,202 800,481 766,366 829,625 854,861West Virginia 111,532 90,631 122,230 144,911 151,515Wisconsin 187,543 210,423 266,577 317,106 349,246Wyoming 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, 1999; 2000; 2001; 2002 and 2003. DHHS, CMS, Center for Medicaid & State Operations.


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Medicaid Managed Care Plan Type, As of June 30, 2003

State HIO Commercial

MCOMedicaid-only

MCO PCCM PHP OtherNational Total 5 164 120 42 136 44Alabama 0 0 0 2 1 0Alaska - - - - - -Arizona 0 2 26 0 1 0Arkansas 0 0 0 1 1 0California 5 24 0 2 11 5Colorado 0 0 1 1 9 1Connecticut 0 2 2 0 0 0Delaware 0 1 0 0 0 0District of Columbia 0 0 4 0 1 0Florida 0 9 2 1 2 2Georgia 0 0 0 1 2 0Hawaii 0 2 1 0 2 1Idaho 0 0 0 1 0 0Illinois 0 4 1 0 0 0Indiana 0 0 3 2 0 0Iowa 0 3 0 1 1 0Kansas 0 0 1 1 0 1Kentucky 0 0 1 1 1 0Louisiana 0 0 0 1 0 0Maine 0 0 0 1 0 0Maryland 0 0 6 0 0 1Massachusetts 0 2 2 1 1 6Michigan 0 9 9 0 20 0Minnesota 0 6 3 0 0 1Mississippi - - - - - -Missouri 0 3 4 0 0 1Montana 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 14 15 6 1 17North Carolina 0 1 0 2 0 0North Dakota 0 1 0 1 0 0Ohio 0 4 2 0 0 2Oklahoma 0 3 2 0 0Oregon 0 4 9 1 18 0Pennsylvania 0 2 9 1 28 1Puerto Rico 0 3 0 0 2 0Rhode Island 0 3 0 0 0 0South Carolina 0 0 1 0 1 0South Dakota 0 0 0 1 1 0Tennessee 0 5 3 0 2 1Texas 0 10 2 2 1 0Utah 0 0 0 3 13 0Vermont 0 0 0 1 0 0Virgin Islands - - - - - -Virginia 0 6 1 1 0 0Washington 0 6 2 1 14 1West Virginia 0 2 0 1 0 0Wisconsin 0 28 3 0 2 2Wyoming - - - - - -

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, 2003. DHHS, CMS, Center for Medicaid & State Operations.


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Medicaid Managed Care Enrollment by Plan Type, As of June 30, 2003

State HIO Commercial

MCOMedicaid-only

MCO PCCM PHP OtherNational Total 531,349 9,920,954 6,848,585 6,142,646 10,468,301 195,886Alabama - - - 401,393 391,912 -Alaska - - - - - -Arizona - 68,404 740,102 - 64,021 -Arkansas - - - 325,886 374,067 -California 531,349 2,676,278 0 28,002 255,281 3,610Colorado - - 70,150 82,488 274,174 758Connecticut - 225,057 69,274 - - -Delaware - 86,709 - - - -District of Columbia - - 85,370 - 2,898 -Florida - 463,173 203,728 667,114 90,281 18,268Georgia - - - 840,630 1,215,029 -Hawaii - 94,051 45,756 - 550 1,497Idaho - - - 101,257 - -Illinois - 119,225 18,457 - - -Indiana - - 246,488 255,913 - -Iowa - 64,365 - 73,332 243,954 -Kansas - - 60,891 80,186 - 61Kentucky - - 128,679 375,890 611,878 -Louisiana - - - 505,434 - -Maine - - - 148,151 - -Maryland - - 466,542 - - 146Massachusetts - 103,554 165,162 304,119 324,207 1,195Michigan - 450,816 374,781 - 1,319,096 -Minnesota - 345,968 16,381 - - 825Mississippi - - - - - -Missouri - 113,616 311,545 - - 168Montana - - - 55,372 - -Nebraska - 30,712 - 35,109 - 142,377Nevada - 74,923 - - - -New Hampshire - 13,407 - - - -New Jersey - 43,672 482,192 - - -New Mexico - 261,015 - - - -New York - 968,577 875,494 20,961 6,979 18,313North Carolina - 11,314 - 749,152 - -North Dakota - 821 - 34,694 - -Ohio - 151,026 284,662 - - 458Oklahoma - - 181,451 160,591 - -Oregon - 45,333 175,469 9,110 550,413 -Pennsylvania - 230,556 820,601 135,000 970,455 153Puerto Rico - 857,310 - - 857,310 -Rhode Island - 119,257 - - - -South Carolina - - 53,793 - 17,402 -South Dakota - - - 71,424 90,733 -Tennessee - 979,682 450,012 - 1,304,794 227Texas - 450,054 270,931 332,820 277,613 -Utah - - - 74,422 371,482 -Vermont - - - 85,751 - -Virgin Islands - - - - - -Virginia - 198,288 64,673 80,796 - -Washington - 392,203 78,752 3,917 853,226 184West Virginia - 47,783 - 103,732 - -Wisconsin - 233,805 107,249 - 546 7,646Wyoming - - - - - -

* 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, 2003. DHHS, CMS, Center for Medicaid & State Operations.


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Medicaid Managed Care Enrollment by Payment Arrangement,

As of June 30, 2003

State FEE-FOR-SERVICE (FFS) Fully Capitated (FUL) Partially Capitated (PAR)National Total 6,188,187 27,704,547 214,987 Alabama 401,393 391,912 Alaska Arizona 872,527 Arkansas 325,886 374,067 California 28,002 3,466,518 Colorado 82,488 333,171 11,911 Connecticut 294,331 Delaware 86,709 District of Columbia 85,370 2,898 Florida 685,372 757,192 Georgia 840,630 1,215,029 Hawaii 141,854 Idaho 101,257 Illinois 137,682 Indiana 255,913 246,488 Iowa 73,332 308,319 Kansas 80,186 60,952 Kentucky 375,890 740,557 Louisiana 505,434 Maine 148,151 Maryland 466,688 Massachusetts 304,119 594,118 Michigan 2,144,693 Minnesota 825 362,349 Mississippi Missouri 425,329 Montana 55,372 Nebraska 177,486 30,712 Nevada 74,923 New Hampshire 13,407 New Jersey 525,864 New Mexico 261,015 New York 6,105 1,862,384 21,835 North Carolina 749,152 11,314 North Dakota 34,694 821 Ohio 436,146 Oklahoma 181,451 160,591 Oregon 9,110 771,215 Pennsylvania 135,000 2,021,415 350 Puerto Rico 1,714,620 Rhode Island 119,257 South Carolina 53,793 17,402 South Dakota 71,424 90,733 Tennessee 2,734,715 Texas 332,820 998,598 Utah 133,950 311,954 Vermont 85,751 Virgin Islands Virginia 80,796 262,961 Washington 3,917 1,324,365 West Virginia 103,732 47,783 Wisconsin 349,246 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, 2003. DHHS, CMS, Center for Medicaid & State Operations.


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

SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS

Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide access to care, and comparability requirements under Section 1902 of the Social Security Act. With a 1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e., cost must be less than the Medicaid program would cost without the waiver). Section 1915(b) waivers are typically limited to a targeted geographical area or population, are approved for an initial period of two years, and can be renewed on an ongoing basis if the State reapplies.

Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section 1915(b);

• Paragraph (b)(1) - Case Management: States are allowed to implement case management systems which can be as simple as requiring each beneficiary to choose a primary care provider or as comprehensive as mandating enrollment in a prepaid health plan. The Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries into managed care via a State Plan Amendment.

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

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

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

Refer to the table on page 2-33 for a listing of 1915(b) waivers. Although Section 1915(b) waivers allow States to increase access to managed care plans, States are still limited under Federal regulations and cannot use them to serve beneficiaries beyond Medicaid State Plan Eligibility or change their benefits package. In order to expand their Medicaid programs even further than under Section 1915(b) waivers, States apply for Section 1115 research and demonstration waivers.


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SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

Section 1115 research and demonstration waivers release States from standard Medicaid requirements, allowing them the flexibility to test substantially new ideas of policy merit. Along with Section 1915(b) waivers, Section 1115 waivers allow States to waive freedom of choice, statewide access to care, and comparability requirements. However, a Section 1115 waiver also allows States to provide new and additional services, test new payment methods, offer benefits to new and expanded populations, and contract with managed care organizations that do not meet the necessary criteria of Section 1903 of the Social Security Act.

To receive approval of a Section 1115 waiver, States submit a proposal to CMS for discussion and review. Once operational, States allow formal evaluations of the research and public policy value of the programs and to demonstrate that their programs do not exceed costs, which would have otherwise occurred under traditional Medicaid programs (i.e., States must demonstrate budget neutrality). Section 1115 waivers are usually granted for a five-year period and each State must submit a request for continuation. For example, Arizona has operated its program under a Section 1115 waiver for over 20 years. The Benefits Improvement and Protection Act (BIPA) of 2000 streamlined the process for States to submit requests for and receive extensions of Section 1115 demonstration waivers.

Currently, there are 17 Medicaid programs with Section 1115 waiver approvals: Arizona, 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 2-33 for a listing of implemented Section 1115 waivers.

PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY

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

Pharmacy Plus demonstrations 1) cover an individual’s cost of drugs; 2) cover the individual’s cost sharing obligation for private prescription programs; and 3) provide wrap-around coverage to bring private sources of drug coverage up to the level of the Pharmacy Plus benefit. States may construct their Pharmacy Plus programs to provide eligibility for individuals who are not eligible for full Medicaid benefits and who have incomes below 200 percent of the Federal Poverty Level. Under a Pharmacy Plus waiver, States may elect to provide a prescription and over-the-counter drug benefit that is similar to, or different from, the benefits provided in the Medicaid State Plan. States may choose to deliver the services via fee-for-service or capitation. Last, States may choose whether to perform assets tests and income adjustments, and may also choose to enact an enrollment ceiling on the number of individuals who participate in the demonstration. Like all 1115 demonstrations, Pharmacy Plus waivers must be budget neutral to the Federal government. Under the terms and conditions of an approved plan, which is usually granted for a 5-year period, a ceiling cap is placed on Federal financial payments for services included in the budget neutrality agreement. States are encouraged to involve the private sector in implementing these programs and are encouraged to explore the use of pharmacy benefit managers (PBM). Premiums, cost sharing (deductibles, co-payments and coinsurance), and benefit limitations are all available tools for providing incentives and cost containment.


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As of September 24, 2003, four States had received Pharmacy Plus demonstration approval: Florida, Illinois, South Carolina and Wisconsin. Another 8 states had applications pending and one state withdrew its request. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) establishes a new Part D that provides a prescription drug benefit to all Medicare beneficiaries beginning in 2006. When the new benefit begins, states with Pharmacy Plus waivers may want to eliminate or substantially revise them because Medicare will be providing prescription drug coverage to seniors now covered by Pharmacy Plus. Refer to the table on page 2-36 for a complete status of the Pharmacy Plus Demonstrations Program.


2-32


2-33

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

State Program(s) Approved

1915(b) Statutes Utilized Implemented Expiration

Alabama 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 11/19/02

Partnership 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 -- -- --


2-34

State Program(s) Approved

1915(b) Statutes Utilized Implemented Expiration

Massachuse None -- -- --Comprehensive Health Care 1, 2, 4 7/1/97 9/24/04Michigan 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 None -- -- --New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 9/30/02New 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 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 6/16/04Puerto Rico None -- -- --Rhode None -- -- --South None -- -- --South 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 12/22/04West

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


2-35

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.


2-36

Pharmacy Plus Demonstrations Program Status

Pharmacy Waivers Under 1115 Authority

STATE PROGRAM NAME STATUS

Arkansas Arkansas RX Senior Care Pending

Connecticut ConnPACE Program Rx Pending

Delaware Delaware Pharmacy Assistance Program Disapproved

Florida Ron Silver Senior Rx Program Approved

Hawaii Prescription Plus Disapproved

Illinois Prescription Drug Benefit for Illinois’ Low Income Approved

Maine Maine Health Prescription Drug Demonstration Pending

Massachusetts Pharmacy Waiver Withdrawn

Michigan EPIC Ex Pending

New Jersey Pharmaceutical Assistance for the Aged and Disabled Pending

North Carolina North Carolina Senior Care Pending

Rhode Island Rhode Island RX+ Pending

South Carolina Prescription Drug Benefit for South Carolina’s Low Income Seniors

Approved

Wisconsin WI Senior Care Approved

Source: CMS Website at www.cms.DHHS.gov/medicaid/1115/pharmplusstatus.asp; last modified on September 24, 2003.


3- 1

Section 3: State Characteristics


3-2


3-3

STATE CHARACTERISTICS Presented in Section 3 of the Compilation is State-by-State information on several topics. The Section begins with a series of tables showing select State demographic characteristics including age composition and racial/Hispanic status. Next, insurance coverage, poverty status, employment, and income data for each State are presented. The final group of tables show select components of each State’s health care system including Medicare and Medicaid certified facilities (hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics), licensed pharmacies, and health manpower (physicians, Registered Nurses, and pharmacists). The data in Section 3 have been compiled from a myriad of sources. These include: • CMS • The U.S. Bureau of the Census • The Bureau of Labor Statistics (BLS) • The Health Resources and Services Administration (HRSA) • The National Association of Boards of Pharmacy Because of the unevenness with which the various government agencies and other organizations have released updated information, we have carefully reviewed all possible information sources and made judgments on which data to present. In the final analysis, we have included those data that, in our opinion, best reflect the factors and characteristics on which we have reported. However, certain limitations in the different sources have resulted in some inconsistencies among the tables. The following examples illustrate this problem. The table showing the age distribution of the population is derived from the 2002 American Community Survey conducted by the U.S. Bureau of the Census. It is the only 2002 age breakout on a State-by-State basis that the Bureau had released while data collection for the 2003 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 2003 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. In addition, more detailed data on poverty, also compiled from The March 2003 Supplement to the Current Population Survey have been included in this year’s Compilation. 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 iteration of this survey, which is conducted every four years, is the 2000 version. Unfortunately, these data are somewhat out-of-date. We, therefore, turned to another source, The Area Resource File (ARF), for data on the number of requested nurses. However, as is often the case, data from different sources are not exactly the same. The Area Resource File, for example, provides information on the number of “full-time equivalent” registered nurses, not a simple body count of the number of full-time and part-time RNs. Hence, the nursing numbers included in 2003 Compilation are lower than those presented last year.


3-4

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.


3-5

Age Demographics, 2002*

State Total

Population Percent Ages19 and under

Percent Ages 20-44

Percent Ages 45-64

PercentAges 65+

National Total 280,540,330 28.2% 36.2% 23.6% 12.0%Alabama 4,370,221 27.8% 35.3% 24.1% 12.9%Alaska 624,252 33.2% 35.2% 25.6% 6.1%Arizona 5,346,616 30.0% 35.6% 21.9% 12.6%Arkansas 2,634,848 28.0% 34.4% 24.2% 13.4%California 34,292,871 30.0% 38.0% 21.6% 10.3%Colorado 4,403,659 28.4% 38.2% 24.1% 9.3%Connecticut 3,350,345 27.9% 34.1% 24.8% 13.1%Delaware 782,221 26.3% 37.0% 24.0% 12.8%District of Columbia 535,632 21.5% 42.8% 23.8% 12.0%Florida 16,318,656 25.8% 33.3% 24.1% 16.8%Georgia 8,326,251 29.6% 39.1% 22.1% 9.2%Hawaii 1,208,537 26.7% 35.3% 24.7% 13.3%Idaho 1,308,320 31.1% 34.4% 23.6% 10.9%Illinois 12,279,027 28.7% 36.8% 23.0% 11.4%Indiana 5,980,881 28.7% 36.0% 23.4% 11.9%Iowa 2,832,392 26.8% 34.5% 24.7% 14.1%Kansas 2,634,122 28.7% 35.4% 23.2% 12.7%Kentucky 3,978,103 25.8% 36.9% 25.2% 12.0%Louisiana 4,347,642 29.9% 35.4% 23.3% 11.3%Maine 1,259,547 24.3% 34.6% 27.2% 13.8%Maryland 5,321,993 28.3% 36.3% 24.4% 11.0%Massachusetts 6,210,578 25.4% 37.3% 24.4% 13.0%Michigan 9,797,198 28.6% 35.3% 24.1% 11.9%Minnesota 4,882,303 28.1% 36.7% 23.9% 11.3%Mississippi 2,775,227 30.0% 35.4% 22.9% 11.7%Missouri 5,505,963 27.7% 35.4% 24.1% 12.8%Montana 884,587 27.0% 32.7% 27.2% 13.1%Nebraska 1,677,978 28.5% 35.3% 23.3% 12.8%Nevada 2,139,794 28.9% 36.6% 23.6% 10.9%New Hampshire 1,238,917 26.8% 36.0% 25.7% 11.4%New Jersey 8,395,357 27.3% 35.6% 24.4% 12.6%New Mexico 1,818,718 30.1% 34.4% 23.4% 12.1%New York 18,571,545 26.9% 36.7% 23.9% 12.5%North Carolina 8,063,874 27.7% 37.0% 23.7% 11.6%North Dakota 610,245 26.4% 35.3% 24.3% 14.1%Ohio 11,122,112 28.1% 35.1% 24.0% 12.8%Oklahoma 3,379,515 28.2% 35.1% 24.0% 12.8%Oregon 3,444,153 27.0% 35.4% 25.2% 12.3%Pennsylvania 11,897,522 26.0% 34.0% 25.0% 14.9%Rhode Island 1,030,762 24.7% 37.1% 24.2% 14.0%South Carolina 3,971,899 26.8% 36.4% 25.1% 11.7%South Dakota 731,963 29.0% 33.9% 23.4% 13.7%Tennessee 5,644,716 27.0% 36.1% 24.8% 12.0%Texas 21,215,494 31.4% 37.3% 21.8% 9.6%Utah 2,275,861 34.5% 38.7% 18.4% 8.4%Vermont 595,826 25.4% 34.8% 27.4% 12.5%Virginia 7,063,247 27.4% 37.2% 24.5% 10.9%Washington 5,930,307 27.9% 36.7% 24.5% 10.8%

West Virginia 1,758,096 24.3% 33.4% 27.3% 15.0%Wisconsin 5,285,604 27.5% 35.7% 24.3% 12.5%Wyoming 484,833 27.7% 33.9% 26.7% 11.6%

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


3-6

Race Demographics, 2002*

State

Total Population

PercentWhite

PercentBlack

Percent Other**

PercentIndicated 2

or More Races National Total 280,540,330 75.8% 12.0% 9.9% 2.9%Alabama 4,370,221 71.0% 25.6% 1.8% 1.7%Alaska 624,252 69.3% 3.0% 19.5% 8.5%Arizona 5,346,616 74.9% 2.8% 18.8% 4.8%Arkansas 2,634,848 80.0% 15.8% 2.5% 1.9%California 34,292,871 63.3% 6.1% 26.7% 5.3%Colorado 4,403,659 82.9% 3.7% 10.9% 3.1%Connecticut 3,350,345 81.9% 9.2% 7.0% 2.3%Delaware 782,221 75.2% 18.8% 4.4% 2.0%District of Columbia 535,632 29.3% 59.6% 9.0% 2.8%Florida 16,318,656 77.6% 15.1% 5.4% 2.7%Georgia 8,326,251 65.2% 28.3% 5.2% 1.7%Hawaii 1,208,537 24.5% 1.8% 48.9% 25.8%Idaho 1,308,320 91.6% 0.3% 6.0% 2.6%Illinois 12,279,027 74.7% 14.4% 9.0% 2.4%Indiana 5,980,881 87.4% 8.1% 2.9% 1.9%Iowa 2,832,392 93.4% 2.0% 3.1% 1.8%Kansas 2,634,122 85.9% 5.9% 5.9% 2.6%Kentucky 3,978,103 89.9% 6.7% 1.8% 1.7%Louisiana 4,347,642 63.7% 32.3% 3.0% 1.1%Maine 1,259,547 96.9% 0.4% 1.6% 1.2%Maryland 5,321,993 64.6% 27.1% 6.3% 2.4%Massachusetts 6,210,578 84.4% 5.9% 8.2% 2.1%Michigan 9,797,198 80.2% 13.9% 4.0% 2.2%Minnesota 4,882,303 88.6% 3.7% 6.3% 1.7%Mississippi 2,775,227 60.8% 37.0% 1.5% 0.8%Missouri 5,505,963 84.8% 11.0% 2.4% 1.9%Montana 884,587 90.2% 0.5% 7.0% 2.6%Nebraska 1,677,978 89.7% 3.7% 4.5% 2.7%Nevada 2,139,794 77.8% 6.3% 11.8% 5.8%New Hampshire 1,238,917 95.8% 0.8% 2.3% 1.4%New Jersey 8,395,357 72.3% 13.0% 12.9% 2.4%New Mexico 1,818,718 69.8% 1.6% 24.9% 5.3%New York 18,571,545 68.6% 15.9% 13.2% 3.3%North Carolina 8,063,874 71.9% 21.2% 5.2% 1.9%North Dakota 610,245 91.9% 0.8% 5.9% 1.6%Ohio 11,122,112 85.0% 11.2% 2.4% 1.6%Oklahoma 3,379,515 76.5% 7.2% 9.4% 7.4%Oregon 3,444,153 86.7% 1.5% 8.6% 3.7%Pennsylvania 11,897,522 85.3% 9.8% 3.6% 1.5%Rhode Island 1,030,762 84.7% 4.5% 8.7% 2.7%South Carolina 3,971,899 67.1% 29.6% 2.3% 1.2%South Dakota 731,963 94.3% 0.7% 3.1% 2.0%Tennessee 5,644,716 80.1% 16.1% 2.7% 1.3%Texas 21,215,494 73.1% 10.9% 13.9% 3.2%Utah 2,275,861 90.2% 0.8% 6.6% 2.9%Vermont 595,826 96.5% 0.6% 1.7% 1.3%Virginia 7,063,247 72.7% 19.4% 6.0% 2.4%Washington 5,930,307 80.9% 3.3% 11.7% 4.8%West Virginia 1,758,096 95.2% 3.0% 0.8% 1.1%Wisconsin 5,285,604 88.5% 5.3% 4.6% 1.8%Wyoming 484,833 92.2% 0.6% 4.7% 3.1%This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2002. *Sum of percentages may not equal 100 percent due to rounding. ** 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, 2002 American Community Survey.


3-7

Hispanic Demographics, 2002

State Total Population Hispanic Population Percent HispanicNational Total 280,540,330 37,872,475 13.5%Alabama 4,370,221 86,450 2.0%Alaska 624,252 25,156 4.0%Arizona 5,346,616 1,452,223 27.2%Arkansas 2,634,848 92,400 3.5%California 34,292,871 11,647,324 34.0%Colorado 4,403,659 801,801 18.2%Connecticut 3,350,345 334,926 10.0%Delaware 782,221 40,625 5.2%District of Columbia 535,632 51,068 9.5%Florida 16,318,656 2,969,016 18.2%Georgia 8,326,251 502,157 6.0%Hawaii 1,208,537 87,769 7.3%Idaho 1,308,320 111,295 8.5%Illinois 12,279,027 1,663,514 13.5%Indiana 5,980,881 231,613 3.9%Iowa 2,832,392 87,447 3.1%Kansas 2,634,122 184,148 7.0%Kentucky 3,978,103 65,532 1.6%Louisiana 4,347,642 106,445 2.4%Maine 1,259,547 8,870 0.7%Maryland 5,321,993 253,012 4.8%Massachusetts 6,210,578 451,811 7.3%Michigan 9,797,198 336,104 3.4%Minnesota 4,882,303 157,540 3.2%Mississippi 2,775,227 31,985 1.2%Missouri 5,505,963 112,698 2.0%Montana 884,587 17,398 2.0%Nebraska 1,677,978 101,573 6.1%Nevada 2,139,794 458,223 21.4%New Hampshire 1,238,917 20,756 1.7%New Jersey 8,395,357 1,198,470 14.3%New Mexico 1,818,718 783,315 43.1%New York 18,571,545 2,997,676 16.1%North Carolina 8,063,874 434,048 5.4%North Dakota 610,245 7,403 1.2%Ohio 11,122,112 225,447 2.0%Oklahoma 3,379,515 185,361 5.5%Oregon 3,444,153 306,244 8.9%Pennsylvania 11,897,522 388,046 3.3%Rhode Island 1,030,762 96,510 9.4%South Carolina 3,971,899 104,814 2.6%South Dakota 731,963 10,404 1.4%Tennessee 5,644,716 132,687 2.4%Texas 21,215,494 7,191,546 33.9%Utah 2,275,861 220,283 9.7%Vermont 595,826 4,803 0.8%Virginia 7,063,247 363,544 5.1%Washington 5,930,307 480,917 8.1%West Virginia 1,758,096 12,211 0.7%Wisconsin 5,285,604 205,397 3.9%Wyoming 484,833 32,470 6.7%

This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during 2002. Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.


3-8

Insurance Status - Populations, 2002*

State

Total

Population Medicaid

PopulationMedicare

PopulationMilitary

Insurance

Privately

Insured Not Insured

National Total 285,933,000 33,246,000 38,448,000 10,063,000 198,973,000 43,574,000Alabama 4,440,000 459,000 754,000 171,000 3,143,000 564,000Alaska 635,000 92,000 53,000 81,000 399,000 119,000Arizona 5,442,000 666,000 792,000 363,000 3,555,000 916,000Arkansas 2,692,000 396,000 487,000 203,000 1,644,000 440,000California 35,159,000 4,985,000 3,777,000 1,046,000 22,891,000 6,398,000Colorado 4,476,000 331,000 501,000 299,000 3,211,000 720,000Connecticut 3,383,000 314,000 544,000 82,000 2,610,000 356,000Delaware 798,000 86,000 112,000 30,000 608,000 79,000District of Columbia 572,000 103,000 75,000 12,000 373,000 74,000Florida 16,429,000 1,764,000 3,020,000 820,000 10,666,000 2,843,000Georgia 8,426,000 863,000 869,000 309,000 5,924,000 1,354,000Hawaii 1,224,000 128,000 173,000 104,000 899,000 123,000Idaho 1,300,000 136,000 162,000 44,000 903,000 233,000Illinois 12,504,000 1,180,000 1,618,000 142,000 9,086,000 1,767,000Indiana 6,100,000 458,000 850,000 98,000 4,628,000 797,000Iowa 2,903,000 275,000 436,000 75,000 2,314,000 277,000Kansas 2,684,000 216,000 377,000 194,000 2,084,000 280,000Kentucky 4,046,000 471,000 641,000 342,000 2,828,000 548,000Louisiana 4,447,000 694,000 602,000 208,000 2,703,000 820,000Maine 1,269,000 204,000 229,000 55,000 885,000 144,000Maryland 5,458,000 355,000 653,000 211,000 4,203,000 730,000Massachusetts 6,471,000 769,000 890,000 145,000 4,772,000 644,000Michigan 9,910,000 1,158,000 1,279,000 89,000 7,494,000 1,158,000Minnesota 5,054,000 489,000 586,000 118,000 4,158,000 397,000Mississippi 2,787,000 559,000 387,000 108,000 1,703,000 465,000Missouri 5,585,000 594,000 745,000 192,000 4,253,000 646,000Montana 906,000 108,000 157,000 62,000 618,000 139,000Nebraska 1,704,000 167,000 237,000 69,000 1,312,000 174,000Nevada 2,121,000 127,000 265,000 85,000 1,464,000 418,000New Hampshire 1,266,000 78,000 164,000 41,000 1,015,000 125,000New Jersey 8,605,000 789,000 1,241,000 106,000 6,378,000 1,197,000New Mexico 1,840,000 313,000 294,000 86,000 1,047,000 388,000New York 19,283,000 2,964,000 2,617,000 278,000 12,635,000 3,042,000North Carolina 8,162,000 942,000 1,190,000 449,000 5,393,000 1,368,000North Dakota 633,000 56,000 94,000 35,000 481,000 69,000Ohio 11,282,000 1,061,000 1,554,000 213,000 8,640,000 1,344,000Oklahoma 3,477,000 411,000 511,000 205,000 2,280,000 601,000Oregon 3,510,000 438,000 488,000 126,000 2,475,000 511,000Pennsylvania 12,189,000 1,187,000 2,033,000 235,000 9,311,000 1,380,000Rhode Island 1,056,000 165,000 161,000 16,000 763,000 104,000South Carolina 3,997,000 607,000 678,000 183,000 2,701,000 500,000South Dakota 744,000 74,000 102,000 38,000 570,000 85,000Tennessee 5,672,000 1,091,000 734,000 212,000 3,883,000 614,000Texas 21,529,000 2,425,000 2,339,000 762,000 12,738,000 5,556,000Utah 2,310,000 219,000 192,000 60,000 1,743,000 310,000Vermont 619,000 112,000 86,000 14,000 438,000 66,000Virginia 7,118,000 496,000 891,000 716,000 5,203,000 962,000Washington 6,001,000 782,000 684,000 301,000 4,214,000 850,000West Virginia 1,751,000 299,000 360,000 80,000 1,107,000 255,000Wisconsin 5,476,000 545,000 701,000 124,000 4,298,000 538,000Wyoming 488,000 45,000 65,000 26,000 334,000 86,000

*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one category.

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement, March 2003.


3-9

Insurance Status - Percentages, 2002*

State

Total

Population % Covered by

Medicaid% Covered by

Medicare

% Covered by Military

Insurance

% Covered by Private

Insurance % Not Insured National Total 285,933,000 11.6% 13.4% 3.5% 69.6% 15.2%Alabama 4,440,000 10.3% 17.0% 3.9% 70.8% 12.7%Alaska 635,000 14.5% 8.3% 12.8% 62.8% 18.7%Arizona 5,442,000 12.2% 14.6% 6.7% 65.3% 16.8%Arkansas 2,692,000 14.7% 18.1% 7.5% 61.1% 16.3%California 35,159,000 14.2% 10.7% 3.0% 65.1% 18.2%Colorado 4,476,000 7.4% 11.2% 6.7% 71.7% 16.1%Connecticut 3,383,000 9.3% 16.1% 2.4% 77.2% 10.5%Delaware 798,000 10.8% 14.0% 3.8% 76.2% 9.9%District of Columbia 572,000 18.0% 13.1% 2.1% 65.2% 12.9%Florida 16,429,000 10.7% 18.4% 5.0% 64.9% 17.3%Georgia 8,426,000 10.2% 10.3% 3.7% 70.3% 16.1%Hawaii 1,224,000 10.5% 14.1% 8.5% 73.4% 10.0%Idaho 1,300,000 10.5% 12.5% 3.4% 69.5% 17.9%Illinois 12,504,000 9.4% 12.9% 1.1% 72.7% 14.1%Indiana 6,100,000 7.5% 13.9% 1.6% 75.9% 13.1%Iowa 2,903,000 9.5% 15.0% 2.6% 79.7% 9.5%Kansas 2,684,000 8.0% 14.0% 7.2% 77.6% 10.4%Kentucky 4,046,000 11.6% 15.8% 8.5% 69.9% 13.5%Louisiana 4,447,000 15.6% 13.5% 4.7% 60.8% 18.4%Maine 1,269,000 16.1% 18.0% 4.3% 69.7% 11.3%Maryland 5,458,000 6.5% 12.0% 3.9% 77.0% 13.4%Massachusetts 6,471,000 11.9% 13.8% 2.2% 73.7% 10.0%Michigan 9,910,000 11.7% 12.9% 0.9% 75.6% 11.7%Minnesota 5,054,000 9.7% 11.6% 2.3% 82.3% 7.9%Mississippi 2,787,000 20.1% 13.9% 3.9% 61.1% 16.7%Missouri 5,585,000 10.6% 13.3% 3.4% 76.2% 11.6%Montana 906,000 11.9% 17.3% 6.8% 68.2% 15.3%Nebraska 1,704,000 9.8% 13.9% 4.0% 77.0% 10.2%Nevada 2,121,000 6.0% 12.5% 4.0% 69.0% 19.7%New Hampshire 1,266,000 6.2% 13.0% 3.2% 80.2% 9.9%New Jersey 8,605,000 9.2% 14.4% 1.2% 74.1% 13.9%New Mexico 1,840,000 17.0% 16.0% 4.7% 56.9% 21.1%New York 19,283,000 15.4% 13.6% 1.4% 65.5% 15.8%North Carolina 8,162,000 11.5% 14.6% 5.5% 66.1% 16.8%North Dakota 633,000 8.8% 14.8% 5.5% 76.0% 10.9%Ohio 11,282,000 9.4% 13.8% 1.9% 76.6% 11.9%Oklahoma 3,477,000 11.8% 14.7% 5.9% 65.6% 17.3%Oregon 3,510,000 12.5% 13.9% 3.6% 70.5% 14.6%Pennsylvania 12,189,000 9.7% 16.7% 1.9% 76.4% 11.3%Rhode Island 1,056,000 15.6% 15.2% 1.5% 72.3% 9.8%South Carolina 3,997,000 15.2% 17.0% 4.6% 67.6% 12.5%South Dakota 744,000 9.9% 13.7% 5.1% 76.6% 11.4%Tennessee 5,672,000 19.2% 12.9% 3.7% 68.5% 10.8%Texas 21,529,000 11.3% 10.9% 3.5% 59.2% 25.8%Utah 2,310,000 9.5% 8.3% 2.6% 75.5% 13.4%Vermont 619,000 18.1% 13.9% 2.3% 70.8% 10.7%Virginia 7,118,000 7.0% 12.5% 10.1% 73.1% 13.5%Washington 6,001,000 13.0% 11.4% 5.0% 70.2% 14.2%West Virginia 1,751,000 17.1% 20.6% 4.6% 63.2% 14.6%Wisconsin 5,476,000 10.0% 12.8% 2.3% 78.5% 9.8%Wyoming 488,000 9.2% 13.3% 5.3% 68.4% 17.6%

*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one category.

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement, March 2003.


3-10

Poverty Status - Populations, 2002

State Total

Population

Population Below 100%

FPL*


FPL*


FPL*


FPL* National Total 285,317,000 34,570,000 52,736,000 61,054,000 87,028,000Alabama 4,432,000 640,000 979,000 1,094,000 1,490,000Alaska 632,000 56,000 89,000 106,000 153,000Arizona 5,424,000 735,000 1,120,000 1,305,000 1,791,000Arkansas 2,690,000 532,000 695,000 808,000 1,086,000California 35,068,000 4,605,000 7,092,000 8,406,000 11,563,000Colorado 4,470,000 436,000 670,000 779,000 1,159,000Connecticut 3,377,000 279,000 434,000 518,000 763,000Delaware 796,000 73,000 112,000 130,000 197,000District of Columbia 570,000 97,000 133,000 149,000 191,000Florida 16,391,000 2,058,000 3,297,000 3,818,000 5,438,000Georgia 8,413,000 939,000 1,434,000 1,650,000 2,511,000Hawaii 1,219,000 138,000 194,000 225,000 330,000Idaho 1,296,000 147,000 235,000 292,000 437,000Illinois 12,495,000 1,594,000 2,269,000 2,566,000 3,630,000Indiana 6,086,000 552,000 908,000 1,097,000 1,730,000Iowa 2,899,000 267,000 447,000 530,000 783,000Kansas 2,681,000 269,000 407,000 496,000 725,000Kentucky 4,033,000 571,000 849,000 976,000 1,370,000Louisiana 4,445,000 777,000 1,137,000 1,336,000 1,688,000Maine 1,265,000 170,000 245,000 280,000 408,000Maryland 5,419,000 400,000 608,000 706,000 1,057,000Massachusetts 6,469,000 648,000 977,000 1,134,000 1,563,000Michigan 9,897,000 1,152,000 1,715,000 1,919,000 2,861,000Minnesota 5,044,000 325,000 540,000 668,000 1,016,000Mississippi 2,785,000 513,000 780,000 891,000 1,127,000Missouri 5,581,000 551,000 864,000 1,012,000 1,487,000Montana 902,000 122,000 202,000 244,000 331,000Nebraska 1,700,000 181,000 289,000 328,000 474,000Nevada 2,114,000 188,000 357,000 430,000 657,000New Hampshire 1,264,000 73,000 117,000 147,000 242,000New Jersey 8,585,000 681,000 1,060,000 1,237,000 1,862,000New Mexico 1,837,000 328,000 475,000 540,000 747,000New York 19,224,000 2,690,000 3,868,000 4,434,000 6,115,000North Carolina 8,146,000 1,165,000 1,711,000 2,003,000 2,801,000North Dakota 632,000 73,000 113,000 130,000 194,000Ohio 11,253,000 1,099,000 1,727,000 2,054,000 3,034,000Oklahoma 3,473,000 489,000 761,000 875,000 1,232,000Oregon 3,503,000 380,000 638,000 761,000 1,059,000Pennsylvania 12,168,000 1,152,000 1,902,000 2,209,000 3,238,000Rhode Island 1,055,000 116,000 175,000 200,000 276,000South Carolina 3,989,000 568,000 824,000 963,000 1,290,000South Dakota 743,000 85,000 131,000 153,000 234,000Tennessee 5,655,000 839,000 1,236,000 1,368,000 1,934,000Texas 21,482,000 3,362,000 5,066,000 5,710,000 8,348,000Utah 2,308,000 228,000 395,000 452,000 655,000Vermont 616,000 61,000 99,000 115,000 164,000Virginia 7,108,000 702,000 986,000 1,113,000 1,739,000Washington 5,988,000 657,000 1,075,000 1,194,000 1,678,000West Virginia 1,747,000 293,000 438,000 520,000 720,000Wisconsin 5,463,000 467,000 786,000 893,000 1,300,000Wyoming 488,000 44,000 72,000 90,000 151,000

*FPL- Federal Poverty Level Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement, March 2003.


3-11

Poverty Status - Percentages, 2002

State Total

Population

Percent Below 100%

FPL*

Percent Below 135%

FPL*

Percent Below 150%

FPL*

Percent Below 200%

FPL* National Total 285,317,000 12.1% 22.1% 21.4% 30.5%Alabama 4,432,000 14.5% 14.1% 24.7% 33.6%Alaska 632,000 8.8% 20.6% 16.7% 24.2%Arizona 5,424,000 13.5% 25.8% 24.1% 33.0%Arkansas 2,690,000 19.8% 20.2% 30.0% 40.4%California 35,068,000 13.1% 15.0% 24.0% 33.0%Colorado 4,470,000 9.8% 12.9% 17.4% 25.9%Connecticut 3,377,000 8.3% 14.0% 15.3% 22.6%Delaware 796,000 9.1% 23.4% 16.3% 24.7%District of Columbia 570,000 17.0% 20.1% 26.1% 33.5%Florida 16,391,000 12.6% 17.0% 23.3% 33.2%Georgia 8,413,000 11.2% 15.9% 19.6% 29.8%Hawaii 1,219,000 11.3% 18.2% 18.5% 27.1%Idaho 1,296,000 11.3% 18.2% 22.5% 33.7%Illinois 12,495,000 12.8% 14.9% 20.5% 29.1%Indiana 6,086,000 9.1% 15.4% 18.0% 28.4%Iowa 2,899,000 9.2% 15.2% 18.3% 27.0%Kansas 2,681,000 10.1% 21.0% 18.5% 27.0%Kentucky 4,033,000 14.2% 25.6% 24.2% 34.0%Louisiana 4,445,000 17.5% 19.4% 30.1% 38.0%Maine 1,265,000 13.4% 11.2% 22.2% 32.2%Maryland 5,419,000 7.4% 15.1% 13.0% 19.5%Massachusetts 6,469,000 10.0% 17.3% 17.5% 24.2%Michigan 9,897,000 11.6% 10.7% 19.4% 28.9%Minnesota 5,044,000 6.5% 28.0% 13.2% 20.1%Mississippi 2,785,000 18.4% 15.5% 32.0% 40.5%Missouri 5,581,000 9.9% 22.4% 18.1% 26.7%Montana 902,000 13.5% 17.0% 27.0% 36.7%Nebraska 1,700,000 10.6% 16.9% 19.3% 27.9%Nevada 2,114,000 8.9% 9.2% 20.3% 31.1%New Hampshire 1,264,000 5.8% 12.4% 11.6% 19.1%New Jersey 8,585,000 7.9% 25.9% 14.4% 21.7%New Mexico 1,837,000 17.9% 20.1% 29.4% 40.7%New York 19,224,000 14.0% 21.0% 23.1% 31.8%North Carolina 8,146,000 14.3% 17.9% 24.6% 34.4%North Dakota 632,000 11.6% 15.3% 20.6% 30.7%Ohio 11,253,000 9.8% 21.9% 18.3% 27.0%Oklahoma 3,473,000 14.1% 18.2% 25.2% 35.5%Oregon 3,503,000 10.9% 15.6% 21.7% 30.2%Pennsylvania 12,168,000 9.5% 16.5% 18.2% 26.6%Rhode Island 1,055,000 11.0% 20.7% 18.9% 26.2%South Carolina 3,989,000 14.3% 17.6% 24.2% 32.3%South Dakota 743,000 11.5% 21.9% 20.5% 31.5%Tennessee 5,655,000 14.8% 23.6% 24.2% 34.2%Texas 21,482,000 15.6% 17.1% 26.6% 38.9%Utah 2,308,000 9.9% 16.1% 19.6% 28.4%Vermont 616,000 9.9% 13.9% 18.7% 26.7%Virginia 7,108,000 9.9% 17.9% 15.7% 24.5%Washington 5,988,000 11.0% 25.1% 19.9% 28.0%West Virginia 1,747,000 16.8% 14.4% 29.8% 41.2%Wisconsin 5,463,000 8.6% 14.7% 16.3% 23.8%Wyoming 488,000 9.0% 22.1% 18.4% 30.9%

*FPL- Federal Poverty Level Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement, March 2003.


3-12

Employment Status, 2003*

State Total

PopulationCivilian

Labor ForcePopulation

Unemployed Unemployment

Rate

National Total 221,168,000146,510,000 8,774,000 6.0%

Alabama 3,442,000 2,147,000 125,000 5.8%Alaska 459,000 332,000 27,000 8.0%Arizona 4,131,000 2,690,000 151,000 5.6%Arkansas 2,071,000 1,265,000 78,000 6.2%California 26,490,000 17,460,000 1,177,000 6.7%Colorado 3,440,000 2,478,000 150,000 6.0%Connecticut 2,680,000 1,803,000 99,000 5.5%Delaware 625,000 417,000 18,000 4.4%District of Columbia 454,000 302,000 21,000 7.0%Florida 13,211,000 8,164,000 420,000 5.1%Georgia 6,431,000 4,414,000 207,000 4.7%Hawaii 944,000 618,000 27,000 4.3%Idaho 1,013,000 693,000 37,000 5.4%Illinois 9,583,000 6,330,000 422,000 6.7%Indiana 4,679,000 3,188,000 163,000 5.1%Iowa 2,286,000 1,612,000 72,000 4.5%Kansas 2,049,000 1,434,000 77,000 5.4%Kentucky 3,153,000 1,956,000 120,000 6.2%Louisiana 3,348,000 2,037,000 134,000 6.6%Maine 1,039,000 693,000 35,000 5.1%Maryland 4,181,000 2,904,000 131,000 4.5%Massachusetts 5,028,000 3,416,000 198,000 5.8%Michigan 7,706,000 5,042,000 368,000 7.3%Minnesota 3,896,000 2,923,000 145,000 5.0%Mississippi 2,138,000 1,312,000 83,000 6.3%Missouri 4,352,000 3,021,000 170,000 5.6%Montana 714,000 475,000 22,000 4.7%Nebraska 1,318,000 976,000 39,000 4.0%Nevada 1,686,000 1,141,000 59,000 5.2%New Hampshire 1,005,000 719,000 31,000 4.3%New Jersey 6,619,000 4,375,000 257,000 5.9%New Mexico 1,401,000 897,000 57,000 6.4%New York 14,891,000 9,315,000 589,000 6.3%North Carolina 6,328,000 4,230,000 273,000 6.5%North Dakota 490,000 346,000 14,000 4.0%Ohio 8,771,000 5,915,000 363,000 6.1%Oklahoma 2,646,000 1,696,000 96,000 5.7%Oregon 2,770,000 1,859,000 152,000 8.2%Pennsylvania 9,663,000 6,170,000 344,000 5.6%Rhode Island 844,000 573,000 30,000 5.3%South Carolina 3,142,000 2,003,000 136,000 6.8%South Dakota 576,000 425,000 15,000 3.6%Tennessee 4,501,000 2,909,000 169,000 5.8%Texas 16,047,000 10,910,000 738,000 6.8%Utah 1,660,000 1,184,000 67,000 5.6%Vermont 494,000 351,000 16,000 4.6%Virginia 5,532,000 3,773,000 154,000 4.1%Washington 4,697,000 3,140,000 237,000 7.5%West Virginia 1,442,000 787,000 48,000 6.1%Wisconsin 4,224,000 3,078,000 174,000 5.6%Wyoming 387,000 278,000 12,000 4.4%

*This information was compiled from the U.S. Department of Labor, Bureau of Labor Statistics News Release on State and Regional Unemployment, 2003 Annual Averages, released on February 27, 2004. The table summarizes the employment status of the civilian noninstitutional population, 16 years of age and over, by state. Source: U.S. Department of Labor, Bureau of Labor Statistics, February 27, 2004.


3-13

Medicaid/Medicare Certified Facilities, 2003

State Hospitals Skilled Nursing

FacilitiesICF-MR Facilities

Home Health Agencies

Rural Health Clinics

National Total* 5,988 14,926 6,606 7,163 3,401Alabama 122 225 7 140 61Alaska 24 14 0 15 6Arizona 89 134 13 62 6Arkansas 108 199 41 174 72California 437 1,256 1,109 604 244Colorado 84 194 3 129 37Connecticut 46 252 120 83 0Delaware 10 37 2 14 0District of Columbia 14 20 126 15 0Florida 235 689 107 421 148Georgia 176 333 13 97 102Hawaii 27 41 17 14 0Idaho 47 77 66 49 42Illinois 216 673 309 298 197Indiana 157 489 562 161 50Iowa 119 359 130 180 127Kansas 150 263 37 131 172Kentucky 116 296 14 108 105Louisiana 214 285 480 228 52Maine 41 120 21 31 46Maryland 65 233 4 45 0Massachusetts 112 468 7 114 0Michigan 176 394 1 212 158Minnesota 147 404 225 223 68Mississippi 105 164 13 60 128Missouri 137 477 20 160 248Montana 64 100 2 46 40Nebraska 94 177 4 62 76Nevada 41 42 19 45 6New Hampshire 30 70 1 36 19New Jersey 106 356 9 52 0New Mexico 53 71 44 58 10New York 249 669 720 198 9North Carolina 139 420 330 169 111North Dakota 50 83 66 30 64Ohio 211 929 421 351 16Oklahoma 151 256 68 186 48Oregon 62 121 1 59 36Pennsylvania 246 723 194 279 44Rhode Island 15 95 5 21 1South Carolina 76 178 132 71 90South Dakota 67 90 1 47 56Tennessee 152 305 83 138 37Texas 499 1,011 909 1,045 338Utah 48 80 14 47 15Vermont 16 42 1 12 18Virginia 109 244 21 156 52Washington 101 249 14 61 104West Virginia 66 121 61 65 64Wisconsin 140 365 37 123 59Wyoming 29 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, December 9, 2003.


3-14

Licensed Pharmacies (As of June 30, 2003)*

State Total

Pharmacies

Hospital/ Institutional Pharmacies

Independent Community Pharmacies

Chain Pharmacies (Four or More)

Out-of-State or Non-Resident

PharmaciesNational Total 78,505 8,729 20,249 15,835 11,756Alabama 1,873 165 744 578 361Alaska 158 (G) 17 (H) 264Arizona 1,872 149 204 1,033 257Arkansas 745 186 415 330 182California 6,204 602 202Colorado 1,083 424Connecticut 605 (D) 50 (D) 168 (D) 437 (D) 277 (D)Delaware 165 11 31 134 258District of Columbia 123 13 27 61 0Florida 6,567 2,097 4,098 (A) (A) 341Georgia 3,689 205 (P) (P) Hawaii 224 162Idaho 639 69 255 (A, E) 231Illinois 2,451 342 2,183 (A) (A) 296Indiana 1,367 205 371Iowa 1,242 130 (F) 791 (A, F) (A) 301Kansas 802 172 630 (A) 332Kentucky 1,514 138 475 749 176Louisiana 1,818 179 573 541 353Maine 290 42 187Maryland 1,425 (I) 66 155 689 296Massachusetts 1,048 (J) 158 250 740 0Michigan 2547 150Minnesota 1,471 138 537 545 280Mississippi 962 130 220Missouri 1,543 (K) 173 646 661 371Montana 317 99 153Nebraska 487 255 (L)Nevada 731 268New Hampshire 269 32 39 177 245New Jersey 2,489 New Mexico 612 61 298 (A) 283New York 4,518 493 (Q) 1,993 2,029 91North Carolina 2,062 (F) 161 561 968 259North Dakota 530 43 149 32 249Ohio 2,953 (N) 219 559 1,581 328Oklahoma 1,304 81 (D) 860 (A) (A) 343Oregon 1,119 122 310 457 242Pennsylvania 3,148 291 0Rhode Island 191 20 41 5 227South Carolina 1,132 346South Dakota 507 44 130 89 254Tennessee 1,852 405 508 822 117Texas 5,753 (B) 847 1,720 2,430 289Utah 280 99 415 (A) A 246Vermont 155 18 139 0Virginia 1,515 426Washington 1,588 228 (C) 345 747 268West Virginia 544 308Wisconsin 1,286 0 Wyoming 134 (F) 29 276 *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: 2003-2004 National Association of Boards of Pharmacy, Survey of Pharmacy Law.


3-15

LEGEND A — Chains included in independent community pharmacies figure. B — Also licenses 873 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies. C — Includes 121 hospital, 23 nursing home, 18 home infusion, 8 nuclear, 40 HMO, and 18 other pharmacies. D — Approximately. E — Plus 22 limited service and 61 parenteral admixture pharmacies. F — In-state. G — Includes 21 wholesalers drug distributors. H — Drug rooms. I — 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. J — Total also includes home IV and mail-order pharmacies. K — Includes the following pharmacy categories: 30 long-term care, 17 home health, 8 radiopharmaceutical, 2 renal dialysis, 1 sterile pharmaceuticals, 2 consultants pharmacies. L — Nebraska “registers” out-of-state pharmacies. N — Includes 263 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmacies serving nursing homes only. P — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic pharmacies, and 2 pharmacy schools). Q — 16 nuclear pharmacies.


3-16

Physicians, 2001

State Physicians Physicians

Per 1,000 Pop. Office Based

PhysiciansPercent

Office BasedPrimary Care

Physicians* Percent

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

Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File, February 2003.


3-17

Other Providers, 2001/2003

State

# FTERegistered

Nurses*

# FTERegistered Nurses*

per 1,000 populationPharmacists**

(Licensed by State) Pharmacists**

per 1,000 populationNational Total 962,195 3.4 356,201 1.2Alabama 17,143 3.8 6,006 1.3Alaska 2,339 3.7 632 1.0Arizona 13,058 2.5 7,832 1.4Arkansas 9,898 3.7 3,680 1.4California 85,878 2.5 31,133 0.9Colorado 12,034 2.7 5,586 1.2Connecticut 9,930 2.9 4,454 1.3Delaware 2,971 3.7 1,287 1.6District of Columbia 5,011 8.7 1,564 2.8Florida 56,078 3.4 20,052 1.2Georgia 28,447 3.4 10,474 1.2Hawaii 3,470 2.8 1,556 1.2Idaho 3,599 2.7 1,569 1.1Illinois 45,501 3.6 13,151 1.0Indiana 21,436 3.5 8,480 1.4Iowa 12,404 4.2 5,034 1.7Kansas 9,102 3.4 3,584 1.3Kentucky 16,213 4.0 5,008 1.2Louisiana 17,274 3.9 5,890 1.3Maine 5,265 4.1 1,267 1.0Maryland 16,623 3.1 7,153 1.3Massachusetts 24,133 3.8 9,940 1.5Michigan 35,094 3.5 11,322 1.1Minnesota 16,122 3.2 6,023 1.2Mississippi 12,356 4.3 3,483 1.2Missouri 23,650 4.2 7,149 1.3Montana 3,205 3.5 1,503 1.6Nebraska 7,249 4.2 2,664 1.5Nevada 5,084 2.4 8,359 3.7New Hampshire 4,206 3.3 1,920 1.5New Jersey 28,082 3.3 16,245 1.9New Mexico 5,258 2.9 2,434 1.3New York 72,057 3.8 18,448 1.0North Carolina 32,695 4.0 9,669 1.2North Dakota 3,175 5.0 2,132 3.4Ohio 43,869 3.9 14,476 1.3Oklahoma 10,827 3.1 4,750 1.4Oregon 11,674 3.4 4,091 1.1Pennsylvania 48,786 4.0 17,219 1.4Rhode Island 2,850 2.7 1,788 1.7South Carolina 14,942 3.7 5,221 1.3South Dakota 3,829 5.1 1,429 1.9Tennessee 20,777 3.6 7,397 1.3Texas 65,056 3.0 21,245 1.0Utah 5,446 2.4 2,171 0.9Vermont 1,656 2.7 830 1.3Virginia 23,152 3.2 8,605 1.2Washington 15,440 2.6 6,955 1.1West Virginia 9,307 5.2 2,973 1.6Wisconsin 16,878 3.1 5,737 1.0Wyoming 1,666 3.4 997 2.0

*FTE- Full-time equivalent employees as of 2001 **As of June 30, 2003

Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File, February 2003. 2003-2004 National Association of Boards of Pharmacy, Survey of Pharmacy Law.


3-18


4-1

Section 4: Pharmacy Program Characteristics


4-2


4-3

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.


4-4

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.


4-5

Drug Expenditures Trends*

State 2001 2002 % Change 2001-2002National Total $24,656,812,921 $29,339,050,970 19.0%Alabama $386,876,131 $452,269,953 16.9%Alaska $55,754,050 $70,708,412 26.8%Arizona $2,573,205 $3,725,371 44.8%Arkansas $241,558,369 $273,257,660 13.1%California $2,984,162,770 $3,591,537,830 20.4%Colorado $166,000,664 $189,717,036 14.3%Connecticut $304,780,286 $357,919,257 17.4%Delaware $81,156,928 $97,750,161 20.4%District of Columbia $63,504,500 $66,129,208 4.1%Florida $1,475,766,739 $1,717,652,527 16.4%Georgia $735,944,558 $873,703,133 18.7%Hawaii $74,869,859 $88,256,904 17.9%Idaho $102,975,196 $119,177,013 15.7%Illinois $884,018,166 $1,293,435,797 46.3%Indiana $561,642,082 $631,637,846 12.5%Iowa $234,716,795 $285,467,642 21.6%Kansas $185,017,060 $213,778,616 15.5%Kentucky $592,096,755 $652,904,065 10.3%Louisiana $585,388,809 $714,107,841 22.0%Maine $191,785,942 $220,420,714 14.9%Maryland $244,203,084 $297,291,733 21.7%Massachusetts $797,859,072 $958,972,520 20.2%Michigan $584,670,445 $674,222,281 15.3%Minnesota $265,726,228 $310,174,144 16.7%Mississippi $493,177,297 $567,313,801 15.0%Missouri $675,647,147 $790,853,387 17.1%Montana $72,577,455 $83,587,410 15.2%Nebraska $170,897,014 $207,782,737 21.6%Nevada $61,500,721 $86,929,536 41.3%New Hampshire $91,703,067 $99,682,997 8.7%New Jersey $651,442,945 $694,669,924 6.6%New Mexico $57,995,801 $73,877,785 27.4%New York $2,986,292,455 $3,660,427,024 22.6%North Carolina $984,653,306 $1,100,822,176 11.8%North Dakota $44,067,986 $52,495,878 19.1%Ohio $1,099,697,768 $1,333,992,298 21.3%Oklahoma $171,188,873 $285,068,869 66.5%Oregon $228,670,426 $279,029,096 22.0%Pennsylvania $692,665,382 $718,210,352 3.7%Rhode Island $102,708,476 $125,187,888 21.9%South Carolina $438,897,100 $451,846,044 3.0%South Dakota $51,748,770 $62,382,937 20.5%Tennessee $681,454,847 $905,405,421 32.9%Texas $1,325,987,804 $1,591,064,713 20.0%Utah $117,170,006 $140,275,267 19.7%Vermont $104,250,880 $114,157,870 9.5%Virginia $417,689,526 $458,953,342 9.9%Washington $458,332,414 $541,963,790 18.2%West Virginia $259,638,952 $277,039,990 6.7%Wisconsin $382,272,975 $442,718,195 15.8%Wyoming $31,435,835 $39,094,579 24.4%

*Rebates have not been subtracted from these figures. Source: CMS, CMS-64 Report, FY 2001 and FY 2002.


4-6

Ranking Based on Drug Expenditures*

State 2002

Payments2002

Ranking

% of 2002 NationalMedicaid Drug

Expenditures

2001

Payments 2001

RankingNational Total $29,339,050,970 $24,656,812,921 New York $3,660,427,024 1 12.5% $2,986,292,455 1California $3,591,537,830 2 12.2% $2,984,162,770 2Florida $1,717,652,527 3 5.9% $1,475,766,739 3Texas $1,591,064,713 4 5.4% $1,325,987,804 4Ohio $1,333,992,298 5 4.5% $1,099,697,768 5Illinois $1,293,435,797 6 4.4% $884,018,166 7North Carolina $1,100,822,176 7 3.8% $984,653,306 6Massachusetts $958,972,520 8 3.3% $797,859,072 8Tennessee $905,405,421 9 3.1% $681,454,847 11Georgia $873,703,133 10 3.0% $735,944,558 9Missouri $790,853,387 11 2.7% $675,647,147 12Pennsylvania $718,210,352 12 2.4% $692,665,382 10Louisiana $714,107,841 13 2.4% $585,388,809 15New Jersey $694,669,924 14 2.4% $651,442,945 13Michigan $674,222,281 15 2.3% $584,670,445 16Kentucky $652,904,065 16 2.2% $592,096,755 14Indiana $631,637,846 17 2.2% $561,642,082 17Mississippi $567,313,801 18 1.9% $493,177,297 18Washington $541,963,790 19 1.8% $458,332,414 19Virginia $458,953,342 20 1.6% $417,689,526 21Alabama $452,269,953 21 1.5% $386,876,131 22South Carolina $451,846,044 22 1.5% $438,897,100 20Wisconsin $442,718,195 23 1.5% $382,272,975 23Connecticut $357,919,257 24 1.2% $304,780,286 24Minnesota $310,174,144 25 1.1% $265,726,228 25Maryland $297,291,733 26 1.0% $244,203,084 27Iowa $285,467,642 27 1.0% $234,716,795 29Oklahoma $285,068,869 28 1.0% $171,188,873 33Oregon $279,029,096 29 1.0% $228,670,426 30West Virginia $277,039,990 30 0.9% $259,638,952 26Arkansas $273,257,660 31 0.9% $241,558,369 28Maine $220,420,714 32 0.8% $191,785,942 31Kansas $213,778,616 33 0.7% $185,017,060 32Nebraska $207,782,737 34 0.7% $170,897,014 34Colorado $189,717,036 35 0.6% $166,000,664 35Utah $140,275,267 36 0.5% $117,170,006 36Rhode Island $125,187,888 37 0.4% $102,708,476 39Idaho $119,177,013 38 0.4% $102,975,196 38Vermont $114,157,870 39 0.4% $104,250,880 37New Hampshire $99,682,997 40 0.3% $91,703,067 40Delaware $97,750,161 41 0.3% $81,156,928 41Hawaii $88,256,904 42 0.3% $74,869,859 42Nevada $86,929,536 43 0.3% $61,500,721 45Montana $83,587,410 44 0.3% $72,577,455 43New Mexico $73,877,785 45 0.3% $57,995,801 46Alaska $70,708,412 46 0.2% $55,754,050 47Dist. of Columbia $66,129,208 47 0.2% $63,504,500 44South Dakota $62,382,937 48 0.2% $51,748,770 48North Dakota $52,495,878 49 0.2% $44,067,986 49Wyoming $39,094,579 50 0.1% $31,435,835 50Arizona $3,725,371 51 0.0% $2,573,205 51

*Rebates have not been subtracted from these figures. Source: CMS, HCFA-64 Report, FY 2001 and FY 2002.


4-7

Drugs as a Percentage of Total Net Expenditures, 2002

State

Total MedicaidNet Medical Assistance

ExpendituresTotal Drug

Expenditures*% of Total

Net ExpendituresNational Total $245,697,620,676 $29,339,050,970 11.9%Alabama $3,093,270,640 $452,269,953 14.6%Alaska $685,772,985 $70,708,412 10.3%Arizona $3,541,598,721 $3,725,371 0.1%Arkansas $2,237,817,554 $273,257,660 12.2%California $26,890,540,967 $3,591,537,830 13.4%Colorado $2,323,068,699 $189,717,036 8.2%Connecticut $3,456,338,545 $357,919,257 10.4%Delaware $634,046,351 $97,750,161 15.4%District of Columbia $1,021,772,693 $66,129,208 6.5%Florida $9,871,508,234 $1,717,652,527 17.4%Georgia $6,241,211,454 $873,703,133 14.0%Hawaii $740,007,314 $88,256,904 11.9%Idaho $773,534,776 $119,177,013 15.4%Illinois $8,809,060,004 $1,293,435,797 14.7%Indiana $4,448,318,143 $631,637,846 14.2%Iowa $2,575,146,342 $285,467,642 11.1%Kansas $1,836,717,196 $213,778,616 11.6%Kentucky $3,763,204,047 $652,904,065 17.3%Louisiana $4,885,971,853 $714,107,841 14.6%Maine $1,430,109,134 $220,420,714 15.4%Maryland $3,613,476,100 $297,291,733 8.2%Massachusetts $8,063,005,258 $958,972,520 11.9%Michigan $7,562,053,407 $674,222,281 8.9%Minnesota $4,414,511,470 $310,174,144 7.0%Mississippi $2,877,013,521 $567,313,801 19.7%Missouri $5,360,607,640 $790,853,387 14.8%Montana $571,456,455 $83,587,410 14.6%Nebraska $1,339,132,070 $207,782,737 15.5%Nevada $808,198,344 $86,929,536 10.8%New Hampshire $1,016,094,814 $99,682,997 9.8%New Jersey $7,745,877,997 $694,669,924 9.0%New Mexico $1,776,811,688 $73,877,785 4.2%New York $36,295,107,368 $3,660,427,024 10.1%North Carolina $6,723,598,560 $1,100,822,176 16.4%North Dakota $461,401,546 $52,495,878 11.4%Ohio $9,658,040,587 $1,333,992,298 13.8%Oklahoma $2,260,403,490 $285,068,869 12.6%Oregon $2,571,560,664 $279,029,096 10.9%Pennsylvania $12,130,925,035 $718,210,352 5.9%Rhode Island $1,358,500,649 $125,187,888 9.2%South Carolina $3,292,901,444 $451,846,044 13.7%South Dakota $549,884,391 $62,382,937 11.3%Tennessee $5,787,079,096 $905,405,421 15.6%Texas $13,523,486,149 $1,591,064,713 11.8%Utah $984,160,785 $140,275,267 14.3%Vermont $660,731,979 $114,157,870 17.3%Virginia $3,812,166,436 $458,953,342 12.0%Washington $5,168,511,470 $541,963,790 10.5%West Virginia $1,584,166,286 $277,039,990 17.5%Wisconsin $4,193,175,197 $442,718,195 10.6%Wyoming $274,565,128 $39,094,579 14.2%

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


4-8

Drugs as a Percentage of Total Net Expenditures, 2000-2002*

State 2000 2001 2002 National Total 10.5% 11.4% 11.9% Alabama 12.4% 13.5% 14.6% Alaska 9.3% 9.7% 10.3% Arizona 0.1% 0.1% 0.1% Arkansas 13.1% 13.0% 12.2% California 11.7% 12.5% 13.4% Colorado 7.4% 7.7% 8.2% Connecticut 8.5% 9.5% 10.4% Delaware 12.6% 13.7% 15.4% District of Columbia 6.7% 6.5% 6.5% Florida 18.1% 17.2% 17.4% Georgia 13.4% 14.6% 14.0% Hawaii 9.6% 11.8% 11.9% Idaho 14.2% 14.9% 15.4% Illinois 10.8% 11.4% 14.7% Indiana 13.3% 14.0% 14.2% Iowa 12.0% 14.1% 11.1% Kansas 11.7% 11.0% 11.6% Kentucky 15.3% 17.9% 17.3% Louisiana 14.8% 13.9% 14.6% Maine 14.4% 14.6% 15.4% Maryland 6.8% 7.5% 8.2% Massachusetts 11.0% 12.1% 11.9% Michigan 5.9% 8.1% 8.9% Minnesota 7.0% 6.9% 7.0% Mississippi 18.6% 20.2% 19.7% Missouri 15.1% 14.2% 14.8% Montana 13.4% 15.0% 14.6% Nebraska 13.7% 14.4% 15.5% Nevada 8.4% 9.1% 10.8% New Hampshire 10.3% 10.5% 9.8% New Jersey 9.9% 9.1% 9.0% New Mexico 4.0% 4.0% 4.2% New York 8.4% 9.5% 10.1% North Carolina 14.7% 16.0% 16.4% North Dakota 9.1% 10.8% 11.4% Ohio 11.8% 13.0% 13.8% Oklahoma 10.2% 8.5% 12.6% Oregon 8.0% 8.6% 10.9% Pennsylvania 5.7% 6.3% 5.9% Rhode Island 7.8% 8.6% 9.2% South Carolina 13.1% 14.5% 13.7% South Dakota 11.2% 11.1% 11.3% Tennessee 5.5% 12.4% 15.6% Texas 10.6% 11.4% 11.8% Utah 12.5% 14.1% 14.3% Vermont 16.6% 17.3% 17.3% Virginia 14.2% 13.8% 12.0% Washington 10.0% 10.6% 10.5% West Virginia 15.6% 16.8% 17.5% Wisconsin 10.6% 9.6% 10.6% Wyoming 12.6% 12.9% 14.2%

*Percentages are based on figures that have not had rebates subtracted from them. Source: CMS, HCFA-64 Report, FY 2000 - FY 2002.


4-9

Share of Drug Expenditures by Category, 2002

State Central Nervous

System Drugs Cardiovascular

DrugsAnti-Infective

AgentsGastrointestinal

Drugs

Hormones and Synthetic

SubstitutesNational Total $11,110,878,554 $3,309,235,175 $3,123,794,684 $2,220,293,730 $2,450,336,932Alabama $162,427,968 $58,939,919 $53,191,197 $19,724,615 $47,715,140 Alaska $40,138,250 $6,871,390 $8,258,256 $8,448,493 $5,749,324 Arizona* - - - - -Arkansas $104,327,247 $28,178,010 $34,062,548 $17,516,577 $25,063,050 California $1,326,623,035 $496,583,694 $340,238,011 $299,960,881 $408,010,804 Colorado $83,397,713 $18,457,938 $14,225,625 $19,891,233 $15,025,084 Connecticut $160,777,341 $40,992,549 $32,005,763 $30,864,193 $24,067,812 Delaware $33,137,878 $8,754,892 $14,857,621 $7,558,824 $7,523,594 District of Columbia $16,566,443 $8,980,540 $15,878,461 $2,293,635 $4,126,743 Florida $567,979,172 $187,207,113 $287,185,968 $128,405,638 $126,663,957 Georgia $293,303,215 $94,504,922 $116,609,831 $37,372,052 $73,825,742 Hawaii $34,086,249 $13,717,144 $7,463,253 $3,648,598 $8,519,468 Idaho $51,034,605 $7,528,366 $12,505,892 $8,638,278 $8,818,138 Illinois $350,382,552 $122,510,875 $119,743,795 $81,780,842 $91,373,328 Indiana $261,850,680 $56,525,273 $52,568,049 $43,805,799 $49,950,818 Iowa $133,389,066 $26,919,865 $25,133,166 $17,166,772 $23,699,984 Kansas $92,620,891 $18,956,370 $14,404,125 $16,375,484 $16,126,439 Kentucky $246,745,840 $76,276,780 $59,717,916 $47,258,191 $57,303,474 Louisiana $215,776,810 $77,561,164 $98,070,631 $50,354,434 $58,436,886 Maine $102,697,707 $32,706,097 $15,813,854 $20,571,791 $23,502,715 Maryland $155,536,684 $34,300,423 $25,569,033 $22,383,011 $18,483,071 Massachusetts $430,570,903 $92,069,851 $97,049,019 $71,551,884 $65,280,437 Michigan $340,976,049 $73,768,758 $39,031,663 $45,338,916 $48,709,565 Minnesota $168,448,868 $22,183,423 $20,695,558 $24,111,242 $22,047,764 Mississippi $163,971,736 $74,830,740 $57,550,451 $38,835,119 $47,224,420 Missouri $345,195,541 $88,695,064 $76,038,064 $40,234,018 $69,509,901 Montana $34,810,221 $6,010,486 $5,521,773 $7,116,556 $6,146,901 Nebraska $81,936,002 $16,357,515 $16,977,505 $18,138,100 $15,440,716 Nevada $38,425,453 $9,365,878 $9,266,546 $5,789,204 $6,733,244 New Hampshire $50,011,843 $8,064,813 $6,784,686 $7,427,069 $7,511,020 New Jersey $233,071,337 $84,618,207 $76,763,184 $55,305,576 $43,057,935 New Mexico $29,130,298 $9,205,694 $5,923,305 $8,455,563 $9,789,382 New York $1,140,536,063 $421,174,650 $582,777,416 $263,380,736 $292,497,125 North Carolina $378,957,583 $131,377,542 $110,556,228 $122,152,344 $91,412,449 North Dakota $24,261,002 $4,805,781 $3,723,614 $4,123,091 $4,136,352 Ohio $548,273,256 $136,785,856 $117,486,151 $133,074,736 $106,110,103 Oklahoma $104,495,550 $29,741,991 $25,469,725 $16,950,080 $22,005,051 Oregon $167,833,786 $19,501,122 $17,189,123 $12,676,327 $18,126,559 Pennsylvania $277,892,318 $76,953,109 $50,334,104 $66,460,266 $52,304,661 Rhode Island $54,554,473 $15,629,844 $10,756,138 $12,760,847 $9,079,709 South Carolina $166,326,864 $65,363,553 $58,789,210 $26,958,237 $48,429,827 South Dakota $24,744,099 $4,278,404 $5,738,550 $5,566,752 $4,721,494 Tennessee $498,494,118 $126,602,215 $39,685,343 $80,012,408 $63,222,119 Texas $534,365,292 $170,623,922 $188,773,209 $105,134,911 $144,900,535 Utah $66,525,169 $9,033,014 $11,164,654 $10,721,510 $10,004,484 Vermont $15,204,207 $1,996,150 $4,094,728 $1,825,472 $3,386,327 Virginia $169,780,908 $56,516,797 $34,656,425 $49,598,408 $33,627,141 Washington $240,264,995 $52,602,760 $42,461,101 $42,712,396 $44,968,562 West Virginia $114,111,323 $35,490,850 $27,406,002 $15,554,339 $28,201,869 Wisconsin $219,043,257 $46,738,020 $29,955,583 $40,886,751 $34,911,470 Wyoming $15,866,694 $2,375,842 $3,672,631 $3,421,531 $2,854,239

* Data not reported for Arizona. Arizona has an 115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2002


4-10

Share of Drug Expenditures by Category, 2002 (con't.)

State

Unclassified Therapeutic

Agents Autonomic

DrugsBlood Formation and Coagulation Other Total

National Average $1,359,408,404 $1,310,216,943 $990,931,837 $3,558,911,926 $29,434,008,185 Alabama $22,738,666 $25,079,219 $14,344,026 $73,878,759 $478,039,509 Alaska $3,581,523 $3,755,322 $5,983,211 $7,629,178 $90,414,947 Arizona* - - - - -Arkansas $13,863,613 $14,761,594 $12,118,144 $36,775,275 $286,666,058 California $157,970,901 $120,211,219 $209,658,251 $346,042,559 $3,705,299,355 Colorado $10,839,480 $9,701,591 $3,878,876 $20,711,072 $196,128,612 Connecticut $14,860,816 $13,959,149 $9,952,330 $36,195,541 $363,675,494 Delaware $4,793,777 $4,361,417 $2,059,247 $12,024,599 $95,071,849 District of Columbia $2,027,293 $1,757,168 $2,061,662 $8,100,729 $61,792,674 Florida $93,146,712 $79,021,471 $65,139,602 $214,181,262 $1,748,930,895 Georgia $35,344,409 $51,251,712 $23,350,249 $135,189,926 $860,752,058 Hawaii $5,739,678 $3,682,979 $3,725,363 $9,623,486 $90,206,218 Idaho $4,702,849 $4,537,192 $2,090,222 $10,675,638 $110,531,180 Illinois $51,201,123 $49,711,098 $42,312,778 $125,591,419 $1,034,607,810 Indiana $30,428,285 $34,113,121 $30,588,581 $88,424,694 $648,255,300 Iowa $14,503,456 $14,515,299 $4,634,670 $30,708,063 $290,670,341 Kansas $8,882,991 $10,341,541 $2,710,267 $22,665,160 $203,083,268 Kentucky $32,858,754 $44,179,459 $16,546,274 $92,326,826 $673,213,514 Louisiana $28,664,540 $37,300,313 $22,766,784 $126,322,534 $715,254,096 Maine $11,567,546 $13,021,181 $7,032,641 $23,157,560 $250,071,092 Maryland $12,230,384 $9,621,667 $12,500,270 $27,905,071 $318,529,614 Massachusetts $39,070,997 $34,788,062 $25,993,252 $93,515,983 $949,890,388 Michigan $36,673,123 $28,611,197 $21,000,992 $78,003,615 $712,113,878 Minnesota $14,145,281 $12,275,238 $10,275,040 $28,487,965 $322,670,379 Mississippi $26,530,965 $26,109,283 $10,028,232 $71,978,643 $517,059,589 Missouri $39,157,120 $42,009,219 $27,370,560 $107,787,109 $835,996,596 Montana $4,849,421 $3,999,013 $1,873,361 $8,043,097 $78,370,829 Nebraska $8,345,459 $9,248,417 $4,526,460 $26,832,410 $197,802,584 Nevada $4,479,913 $4,540,225 $3,355,258 $10,558,557 $92,514,278 New Hampshire $4,030,559 $5,036,489 $1,726,064 $11,498,389 $102,090,932 New Jersey $33,208,357 $28,777,427 $31,413,603 $82,236,456 $668,452,082 New Mexico $4,858,911 $3,660,437 $2,321,704 $10,427,651 $83,772,945 New York $164,083,098 $144,160,697 $128,216,711 $448,781,131 $3,585,607,627 North Carolina $52,831,364 $47,151,722 $34,051,151 $154,246,658 $1,122,737,041 North Dakota $2,190,494 $2,402,271 $1,200,697 $6,203,497 $53,046,799 Ohio $61,882,420 $73,814,087 $31,269,079 $171,884,121 $1,380,579,809 Oklahoma $15,423,385 $14,719,001 $12,077,645 $32,175,743 $273,058,171 Oregon $11,165,553 $10,626,003 $3,269,333 $17,340,074 $277,727,880 Pennsylvania $36,543,215 $37,155,760 $28,115,340 $81,438,693 $707,197,466 Rhode Island $5,349,865 $4,968,045 $2,243,417 $12,019,287 $127,361,625 South Carolina $23,527,729 $22,180,993 $12,869,914 $73,393,454 $497,839,781 South Dakota $2,662,003 $3,005,290 $2,132,526 $8,156,411 $61,005,529 Tennessee $42,907,863 $35,886,456 $11,623,384 $74,216,876 $972,650,782 Texas $71,446,566 $79,465,180 $47,090,505 $281,968,505 $1,623,768,625 Utah $5,777,363 $5,309,763 $1,236,279 $15,712,079 $135,484,315 Vermont $1,538,173 $1,484,182 $910,603 $4,175,415 $34,615,257 Virginia $21,636,958 $22,121,039 $14,515,501 $57,867,501 $460,320,678 Washington $25,745,981 $22,298,725 $12,901,679 $54,928,168 $538,884,367 West Virginia $14,341,914 $16,315,461 $3,412,406 $35,444,231 $290,278,395 Wisconsin $23,072,206 $21,426,205 $9,215,035 $47,029,239 $472,277,766 Wyoming $1,985,352 $1,787,344 $1,242,658 $4,431,617 $37,637,908

* Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2002.


4-11

Share of Prescriptions Processed, 2002

State Central Nervous

System Drugs Cardiovascular

DrugsAnti-Infective

AgentsGastrointestinal

Drugs

Hormones and Synthetic

SubstitutesNational Average 161,232,219 72,443,028 44,093,996 32,548,275 49,926,307Alabama 2,941,431 1,474,573 1,048,966 502,468 1,071,095Alaska 538,815 180,198 117,690 97,338 140,539Arizona* - - - - - Arkansas 1,603,598 760,062 702,941 271,296 565,683California 15,214,602 7,876,231 4,083,588 3,385,060 5,529,844Colorado 1,339,641 511,136 301,986 254,879 446,353Connecticut 2,021,686 847,007 256,096 352,779 521,491Delaware 488,341 174,105 163,401 86,189 151,233District of Columbia 238,638 192,385 75,916 34,750 85,750Florida 8,038,952 4,449,917 2,573,795 1,684,045 2,578,311Georgia 4,836,548 2,272,159 2,201,615 798,841 1,726,279Hawaii 460,387 280,308 85,657 131,081 164,060Idaho 730,380 186,130 241,834 90,662 219,364Illinois 5,998,874 3,043,522 2,011,538 1,612,006 2,087,064Indiana 4,105,446 1,344,857 1,021,660 961,743 1,083,084Iowa 2,042,876 676,484 526,890 289,881 574,214Kansas 1,283,667 478,864 292,629 224,830 403,111Kentucky 3,958,848 1,798,630 1,260,103 1,031,820 1,255,859Louisiana 3,565,125 1,748,774 1,618,788 627,664 1,234,697Maine 1,816,121 992,273 346,253 307,138 669,930Maryland 2,040,489 771,138 235,643 276,028 437,447Massachusetts 6,184,586 2,193,033 1,121,462 871,999 1,597,184Michigan 5,334,314 1,975,384 749,240 804,253 1,233,184Minnesota 2,002,604 505,679 313,581 461,421 449,417Mississippi 2,383,531 1,565,659 1,009,586 446,750 917,779Missouri 4,817,043 2,017,339 1,126,028 822,151 1,473,030Montana 524,752 149,104 123,537 95,044 154,526Nebraska 1,273,870 419,270 399,375 343,820 369,585Nevada 506,986 207,748 116,449 70,849 154,274New Hampshire 782,217 221,431 135,110 168,121 180,316New Jersey 3,019,679 1,720,151 565,815 618,302 871,468New Mexico 514,776 232,761 120,054 123,271 264,285New York 14,908,099 8,342,535 4,737,922 3,717,304 5,014,585North Carolina 5,676,633 3,110,086 1,789,714 1,261,734 2,123,893North Dakota 354,179 138,692 90,114 53,653 117,790Ohio 8,874,351 3,367,729 2,171,902 2,251,991 2,532,337Oklahoma 1,359,234 619,655 469,747 253,620 454,955Oregon 2,482,014 536,975 271,375 274,184 497,490Pennsylvania 4,061,265 1,930,258 844,456 920,012 1,260,625Rhode Island 759,101 288,310 107,145 155,871 178,022South Carolina 2,488,867 1,551,714 956,429 414,746 1,121,193South Dakota 328,166 113,324 132,161 61,797 110,042Tennessee 8,328,542 3,188,238 663,010 1,211,895 1,650,584Texas 8,145,506 2,954,622 4,157,104 1,525,126 2,404,342Utah 985,750 205,220 259,890 170,618 248,371Vermont 233,990 44,219 73,282 24,002 63,883Virginia 2,658,974 1,275,731 549,649 755,313 763,085Washington 3,607,572 1,292,270 681,200 772,019 1,140,120West Virginia 1,978,691 838,280 608,930 296,680 625,931Wisconsin 3,167,088 1,321,310 496,952 541,168 945,241Wyoming 225,374 57,548 85,788 40,063 63,362

*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2002.


4-12

Share of Prescriptions Processed, 2002 (con't)

State

Unclassified Therapeutic

Agents Autonomic

DrugsBlood Formation and Coagulation Other Total

National Average 12,417,152 28,118,352 8,829,418 109,663,158 519,271,905Alabama 236,233 593,690 176,967 2,577,154 10,622,577Alaska 32,981 84,604 21,891 216,774 1,430,830Arizona* - - - - -Arkansas 147,559 304,771 78,382 1,211,543 5,645,835California 1,251,287 2,391,533 1,171,076 9,602,912 50,506,133Colorado 102,310 246,770 78,758 763,212 4,045,045Connecticut 123,141 286,590 118,220 953,334 5,480,344Delaware 39,794 100,817 17,248 332,518 1,553,646District of Columbia 21,194 39,581 14,437 214,858 917,509Florida 814,906 1,488,860 462,674 5,505,188 27,596,648Georgia 386,418 1,116,911 277,778 4,310,917 17,927,466Hawaii 68,661 80,472 24,987 314,766 1,610,379Idaho 45,247 110,953 22,090 335,525 1,982,185Illinois 475,449 1,227,016 444,852 5,101,759 22,002,080Indiana 265,303 693,573 221,927 2,856,633 12,554,226Iowa 119,840 312,212 102,265 1,048,931 5,693,593Kansas 86,239 209,318 62,517 706,425 3,747,600Kentucky 350,628 828,775 218,980 3,124,789 13,828,432Louisiana 283,139 799,945 225,964 3,561,044 13,665,140Maine 139,597 319,159 82,503 836,581 5,509,555Maryland 120,094 241,386 123,481 845,278 5,090,984Massachusetts 350,189 882,646 224,809 2,622,424 16,048,332Michigan 359,466 673,362 278,304 2,470,691 13,878,198Minnesota 98,300 273,845 73,086 908,532 5,086,465Mississippi 255,373 450,278 142,959 2,095,665 9,267,580Missouri 334,079 848,195 263,580 3,036,239 14,737,684Montana 36,544 92,105 19,000 260,368 1,454,980Nebraska 84,578 209,544 64,395 978,024 4,142,461Nevada 46,298 100,059 19,587 262,239 1,484,489New Hampshire 42,495 110,132 31,078 421,656 2,092,556New Jersey 303,410 504,862 182,297 2,056,526 9,842,510New Mexico 42,822 87,788 34,673 415,945 1,836,375New York 1,383,908 3,156,479 756,500 12,587,023 54,604,355North Carolina 527,568 1,035,032 280,164 4,328,993 20,133,817North Dakota 23,616 52,035 19,627 214,883 1,064,589Ohio 605,376 1,656,240 489,554 6,456,527 28,406,007Oklahoma 131,804 278,564 51,310 851,206 4,470,095Oregon 97,919 260,718 65,043 738,907 5,224,625Pennsylvania 371,915 710,505 424,057 2,555,642 13,078,735Rhode Island 50,658 111,718 34,459 372,418 2,057,702South Carolina 228,975 458,400 129,353 2,036,447 9,386,124South Dakota 25,509 59,709 19,269 243,295 1,093,272Tennessee 416,508 848,942 296,281 3,008,859 19,612,859Texas 587,114 1,735,053 384,211 9,091,697 30,984,775Utah 63,353 132,311 29,355 486,901 2,581,769Vermont 20,430 35,855 4,869 99,712 600,242Virginia 215,740 438,542 166,555 1,879,125 8,702,714Washington 220,230 573,523 157,276 1,919,907 10,364,117West Virginia 149,046 344,864 70,280 1,116,604 6,029,306Wisconsin 217,841 480,948 159,848 1,586,155 8,916,551Wyoming 16,068 39,162 10,642 140,407 678,414

*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply. Source: CMS, State Drug Utilization Data, FY 2002.


4-13

Medicaid Average Cost Per Prescription, 2002*

State Drug

PaymentsPrescriptions

ProcessedAverage

Prescription CostNational Average $29,434,008,185 519,271,905 $56.68 Alabama $478,039,509 10,622,577 $45.00 Alaska $90,414,947 1,430,830 $63.19 Arizona** - - -Arkansas $286,666,058 5,645,835 $50.77 California $3,705,299,355 50,506,133 $73.36 Colorado $196,128,612 4,045,045 $48.49 Connecticut $363,675,494 5,480,344 $66.36 Delaware $95,071,849 1,553,646 $61.19 District of Columbia $61,792,674 917,509 $67.35 Florida $1,748,930,895 27,596,648 $63.37 Georgia $860,752,058 17,927,466 $48.01 Hawaii $90,206,218 1,610,379 $56.02 Idaho $110,531,180 1,982,185 $55.76 Illinois $1,034,607,810 22,002,080 $47.02 Indiana $648,255,300 12,554,226 $51.64 Iowa $290,670,341 5,693,593 $51.05 Kansas $203,083,268 3,747,600 $54.19 Kentucky $673,213,514 13,828,432 $48.68 Louisiana $715,254,096 13,665,140 $52.34 Maine $250,071,092 5,509,555 $45.39 Maryland $318,529,614 5,090,984 $62.57 Massachusetts $949,890,388 16,048,332 $59.19 Michigan $712,113,878 13,878,198 $51.31 Minnesota $322,670,379 5,086,465 $63.44 Mississippi $517,059,589 9,267,580 $55.79 Missouri $835,996,596 14,737,684 $56.73 Montana $78,370,829 1,454,980 $53.86 Nebraska $197,802,584 4,142,461 $47.75 Nevada $92,514,278 1,484,489 $62.32 New Hampshire $102,090,932 2,092,556 $48.79 New Jersey $668,452,082 9,842,510 $67.91 New Mexico $83,772,945 1,836,375 $45.62 New York $3,585,607,627 54,604,355 $65.67 North Carolina $1,122,737,041 20,133,817 $55.76 North Dakota $53,046,799 1,064,589 $49.83 Ohio $1,380,579,809 28,406,007 $48.60 Oklahoma $273,058,171 4,470,095 $61.09 Oregon $277,727,880 5,224,625 $53.16 Pennsylvania $707,197,466 13,078,735 $54.07 Rhode Island $127,361,625 2,057,702 $61.90 South Carolina $497,839,781 9,386,124 $53.04 South Dakota $61,005,529 1,093,272 $55.80 Tennessee $972,650,782 19,612,859 $49.59 Texas $1,623,768,625 30,984,775 $52.41 Utah $135,484,315 2,581,769 $52.48 Vermont $34,615,257 600,242 $57.67 Virginia $460,320,678 8,702,714 $52.89 Washington $538,884,367 10,364,117 $52.00 West Virginia $290,278,395 6,029,306 $48.14 Wisconsin $472,277,766 8,916,551 $52.97 Wyoming $37,637,908 678,414 $55.48

*Rebates have not been subtracted from these figures.

**Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.


4-14


4-15

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.


4-16


4-17

Medicaid Drug Rebates, 2002

State

Allocation of Drug Rebate Monies1 Total Rebates2 Federal Share2

National Total $5,917,504,760 $3,407,724,441Alabama Medicaid Drug Budget $84,994,286 $59,956,556Alaska Medicaid General $14,347,654 $8,232,684Arizona* - - -Arkansas Medicaid Drug Budget $56,688,398 $41,263,780California Medicaid Drug Budget $946,651,118 $501,389,213Colorado General Fund $39,054,140 $19,757,318Connecticut General Fund $62,627,160 $31,353,041Delaware Medicaid General $16,990,455 $8,583,285District of Columbia Medicaid General $11,445,790 $8,012,876Florida Medicaid Drug Budget $353,649,807 $200,302,136Georgia Medicaid General $205,469,531 $121,227,024Hawaii Medicaid Drug Budget $15,267,796 $8,601,876Idaho Medicaid General $22,939,130 $16,291,370Illinois Medicaid Drug Budget $190,316,986 $95,869,844Indiana General Fund $126,512,101 $78,488,107Iowa General Fund $50,092,788 $31,591,633Kansas Medicaid General $29,755,595 $17,938,406Kentucky General Fund $133,330,557 $93,351,276Louisiana Medicaid Drug Budget $113,729,749 $80,081,323Maine Medicaid Drug Budget $47,395,300 $31,642,678Maryland Medicaid General $54,261,949 $27,263,281Massachusetts Medicaid General $191,118,385 $95,707,811Michigan General Fund $172,522,597 $97,412,881Minnesota General Fund $62,655,474 $31,327,739Mississippi Medicaid General $115,221,421 $87,844,768Missouri Medicaid Drug Budget $147,281,505 $90,586,777Montana General Fund $15,955,235 $11,659,478Nebraska Medicaid Drug Budget $47,855,128 $28,770,955Nevada General Fund $13,547,604 $6,803,437New Hampshire General Fund $20,888,707 $10,500,160New Jersey Medicaid Drug Budget $127,373,014 $63,850,343New Mexico General Fund $13,274,387 $9,695,612New York General Fund $663,973,100 $331,986,551North Carolina Medicaid General $207,064,443 $127,702,769North Dakota Medicaid Drug Budget $11,651,682 $8,159,556Ohio Medicaid General $263,267,258 $154,748,494Oklahoma Medicaid General $51,471,649 $36,251,483Oregon General Fund $54,474,938 $32,343,683Pennsylvania Outpatient Appropriation $154,338,235 $84,595,091Rhode Island General Fund $26,213,636 $13,749,052South Carolina Medicaid Drug Budget $98,272,773 $68,818,366South Dakota Medicaid Drug Budget $12,056,925 $8,004,147Tennessee Medicaid General $180,613,885 $114,942,676Texas Medicaid Drug Budget $305,110,523 $184,019,819Utah General Fund $36,756,960 $25,760,249Vermont Medicaid General $24,488,863 $15,514,120Virginia General Fund, Medicaid General $76,776,155 $39,595,957Washington General Fund $100,874,789 $51,143,700West Virginia Medicaid General $48,976,536 $36,864,639Wisconsin Medicaid General $89,226,751 $52,764,907Wyoming Medicaid Drug Budget $8,681,912 $5,401,514

*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 2003 NPC Survey. 2 CMS, CMS-64 Report, FY 2002, includes reported state supplemental rebates for CA, FL, MD, and MI.


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Medicaid Drug Rebate Trends, 1998-2002

State 1998 1999 2000 2001 2002National Total $2,469,136,949 $3,338,497,983 $3,980,646,518 $4,948,222,331 $5,917,504,760Alabama $36,537,095 $49,785,076 $60,984,826 $76,624,463 $84,994,286Alaska $5,026,624 $7,050,981 $8,594,014 $11,337,883 $14,347,654Arizona* - - - - -Arkansas $22,518,230 $37,931,853 $40,814,931 $45,744,406 $56,688,398California $362,808,597 $539,928,783 $600,895,711 $786,113,991 $946,651,118Colorado $20,424,896 $25,151,080 $28,832,989 $34,264,574 $39,054,140Connecticut $32,128,587 $38,656,394 $49,164,014 $61,916,192 $62,627,160Delaware $7,096,836 $9,787,444 $13,780,359 $17,042,045 $16,990,455District of Columbia $7,100,983 $8,379,982 $9,215,651 $10,446,499 $11,445,790Florida $150,733,077 $195,512,719 $248,637,014 $297,362,792 $353,649,807Georgia $64,320,077 $95,237,778 $91,886,605 $110,087,285 $205,469,531Hawaii $5,992,722 $8,378,292 $10,947,632 $14,363,603 $15,267,796Idaho $8,614,444 $11,901,778 $13,984,004 $18,841,154 $22,939,130Illinois $100,811,862 $121,540,781 $143,590,170 $170,733,612 $190,316,986Indiana $50,710,861 $62,691,135 $84,453,135 $103,148,144 $126,512,101Iowa $25,265,390 $32,369,409 $36,040,216 $42,602,101 $50,092,788Kansas $19,852,439 $26,878,486 $31,022,023 $39,731,568 $29,755,595Kentucky $57,082,387 $72,676,810 $93,688,165 $104,759,238 $133,330,557Louisiana $65,994,910 $76,147,317 $84,800,897 $115,254,842 $113,729,749Maine $19,650,719 $30,032,364 $31,598,262 $41,847,632 $47,395,300Maryland $25,017,660 $32,311,299 $42,081,781 $34,263,429 $54,261,949Massachusetts $89,011,664 $140,102,747 $146,225,538 $180,517,139 $191,118,385Michigan $72,526,027 $75,674,128 $75,687,945 $111,716,756 $172,522,597Minnesota $31,058,740 $37,389,033 $43,228,324 $54,548,714 $62,655,474Mississippi $39,983,265 $49,332,307 $61,260,326 $88,481,567 $115,221,421Missouri $66,460,159 $84,620,799 $110,025,619 $133,927,028 $147,281,505Montana $7,378,206 $9,290,653 $10,985,923 $13,359,968 $15,955,235Nebraska $16,545,572 $21,609,490 $31,004,940 $30,219,685 $47,855,128Nevada $5,143,136 $7,727,267 $4,863,879 $16,330,579 $13,547,604New Hampshire $9,676,461 $12,956,727 $15,073,211 $13,934,765 $20,888,707New Jersey $70,992,525 $90,472,488 $105,535,091 $124,127,231 $127,373,014New Mexico $10,670,766 $7,972,600 $8,901,456 $12,110,896 $13,274,387New York $251,273,382 $356,088,488 $470,317,992 $543,984,948 $663,973,100North Carolina $81,211,796 $111,326,116 $140,047,825 $207,551,841 $207,064,443North Dakota $4,990,065 $5,954,387 $6,503,601 $8,780,182 $11,651,682Ohio $110,484,575 $148,477,399 $171,685,793 $217,702,350 $263,267,258Oklahoma $23,329,251 $31,992,100 $37,135,809 $40,177,945 $51,471,649Oregon $14,433,179 $21,360,688 $32,056,386 $34,991,037 $54,474,938Pennsylvania $95,692,149 $119,340,064 $118,989,849 $129,265,110 $154,338,235Rhode Island $11,041,552 $14,440,971 $19,223,034 $21,467,002 $26,213,636South Carolina $39,156,574 $55,971,288 $73,052,676 $95,438,155 $98,272,773South Dakota $5,070,643 $5,971,015 $7,198,848 $9,405,933 $12,056,925Tennessee** $840 $22,434,760 $41,302,450 $102,644,077 $180,613,885Texas $145,635,499 $185,695,267 $222,314,531 $268,557,241 $305,110,523Utah $9,988,037 $15,145,126 $21,889,639 $21,949,963 $36,756,960Vermont $8,868,263 $10,579,999 $17,869,053 $22,045,277 $24,488,863Virginia $51,079,391 $67,715,512 $75,630,717 $79,484,868 $76,776,155Washington $39,191,376 $54,331,249 $69,782,396 $91,250,830 $100,874,789West Virginia $26,753,285 $35,941,495 $46,762,149 $52,402,218 $48,976,536Wisconsin $40,776,543 $51,869,264 $66,358,433 $79,554,207 $89,226,751Wyoming $3,025,632 $4,364,795 $4,720,686 $5,809,366 $8,681,912

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

Source: CMS, HCFA-64 Report, FY 1998-FY 2002.


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Medicaid Drug Rebate Trends Annual Percent Change, 1997-2002

State

% Change 97-98

% Change98-99

% Change99-00

% Change 00-01

% Change01-02

National Total 11.6% 35.2% 19.2% 24.3% 19.6%Alabama -22.5% 36.3% 22.5% 25.6% 10.9%Alaska 2.6% 40.3% 21.9% 31.9% 26.5%Arizona* - - - - -Arkansas -8.1% 68.4% 7.6% 12.1% 23.9%California 17.9% 48.8% 11.3% 30.8% 20.4%Colorado 20.5% 23.1% 14.6% 18.8% 14.0%Connecticut 17.6% 20.3% 27.2% 25.9% 1.1%Delaware 21.3% 37.9% 40.8% 23.7% -0.3%District of Columbia 6.5% 18.0% 10.0% 13.4% 9.6%Florida 17.3% 29.7% 27.2% 19.6% 18.9%Georgia 7.6% 48.1% -3.5% 19.8% 86.6%Hawaii 28.8% 39.8% 30.7% 31.2% 6.3%Idaho 2.9% 38.2% 17.5% 34.7% 21.8%Illinois 18.4% 20.6% 18.1% 18.9% 11.5%Indiana 16.2% 23.6% 34.7% 22.1% 22.7%Iowa 16.1% 28.1% 11.3% 18.2% 17.6%Kansas 68.3% 35.4% 15.4% 28.1% -25.1%Kentucky -4.7% 27.3% 28.9% 11.8% 27.3%Louisiana 20.8% 15.4% 11.4% 35.9% -1.3%Maine 7.7% 52.8% 5.2% 32.4% 13.3%Maryland -27.6% 29.2% 30.2% -18.6% 58.4%Massachusetts 21.9% 57.4% 4.4% 23.5% 5.9%Michigan -2.1% 4.3% 0.0% 47.6% 54.4%Minnesota -2.6% 20.4% 15.6% 26.2% 14.9%Mississippi 7.7% 23.4% 24.2% 44.4% 30.2%Missouri 21.7% 27.3% 30.0% 21.7% 10.0%Montana 8.9% 25.9% 18.2% 21.6% 19.4%Nebraska 10.8% 30.6% 43.5% -2.5% 58.4%Nevada -4.6% 50.2% -37.1% 235.8% -17.0%New Hampshire 10.1% 33.9% 16.3% -7.6% 49.9%New Jersey 6.4% 27.4% 16.6% 17.6% 2.6%New Mexico -20.2% -25.3% 11.7% 36.1% 9.6%New York 25.5% 41.7% 32.1% 15.7% 22.1%North Carolina 18.8% 37.1% 25.8% 48.2% -0.2%North Dakota 7.3% 19.3% 9.2% 35.0% 32.7%Ohio 31.2% 34.4% 15.6% 26.8% 20.9%Oklahoma 12.3% 37.1% 16.1% 8.2% 28.1%Oregon 4.2% 48.0% 50.1% 9.2% 55.7%Pennsylvania -17.2% 24.7% -0.3% 8.6% 19.4%Rhode Island 9.1% 30.8% 33.1% 11.7% 22.1%South Carolina 13.0% 42.9% 30.5% 30.6% 3.0%South Dakota 2.6% 17.8% 20.6% 30.7% 28.2%Tennessee** - - 84.1% 148.5% 76.0%Texas 11.5% 27.5% 19.7% 20.8% 13.6%Utah 19.3% 51.6% 44.5% 0.3% 67.5%Vermont 7.4% 19.3% 68.9% 23.4% 11.1%Virginia 12.9% 32.6% 11.7% 5.1% -3.4%Washington 2.3% 38.6% 28.4% 30.8% 10.5%West Virginia 2.6% 34.3% 30.1% 12.1% -6.5%Wisconsin 9.8% 27.2% 27.9% 19.9% 12.2%Wyoming 12.9% 44.3% 8.2% 23.1% 49.4%

*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 1997 – FY 2002.


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Rebates as Percent Drug Expenditures, 2002

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

Source: CMS, CMS-64 Report, FY 2002

State Drug Expenditures RebatesRebates as % Drug

ExpenditureNational Total $29,339,050,970 $5,917,504,760 20.2%Alabama $452,269,953 $84,994,286 18.8%Alaska $70,708,412 $14,347,654 20.3%Arizona* $3,725,371 - -Arkansas $273,257,660 $56,688,398 20.7%California $3,591,537,830 $946,651,118 26.4%Colorado $189,717,036 $39,054,140 20.6%Connecticut $357,919,257 $62,627,160 17.5%Delaware $97,750,161 $16,990,455 17.4%District of Columbia $66,129,208 $11,445,790 17.3%Florida $1,717,652,527 $353,649,807 20.6%Georgia $873,703,133 $205,469,531 23.5%Hawaii $88,256,904 $15,267,796 17.3%Idaho $119,177,013 $22,939,130 19.2%Illinois $1,293,435,797 $190,316,986 14.7%Indiana $631,637,846 $126,512,101 20.0%Iowa $285,467,642 $50,092,788 17.5%Kansas $213,778,616 $29,755,595 13.9%Kentucky $652,904,065 $133,330,557 20.4%Louisiana $714,107,841 $113,729,749 15.9%Maine $220,420,714 $47,395,300 21.5%Maryland $297,291,733 $54,261,949 18.3%Massachusetts $958,972,520 $191,118,385 19.9%Michigan $674,222,281 $172,522,597 25.6%Minnesota $310,174,144 $62,655,474 20.2%Mississippi $567,313,801 $115,221,421 20.3%Missouri $790,853,387 $147,281,505 18.6%Montana $83,587,410 $15,955,235 19.1%Nebraska $207,782,737 $47,855,128 23.0%Nevada $86,929,536 $13,547,604 15.6%New Hampshire $99,682,997 $20,888,707 21.0%New Jersey $694,669,924 $127,373,014 18.3%New Mexico $73,877,785 $13,274,387 18.0%New York $3,660,427,024 $663,973,100 18.1%North Carolina $1,100,822,176 $207,064,443 18.8%North Dakota $52,495,878 $11,651,682 22.2%Ohio $1,333,992,298 $263,267,258 19.7%Oklahoma $285,068,869 $51,471,649 18.1%Oregon $279,029,096 $54,474,938 19.5%Pennsylvania $718,210,352 $154,338,235 21.5%Rhode Island $125,187,888 $26,213,636 20.9%South Carolina $451,846,044 $98,272,773 21.7%South Dakota $62,382,937 $12,056,925 19.3%Tennessee $905,405,421 $180,613,885 19.9%Texas $1,591,064,713 $305,110,523 19.2%Utah $140,275,267 $36,756,960 26.2%Vermont $114,157,870 $24,488,863 21.5%Virginia $458,953,342 $76,776,155 16.7%Washington $541,963,790 $100,874,789 18.6%West Virginia $277,039,990 $48,976,536 17.7%Wisconsin $442,718,195 $89,226,751 20.2%Wyoming $39,094,579 $8,681,912 22.2%


4-21

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.


4-22

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

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

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

• Name and description of the medication;

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

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

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

• Techniques for self-monitoring prescription therapy;

• Proper storage;

• Prescription refill information; and

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

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

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

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

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

Retrospective DUR. This activity continuously assesses data on drug use against established standards, preferably using automated claims processing and information retrieval techniques to monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary, introduce remedial strategies in order to improve the quality of care and to conserve program funds or personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and recipients, or with respect to specific drugs or groups of drugs.

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


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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 Medi-Cal Contract Drug Advisory Committee Ad Hoc Petition with specific content requirementsColorado None - Introductory letter Connecticut Pharmacy and Therapeutic Committee (2004) Quarterly Introductory letter Delaware DUR Board advises Bi-Monthly Introductory letter District of Columbia N/A - Introductory letter Florida Pharmacy and Therapeutic Committee - Introductory letter Georgia Yes Quarterly Introductory letter Hawaii None - Introductory letter, Formulary kit Idaho Pharmacy Committee Weekly Introductory letter, Formulary kit Illinois None - Contact First DataBank Indiana DUR Board advises Monthly Electronic form Iowa DUR Board advises Monthly Introductory letter Kansas DUR Board advises Bi-Monthly Introductory letter Kentucky Pharmacy & Therapeutic Advisory Committee Bi-Monthly Introductory letter, Package insert Louisiana Pharmacy Advisory Committee Semiannually Introductory letter Maine DUR Committee Monthly Introductory letter Maryland None - Introductory letter Massachusetts DUR Committee Quarterly Introductory letter Michigan Pharmacy and Therapeutics Committee Quarterly State form, Introductory letter Minnesota Drug Formulary Committee Quarterly Introductory letter Mississippi Pharmacy and Therapeutics Committee Bi-Monthly Introductory letter Missouri DUR Board & Prior Authorization Committee Quarterly AMPC format dossier Montana DUR Board advises Monthly Introductory letter Nebraska None - Introductory letter Nevada DUR Board Quarterly Introductory letter New Hampshire None - Information packet New Jersey None - Introductory letter New Mexico None - Contact First DataBank New York Pharmacy Advisory Committee Quarterly Introductory letter North Carolina Medical Care Advisory Committee - Introductory letter, Package insert North Dakota None - Manufacturer’s preference Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter Oklahoma DUR Board Monthly E-mail to [email protected] Oregon DUR Board Quarterly Introductory letter 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 Pharmacy Advisory Committee Quarterly Introductory letter Texas None - State form Utah DUR Board Monthly Introductory letter, FDA information Vermont DUR Committee Bi-Monthly Introductory letter Virginia Pharmacy Liaison Committee Quarterly Introductory letter Washington Pharmacy and Therapeutics Committee Quarterly AMCP format dossier West Virginia Medical Services Fund Advisory Council Quarterly Introductory product packet

Wisconsin None - Introductory letter, First DataBank notification

Wyoming DUR Board Bi-Monthly Introductory letter

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

Source: As reported by State drug program administrators in the 2003 NPC Survey.


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Pharmacy Benefit Design - Coverage

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


PA = Prior Authorization, DME = Durable Medical Equipment



4-25

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 as DME Covered Not 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 Not Covered Florida Covered Covered Covered Covered Georgia Covered Covered Covered Covered with RestrictionsHawaii Covered Covered as DME Covered as DME Covered as DME Idaho Covered Covered Covered Covered as 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 with Restrictions Covered Maryland Covered Covered Covered Covered as DME Massachusetts Covered Covered with Restrictions Covered with Restrictions Covered with RestrictionsMichigan Covered Covered Covered Covered Minnesota Covered Not Covered Covered Not Covered Mississippi Covered Not Covered Not Covered Not Covered Missouri Covered Covered Covered Covered Montana Covered Not Covered Not Covered Not Covered Nebraska Covered, PA Required Covered as DME Covered (med. necess.) Covered as DME Nevada Covered Covered Covered Covered New Hampshire Covered Covered Covered Covered New Jersey Covered Covered Covered Covered New Mexico Covered Covered Covered Covered New York Covered Covered Covered Covered North Carolina Covered 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 as DME Covered as DME Pennsylvania Covered Covered Covered Covered Rhode Island Covered Covered Covered Covered as DME South Carolina Covered Covered Covered Covered as DME South Dakota Covered Covered Covered Covered Tennessee* Covered Covered Covered Covered Texas Covered Covered Covered Not Covered Utah Covered Covered Covered with Restrictions Covered Vermont Covered Covered Covered Covered Virginia Covered Covered Covered Covered Washington Covered Covered Covered Covered West Virginia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with RestrictionsWisconsin 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



4-26

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 Not 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 with Restrictions Covered with Restrictions Delaware Covered Covered Covered with Restrictions District of Columbia Not Covered Covered with Restrictions Covered with Restrictions Florida Covered with Restrictions Covered Not Covered Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions Hawaii Covered as DME Covered, PA Required Covered, PA Required Idaho Covered as DME Covered 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 Covered with Restrictions Kentucky Not Covered Covered, PA Required Covered, PA Required Louisiana Covered Covered as DME Covered as DME Maine Covered Not Covered Not Covered Maryland Covered as DME Covered Covered Massachusetts Covered with Restrictions Covered with Restrictions Not Covered Michigan Covered Covered with Restrictions, PA

required Covered with Restrictions, PA required

Minnesota Not Covered Covered Covered Mississippi Not Covered Covered Covered Missouri Covered Covered Covered Montana Not Covered Not Covered Not Covered Nebraska Covered as DME Covered as DME Covered as DME Nevada Covered Covered as DME Covered as DME New Hampshire Covered Covered Covered New Jersey Covered Covered Covered New Mexico Covered Covered Covered New York Covered Covered Covered North Carolina Covered as DME Covered Covered North Dakota Not Covered Covered Not Covered Ohio Covered as DME Covered Covered Oklahoma Covered as DME Covered with Restrictions N/A Oregon Covered as DME Covered, PA Required Covered, PA Required Pennsylvania Covered Covered Covered Rhode Island Covered Covered as DME, PA required Covered as DME, PA Required South Carolina Covered as DME Covered as DME Covered as DME South Dakota Covered Not Covered Not Covered Tennessee* Covered Covered Covered Texas Not Covered Not Covered Not Covered Utah Covered Covered as DME Covered as DME Vermont Covered Covered Covered Virginia Covered Covered 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



4-27

Coverage of Injectables

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

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




4-28

Coverage of Vaccines and Unit Dose

State Method for Vaccine Reimbursement ^ Reimbursement for Unit DoseAlabama EPSDT, VCP Yes Alaska EPSDT, CHIP, VCP Yes Arizona* - - Arkansas VCP Yes California VCP Yes Colorado EPSDT No Connecticut CHIP No Delaware VCP No District of Columbia EPSDT No Florida VCP Yes Georgia EPSDT, VCP Yes Hawaii EPSDT, CHIP, VCP Yes Idaho ESPDT, CHIP, VCP, State Vaccine Program Yes Illinois VCP No Indiana EPSDT, CHIP, VCP Yes Iowa EPSDT, VCP Yes Kansas CHIP, VCP No Kentucky EPSDT, CHIP, VCP, Pharmacy Program Yes Louisiana EPSDT, VCP Yes Maine EPSDT, CHIP, VCP No Maryland VCP No Massachusetts EPSDT, Department of Public Health No Michigan EPSDT, CHIP, VCP Yes Minnesota EPSDT, CHIP, VCP Yes Mississippi VCP Yes Missouri VCP Yes Montana EPSDT, CHIP, VCP Yes Nebraska EPSDT, CHIP, VCP No Nevada EPSDT Yes New Hampshire EPSDT, CHIP, VCP Yes New Jersey EPSDT, VCP Yes, LTC New Mexico EPSDT, CHIP, VCP No New York EPSDT, CHIP, VCP No North Carolina EPSDT, VCP No North Dakota EPSDT No Ohio VCP No Oklahoma EPSDT, VCP No Oregon VCP No Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No Rhode Island VCP, Physician Payment (adults) No South Carolina VCP Yes South Dakota VCP Yes Tennessee* EPSDT, VCP No Texas EPSDT, CHIP, VCP Yes Utah EPSDT, CHIP, VCP Yes 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.



4-29

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 Not Covered California Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Connecticut Covered Not Covered Covered Not Covered Delaware Covered Covered Covered Covered District of Columbia Not Covered Covered with Restrictions Not Covered Not Covered Florida Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Georgia Not Covered Covered with Restrictions Covered with Restrictions Not Covered Hawaii Covered Covered Limited Coverage Covered with Restrictions Idaho Not Covered Not Covered Not Covered Not Covered Illinois 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 Covered with Restrictions Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered Louisiana Not Covered Not Covered Not Covered Not Covered Maine Covered Covered Not Covered Covered with Restrictions Maryland 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 Covered Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage Missouri Limited Coverage Limited Coverage Limited Coverage Not Covered Montana Covered with Restrictions Covered with Restrictions 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 Covered Covered Limited Coverage Limited Coverage New Mexico Covered Covered Covered Covered New York Limited Coverage Limited Coverage Limited Coverage Limited Coverage North Carolina Covered Limited Coverage Limited Coverage Not Covered North Dakota Covered with Restrictions Covered Not Covered Covered with Restrictions Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage Oklahoma Limited Coverage Not Covered Not Covered Covered with Restrictions Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Pennsylvania Covered with Restrictions Covered Covered with Restrictions Covered Rhode Island 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* Covered Covered Not Covered Not Covered Texas Covered Covered Covered Covered Utah Limited Coverage Limited Coverage Limited Coverage Not Covered Vermont PA Required PA Required PA Required PA Required Virginia Covered Covered Covered Covered Washington Limited Coverage Limited Coverage Limited Coverage Not Covered West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required Wisconsin Covered with Restrictions Covered Covered with Restrictions Not Covered Wyoming Covered Covered Covered Not Covered

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



4-30

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

State Digestive Products (non- H2 antagonists) H2 Antagonists Feminine Products Topical Products

Alabama Covered Covered Not Covered Covered with Restrictions Alaska Not Covered Not Covered Limited Coverage Limited Coverage Arizona* - - - - Arkansas Limited Coverage Covered Limited Coverage Limited Coverage California Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Connecticut Covered with Restrictions Covered with Restrictions Not Covered Covered Delaware Covered Covered Not Covered Covered District of Columbia Covered with Restrictions Not Covered Not Covered Not Covered Florida Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions Georgia Not Covered Not Covered Not Covered Not Covered Hawaii Covered 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 Covered with Restrictions Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions Louisiana Not Covered Not Covered Not Covered Not Covered Maine Covered Covered with Restrictions Covered Covered Maryland Not Covered 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 Not Covered Limited Coverage Limited Coverage Missouri Limited Coverage Not Covered Not Covered Limited Coverage 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 Covered 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 Limited Coverage 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 Not Covered 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* Covered Covered Not Covered Covered Texas Covered Covered Not Covered Covered Utah Not Covered Not Covered Limited Coverage Limited Coverage Vermont PA Required PA Required PA Required PA Required Virginia Covered Covered Covered Covered Washington Limited Coverage Limited Coverage Limited Coverage Limited Coverage West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage Wisconsin Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions Wyoming Not Covered Covered Covered Covered


PA= Prior Authorization



4-31

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 9 Quarterly California Yes No - - Colorado Yes No - - Connecticut Yes - - - 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 No - - Idaho Yes Pharmacy Committee 5 Weekly 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 Bi-monthly 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 Bi-monthly Missouri Yes Prior Authorization Committee 9 Quarterly Montana Yes DUR Board 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 Yes No - - Ohio Yes No - - Oklahoma Yes No - - Oregon Yes DUR Board 12 Quarterly Pennsylvania Yes No - - Rhode Island Yes No - - South Carolina Yes No - - South Dakota Yes No - - Tennessee* Yes No - - 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 Pharmacy Prior Authorization Advisory Comm. 9 As needed Wyoming Yes DUR Board 12 Bi-monthly




4-32

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. 1,550 94%Arizona* - - -Arkansas M.D. 155,00 72%California M.D., R.Ph. 2,400,000 90%Colorado M.D. 32,000 87%Connecticut M.D., R.Ph. N/A N/ADelaware M.D. 36,000 90%District of Columbia M.D., R.Ph. 9,000 70%Florida M.D., R.Ph., Pharm. Tech. 440,000 78%Georgia M.D., R.Ph. 104,000 92%Hawaii M.D., R.Ph. N/A 99%Idaho M.D., R.Ph. 24,500 77%Illinois M.D., R.Ph. 500,000 20%Indiana M.D., Other Providers N/A N/AIowa M.D., R.Ph. 56,000 93%Kansas M.D., R.Ph. N/A N/AKentucky M.D., R.Ph. 285,000 58%Louisiana M.D. 171,000 95%Maine M.D. 65,000 82%Maryland M.D., R.Ph 5,300 99%Massachusetts M.D. 137,000 67%Michigan M.D. 120,000 95%Minnesota M.D., R.Ph., Pharm. Tech. N/A N/AMississippi M.D. 216,000 90%Missouri M.D., R.Ph., Physician Extender 35,000 N/AMontana M.D., R.Ph., Pharm. Tech. 16,000 70%Nebraska M.D., R.Ph. 24,000 40%Nevada M.D. - -New Hampshire M.D. 870 88%New Jersey R.Ph., DME Supplier 351,000 97%New Mexico M.D., R.Ph., Pharm. Tech. 1,300 N/ANew York Ordering Provider 180,000 100%North Carolina M.D. N/A N/ANorth Dakota M.D., R.Ph., Pharm. Tech. N/A N/AOhio M.D. 120,000 MostOklahoma M.D., R.Ph. 117,000 59%Oregon M.D. 43,000 66%Pennsylvania M.D., Other Licensed Prescriber N/A N/ARhode Island M.D., R.Ph. N/A N/ASouth Carolina M.D. 37,700 60%South Dakota M.D., R.Ph. 28 100%Tennessee* M.D. 450,000 66%Texas M.D., R.Ph., Other Licensed Provider 3,000 75%Utah M.D. 12,000 50%Vermont M.D. N/A 99%Virginia M.D., R.Ph. 50,000 64%Washington R.Ph., Pharm. Tech. N/A 80%West Virginia M.D., R.Ph. 160,000 78%Wisconsin R.Ph. 182,000 97%Wyoming M.D., R.Ph., Pharm. Tech. 8,200 81%




4-33

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. One business day Fax or telephone inquiry system Colorado Pharm. Tech. 24 hours Phone, fax Connecticut R.Ph. 2 hours Fax, POS system Delaware R.Ph. 1 working day Mail District of Columbia R.Ph., Pharm. Tech. Minutes to 24 hours Phone, fax Florida R.Ph., Pharm. Tech. 30 minutes-24 hours Phone, fax, mail Georgia PBM 24 hours or less Phone, mail Hawaii Pharm. Tech., L.P.N. 24 hours Fax Idaho M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax, mail Illinois M.D., R.Ph. 4-8 hours Automated phone Indiana Medicaid Director or designee 10 days Phone, letter Iowa R.Ph. 24 hours or less Phone, fax Kansas R.N., R.Ph. 24 hours or less Phone, mail Kentucky R.N., R.Ph. 4-24 hours Phone, fax Louisiana R.Ph. 3-5 minutes Phone, fax Maine M.D. 4 hours Mail Maryland M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax Massachusetts R.Ph. 24 hours Phone, mail Michigan M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax Minnesota R.N. Within minutes Phone, mail Mississippi R.N., R.Ph., Pharm. Tech. 6 hours Phone, fax, mail Missouri M.D., R.Ph., Pharm. Tech. < 5 minutes Phone, fax, mail Montana M.D., R.Ph., Pharm. Tech. 24 hours or less 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 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. 24 hours Fax Ohio R.Ph., Pharm. Tech. Immediate Phone Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours Fax, mail Oregon R.Ph., Pharm. Tech. 24 hours or less Phone, fax Pennsylvania R.N., M.D. Immediately to 24 hours Phone Rhode Island R.Ph., Pharm. Tech. Immediately to 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* R.Ph. Same day Fax Texas R.Ph. 72 hours Phone, fax Utah Nurse 8-12 hours Phone, fax, mail Vermont R.N. 24 hours Phone, mail Virginia M.D., R.Ph., Pharm. Tech. Less than 3 minutes Phone, fax, mail

Washington M.D., Drug Utilization Review Team** <24 hours Phone, fax; denial through mail

West Virginia R.Ph. 3 minutes to 2 hours Phone, fax Wisconsin R.Ph., 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.



4-34

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 Covered, PA Required Not Covered California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required Colorado Covered, PA Required Covered, PA Required Not Covered Connecticut Covered Covered Not Covered Delaware Covered Covered, PA Required Not Covered, PA Required District of Columbia Not Covered Partial Coverage, PA Required Partial Coverage, PA Required Florida Covered, PA Required Covered Not Covered Georgia Covered, PA Required Covered, PA Required Not covered Hawaii Covered, PA Required Covered, PA Required Covered, PA Required Idaho Partial Coverage, PA Required Partial Coverage, 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, PA Required Covered, PA Required Covered, PA Required Maryland Covered Covered Not Covered Massachusetts Covered Partial Coverage, PA Required Not Covered Michigan Partial Coverage, PA Required Covered Not Covered Minnesota Covered Partial Coverage, PA Required Not Covered Mississippi Covered Covered, PA Required Not Covered Missouri Partial Coverage Partial Coverage 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, PA Required 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, PA Required Partial Coverage, PA Required Ohio Not Covered Covered Not Covered Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required Oregon Covered, PA Required Covered Not Covered Pennsylvania Covered Covered Not Covered Rhode Island Covered Covered Covered, PA Required South Carolina Covered Covered Not Covered South Dakota Covered Covered Covered Tennessee* Covered Covered, PA Required Covered Texas Covered Covered Covered Utah Not Covered Covered, PA Required Not Covered Vermont Covered Covered Covered Virginia Covered Covered Covered Washington Covered, PA Required Covered, PA Required Not Covered West Virginia Covered Partial Coverage, PA Required Not Covered Wisconsin Covered Covered, PA Required Covered, PA Required Wyoming Not Covered Covered, Some require PA Not Covered

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



4-35

Prior Authorization (con’t)

State Antihistamines Anxiolytics, Sedatives, and Hypnotics

Prescribed Cold Medications

Alabama Covered, PA Required Covered Partial Coverage Alaska Covered Covered Not Covered Arizona* - - - Arkansas Partial Coverage, PA Required Covered Partial Coverage California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required Colorado Covered Covered Covered, PA Required Connecticut Covered Covered Covered Delaware Covered Covered Covered District of Columbia Covered Covered Covered Florida Covered Covered Partial Coverage Georgia Covered Covered, PA Required Partial Coverage Hawaii Partial Coverage, PA Required Covered N/A Idaho Partial Coverage, PA Required Covered Partial Coverage 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, PA Required Partial Coverage Maine Covered, PA Required Covered, PA Required Not Covered Maryland Covered Covered Covered Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage Michigan Covered Covered Partial Coverage Minnesota Covered, PA Required Covered Covered Mississippi Covered, PA Required Covered Partial Coverage Missouri Partial Coverage Covered, PA Required Partial Coverage Montana Partial Coverage, PA Required 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 Partial Coverage, PA Required Covered Partial Coverage North Carolina Covered Covered Covered North Dakota Covered, PA Required Covered Not Covered Ohio Partial Coverage, PA Required Covered Partial Coverage, PA Required Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered Oregon Covered, PA Required Covered, PA Required Covered Pennsylvania Covered Covered Covered Rhode Island Covered, PA Required Covered Covered South Carolina Covered Covered Covered South Dakota Covered Covered Covered Tennessee* Covered, PA Required Covered Not Covered Texas Covered Covered Covered Utah Covered Covered Covered Vermont Covered Covered Covered Virginia Covered Covered Covered Washington Covered, PA Required Covered, PA Required Covered, PA Required West Virginia Covered Partial Coverage Partial Coverage Wisconsin Covered, PA Required Covered Covered Wyoming Covered Covered Covered

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



4-36

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 Not Covered Arizona* - - - 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, PA Required District of Columbia Partial Coverage, PA Required Partial Coverage, PA Required Covered Florida Covered Covered Covered Georgia Covered, PA Required Covered Not Covered Hawaii Covered, PA Required Covered Covered, PA Required Idaho Partial Coverage, PA Required Partial Coverage, 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 Covered, 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 Covered Partial Coverage, PA Required Minnesota Covered Covered, PA Required Covered Mississippi Covered Covered, PA Required Covered Missouri Partial Coverage Partial Coverage, PA Required 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, PA Required Covered Ohio Not Covered Partial Coverage, PA Required Partial Coverage, PA Required Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required Oregon Covered, PA Required Covered, PA Required Covered Pennsylvania Covered Covered Covered Rhode Island Covered, PA Required Covered, PA Required Not Covered South Carolina Covered Covered Not Covered South Dakota Covered, PA Required Covered Partial Coverage Tennessee* Covered Covered Not Covered Texas Covered, PA Required Covered Covered Utah Partial Coverage, PA Required Covered Not Covered Vermont Covered Covered Covered Virginia Covered 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



4-37

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. 916-552-9500 Contracted Aug-95 Colorado Catherine Traugott 303-866-2468 Contracted Dec-98 Connecticut James Zakszewski, R.Ph. 860-424-4961 Contracted Sep-96 Delaware Cynthia Denemark, R.Ph. 302-453-8453 Contracted Feb-94 District of Columbia Donna Bovell, R.Ph. 202-442-5988 In-House Sep-96 Florida Linda Barnes 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., B.C.P.S. 208-364-1821 Contracted Jan-98 Illinois Marvin Hazelwood 217-524-5565 In-House Jan-93 Indiana Karen Clifton 317-232-4307 Contracted Mar-96 Iowa Julie Kuhle, R.Ph. 515-270-0713 Contracted Jul-97 Kansas Vicki Schmidt 785-274-4287 Contracted Nov-96 Kentucky Debra Bahr, R.Ph. 502-564-7940 In-House 1987 Louisiana Mary J. Terrebonne, P.D. 225-342-9768 Contracted Apr-66 Maine Jude Walsh 207-287-1815 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 Debera Eggleston, M.D. 517-335-5181 Contracted Jul-00 Minnesota Mary Beth Reinke, Pharm.D., R. Ph. 651-215-1239 In-House Feb-96 Mississippi Judith P. Clark, R.Ph. 601-359-5253 Contracted Oct-93 Missouri Jayne Zemmer 573-751-1612 In-House 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 Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95 North Carolina Sharman Leinwand, R.Ph., M.P.H. 919-857-4034 Contracted Oct-96 North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-1544 In-House Jul-96 Ohio Jan Lawson 614-466-9698 Both Feb-00 Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000 Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-494-1589 Contracted Mar-94 Pennsylvania 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. 615-532-3107 Contracted Jul-01 Texas Barbara Dean 512-491-1101 In-House Feb-95 Utah Duane Parke 801-538-6452 In-House 1994 Vermont Scott Strenio, M.D. 802-741-7975 Contracted Nov-93 Virginia Javier Menendez, R.Ph. 804-783-2196 Contracted 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



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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 per Rx. Maximum quantities for some drugs Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills Illinois Yes Medically appropriate monthly quantity Indiana No - Iowa Yes Maximum 30 day supply except select maintenance drugs (90 days) Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per

recipient per month Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription Maryland Yes 34 day supply per Rx; Maximum 11 refills per Rx, Refills may not exceed 360 day supply Massachusetts Yes 30 day supply, Maximum 5 refills per prescription Michigan Yes 100 day supply, Quantity limits for selected drugs (e.g., sedative hypnotics) Minnesota Yes 34 day supply Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum Missouri No - Montana Yes 34 day supply Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. 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; Limits on refills by Class Ohio No - Oklahoma Yes 3 Rx per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx Oregon Yes 34 day supply (15 day supply for initial Rx for chronic conditions), duration limits on selected drugs Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override) South Dakota No - Tennessee* Yes 31 day supply, 1 year for non-controlled medications Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills Utah Yes 7 Rx per month, 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx Virginia Yes 34 day supply per Rx Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs West Virginia Yes 34 day supply; 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 Yes Quantity limits on some medications as deemed clinically appropriate.




4-39

PHARMACY PAYMENT AND PATIENT COST SHARING

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

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

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

PATIENT COST SHARING

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

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

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

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

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

• Emergency services;

• Family planning services and supplies;

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

In addition, the law prohibits imposing more than one type of charge on any service.

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


4-40

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


4-41

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 B; AWP-14%, G; AWP-20% $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) $3.00

Connecticut $3.30 AWP-12% $1.50 Delaware $3.65 AWP-14; AWP-16% (LTC)% None DC $4.50 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 - $3.00 Hawaii $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 $4.26 AWP-12% $0.50-$3.00 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 $4.45 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00 Maine $3.35 - $12.50 AWP-15% $2.50,

Max $25/recipient/pharm./month Maryland $3.69-$5.65 Lowest of :WAC+9%, direct+9%, AWP-11% $2.00 for Brand not on PDL Massachusetts $3.50 - $5.00 WAC+6% B: $3.00, G: $1.00 Michigan $3.77 AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) $1.00 (adults) Minnesota $3.65 AWP-11.5% B: $3.00, G: $1.00 Mississippi $3.91 AWP-12% $1.00 - $3.00 Missouri $4.09 - $8.19 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some

1115 waiver pop. Montana $2.00 - $4.70 AWP-15% $1.00 - $5.00 Nebraska $3.27 - $5.00 AWP-11% $2.00 Nevada $4.76 AWP-15% None New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00 New Jersey $3.73 - $4.07 AWP-10%, WAC+30%, AAC for injectables None New Mexico $3.65 AWP-12.5% None (except $2.00 for CHIP and

working disabled) New York B: $3.50 G: $4.50 AWP-12% 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-15% (retail), AWP-11% (institutional) B: $3.00, G: $2.00 Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for General Assist.) Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None South Carolina $4.05 AWP-10% $3.00 South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00 Tennessee* $2.50 AWP-13% Medicaid: None;

Other: $5/$10 Based on Income Texas (EAC+$5.14)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None Utah $3.90 (urban), $4.40 (rural) AWP-15% $3.00 Vermont $4.25 AWP-11.9% B: $3.00, G: $1.00 Virginia $3.75 AWP-10.25% B: $3.00, G: $1.00 Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $2.00 Wisconsin $4.88 (to a maximum $40.11) AWP-12% $1.00-$3.00, 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; PDL= Preferred Drug List *Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions. Source: As reported by State drug program administrators in the 2003 NPC Survey.


4-42

Maximum Allowable Cost (MAC) Programs

State Federal Upper Limits

State-Specific Upper Limits MAC Override Provisions

Alabama Yes Yes Brand medically necessary Alaska Yes No Brand medically necessary and reason for medical necessity Arizona* - - - Arkansas Yes Yes MedWatch form for prior authorization California Yes Yes Medically necessary and other products unavailable at MAC rate Colorado Yes Yes Prior authorization with medical necessity Connecticut No Yes - Delaware Yes Yes MedWatch form for prior authorization District of Columbia Yes No Brand medically necessary plus prior authorization Florida Yes Yes MedWatch form and prior authorization request Georgia Yes Yes Prior authorization Hawaii Yes Yes Prior authorization Idaho Yes Yes Failure of 2 generics plus MedWatch form 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, MedWatch form and prior authorization Kansas Yes Yes Dispense as written Kentucky Yes Yes Brand necessary, brand medically necessary, PA on some drugs Louisiana Yes Yes Brand necessary, brand medically necessary Maine Yes Yes Prior authorization 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 Brand medically necessary and prior authorization Minnesota Yes Yes Dispense as written. No pre-printed DAW allowed. Mississippi Yes No Brand medically necessary or prior authorization for brand multi-source Missouri Yes Yes Prior authorization and MedWatch form 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 New Jersey Yes No Brand medically necessary New Mexico Yes Yes Medically necessary, brand medically necessary New York Yes No Prior authorization North Carolina Yes Yes Brand medically necessary in writing on prescription North Dakota Yes Yes Dispense as written Ohio Yes Yes Prior authorization Oklahoma Yes Yes Brand medically necessary Oregon Yes Yes Brand medically necessary and documentation of generic intolerance Pennsylvania Yes Yes Brand necessary, brand medically necessary, plus 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* Yes Yes - Texas Yes Yes Dispense as written, medically necessary, brand medically necessary Utah Yes Yes Dispense as written, medically necessary, brand medically necessary Vermont Yes Yes Dispense as written Virginia No Yes Dispense as written Washington Yes Yes Medically necessary, 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 2003 NPC Survey.


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Mandatory Substitution

State Incentive Fee for Generic Substitution

Dispensing of Generic Multi-Source Required

Dispensing of Lowest Cost Multi-Source Required

Alabama No No No Alaska No Yes No Arizona* - - - Arkansas $2.00 Yes Yes California No No Yes Colorado No No No Connecticut $0.50 Yes No Delaware No Yes No District of Columbia No Yes Yes Florida No Yes No Georgia $0.50 Yes (brand PA required) No Hawaii No - 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 Yes Yes Yes Massachusetts No Yes No Michigan No No No Minnesota No Yes Yes Mississippi No Yes No Missouri No Yes Yes 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 No 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* Yes Yes Yes Texas No Yes No Utah No Yes Yes 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



4-44

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, New Prescriptions No Florida All Yes (HIV, mental health, diabetes, hypertension) 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, New Prescriptions No Massachusetts All No Michigan All No Minnesota All Yes (Clozaril monitoring) Mississippi All Yes

Missouri All Yes (diabetes, asthma, heart failure, and depression education)

Montana All No Nebraska All No Nevada All No New Hampshire All No New Jersey All 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 No 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: 12002-2003 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug program administrators in the 2003 NPC Survey.


4-45

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 Martha Warner 303-866-3176 Weekly Connecticut James Heuschkel 860-424-5347 Weekly Delaware Dan Cohn 302-453-8453 Weekly District of Columbia Glenn Sharp 804-965-7447 Monthly Florida First DataBank 650-588-5454 Weekly Georgia Express Scripts 952-837-5326 Weekly Hawaii First DataBank 800-633-3453 Weekly Idaho Katie Ayad 208-364-1970 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 Jude Walsh 207-287-1815 Weekly Maryland First DataBank 650-588-5454 Weekly Massachusetts First DataBank 650-588-5454 Weekly Michigan First Health Service Corp. 877-864-9014 Weekly Minnesota First DataBank 650-588-5454 Weekly Mississippi Judith P. Clark, R.Ph. 601-359-5253 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. 800-884-2822 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.. 518-474-9219 Monthly North Carolina Sharon Greeson, R.Ph.. 919-816-4475 Weekly North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-1544 Biweekly Ohio First DataBank 650-588-5454 Monthly Oklahoma First DataBank 800-633-3453 Weekly Oregon First Health Service Corp. 503-391-1980 Biweekly Pennsylvania First DataBank 800-633-3453 Monthly Rhode Island Paula Avarista, R.Ph. 401-462-6390 Biweekly South Carolina First DataBank 650-588-5454 Weekly South Dakota Mark Petersen, R.Ph. 605-773-3495 Biweekly Tennessee* First DataBank 650-588-5454 Weekly Texas Martha McNeill, R.Ph. 512-491-1157 Continuously Utah RaeDell Ashley, R.Ph. 801-538-6495 Bimonthly Vermont Christine Dapkiewicz 802-879-4450 Biweekly Virginia Javier Menendez, R.Ph. 804-786-2196 Weekly Washington Tom Zuchlewski 360-725-1837 Weekly West Virginia Becky Garrigan 770-352-8592 Weekly Wisconsin First DataBank 800-633-3453 Biweekly Wyoming First DataBank 800-633-3453 Weekly



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5-1

Section 5: State Pharmacy Program Profiles


5-2


5-3

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


5-4


Alabama-1

ALABAMA1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE

Type of Benefit Categorically Needy Medically Needy (MN)

Aged Blind/ Disabled

Child Adult Aged Blind/ Disabled

Child Adult

Prescribed Drugs

Inpatient Hospital Care

Outpatient Hospital Care

Laboratory & X-ray Service

Nursing Facility Services

Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $392,482,787 464,695 $452,269,953 RECEIVING CASH ASSISTANCE TOTAL $282,959,267 214,351 Aged $38,349,615 26,574 Blind/Disabled $227,824,175 126,146 Child $9,041,169 45,067 Adult $7,744,308 16,564 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $44,308,667 201,784 Aged $711,972 619 Blind/Disabled $830,003 695 Child $41,406,319 190,910 Adult $1,360,373 9,560 TOTAL OTHER EXPENDITURES/RECIPIENTS* $65,214,853 48,560 *Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. ** 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

1 The State of Alabama did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and

the tables in other sections of the Compilation. Users should check with the Alabama Medicaid program to assess the accuracy and currency of the information included.


Alabama-2

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002. 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; experimental drugs; drugs for anorexia or weight gain; hair growth products; and DESI 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 with preferred drug list. Prior authorization required for non-preferred drugs. Anti-psychotics and HIV/AIDs drugs are exempted from the prior authorization requirements. (For additional information see: www.medicaid.state.al.us.

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.

Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $5.40.

Ingredient Reimbursement Basis: AWP-10%, WAC + 9.2%.

Prescription Charge Formula: Medicaid pays for prescribed legend and non-legend drugs authorized under the program based upon and shall not exceed the lowest of:

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

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

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

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

Incentive Fee: None.

Patient Cost Sharing: Tiered copayment.

Drug Ingredient Cost Copayment $0.00 to $10.00 $0.50

$10.01 to $25.00 $1.00


Alabama-3

$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 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

Prior Authorization Contact

Louise F. Jones 334/242-5039

DUR Contact

Louise Jones 334/242-5039

Medicaid DUR Board

John Searcy, M.D. Jimmy Jackson, R.Ph. Johnny Brooklere, R.Ph. John E. Brandon, M.D. Kathy B. Portner, M.D. Richard Freeman, M.D. Gary Magouirk, M.D. Roger Lander, Pharm.D. (Vice-chair) Frank Skinner, R.Ph. W. Thomas Geary, Jr., M.D. (Chair) Steven Rostand, M.D. Margaret Thrower, Pharm.D. Rob Colburn, R.Ph. Jefferson Underwood, III, M.D.

New Brand Name Products Contact

Louise F. Jones 334/242-5039


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 Contact

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

Cyndi Crocket, Supervisor 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


Alabama-4

334/242-5610


Alabama-5

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] Internet address: www.medicaid.state.al.us John Searcy, M.D. Medical Director Alabama Medicaid Agency 501 Dexter Avenue P.O. Box 5624 Montgomery, AL 36103 334/242-5619

Title XIX Medical Care Advisory Committee

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-6

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. Richard Freeman, M.D. Ben Main, R.Ph. Gary Magouirk, M.D. David Herrick, M.D. Jackie Feldman, M.D. Melanie Smith, R.Ph. Mary McIntyre, M.D. Jefferson Underwood, III, M.D. Rob Colburn, R.Ph.


Alabama-7

Executive Officers of State Medical and Pharmaceutical Societies

Medical Association of the State of Alabama (MASA) Cary Kuhlmann Executive Director 19 S. Jackson Street P.O. Box 1900 Montgomery, AL 36102-1900 T: 334/954-2500 F: 334/269-5200 E-mail: [email protected] Internet address: www.masalink.org Alabama Osteopathic Medical Association E. Jason Hatfield, D.O. Secretary -Treasurer P.O. Box 1857 U.S. Highway 43 Winfield, AL 35594 T: 205/487-7556 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 S Birmingham, AL 35243 T: 205/967-0130 F: 205/967-1009 E-mail: [email protected] Internet address: www.albop.com

Alabama Independent Drugstore Association (AIDA) Sharon Taylor, Executive Director 400 Interstate Park Drive Suite 401 Montgomery, AL 36109 T: 334/213-2432 F: 334/213-2406 E-mail: [email protected] Internet address: www.aidarx.org Alabama Hospital Association Tom Cooper, CEO 500 North East Blvd. Montgomery, AL 36117 T: 334/272-8781 F: 334/270-9527 E-mail: [email protected] Internet address: www.alaha.org


Alaska-1

ALASKA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. DRUG PAYMENTS AND RECIPIENTS 2001 2002** Expenditure Recipients Expenditure Recipients TOTAL $64,923,574 65,278 $70,708,412 RECEIVING CASH ASSISTANCE TOTAL $52,946,651 33,640 Aged $9,954,837 4,747 Blind/Disabled $33,634,846 8,964 Child $1,778,759 9,519 Adult $7,578,209 10,410 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $5,303,090 25,775 Aged $6,244 8 Blind/Disabled $368 2 Child $4,319,775 20,919 Adult $976,703 4,846 TOTAL OTHER EXPENDITURES/RECIPTENTS* $6,673,833 5,863

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Alaska-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered: cosmetics (covered with restrictions); prescribed insulin; disposable needles used for insulin (covered under DME); syringe combinations used for insulin; 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; blood glucose test strips; urine ketone test strips; and intedialytic parenteral nutrition.

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

Therapeutic Category Coverage: Categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; 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. Prior authorization required for: analgesics, antipyretics, and NSAIDs; growth hormones. Categories not covered: anoretics; prescribed cold medications; amphetamines (except for narcolepsy and hyperactivity); prescribed smoking deterrents; cough suppressants; DESI drugs; vitamins (except prenatal); and vitamins with fluoride.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians’ offices.

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

Unit Dose: Unit dose packaging reimbursable.


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

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.


Alaska-3


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 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] Dwayne Peeples, 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]


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

DUR Contact







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


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]


Pam Muth Deputy Director Division of Medical Assistance 4501 Business Park Blvd, Suite 24 Anchorage, AK 99503 907/334-2400 E-mail: [email protected]

Mail Order Pharmacy Benefit

Yes, for Medicaid recipients living in rural areas.

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


Alaska-4

Greg Polston, M.D. Fairbanks, AK. Charlene Hampton, R.Ph. Anchorage, AK Alexander von Hafften, M.D. Anchorage, AK


Alaska State Medical Association Jim Jordan, Executive Director 4107 Laurel Street Anchorage, AK 99508 T: 907/562-0304 F: 907/561-2063 E-mail: [email protected] Alaska Osteopathic Medical Association Holly Macriss AOA Northwest Regional Manager 1900 Point West Way, Suite 188 Sacramento, CA 95815-4705 T: 800/891-0333 F: 916/564-5105 E-mail: [email protected] Internet address: www.do-online.org/aoawesternregion 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 Licensing Examiner P.O. Box 110806 Juneau, AK 99811-0806 T: 907/465-2589 F: 907/465-2974 E-mail: [email protected] Internet address: www.dced.state.ak.us/occ/ppha.htm Alaska State Hospital and Nursing Home Association Rod L. Betit President/CEO 426 Main Street Juneau, AK 99801 T: 907/586-1790 F: 907/463-3573 E-mail: [email protected] Internet address: www.ashnha.com


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) 1115 Research and Demonstration Waiver project, jointly funded by the federal government and the State of Arizona. Begun in October 1982, it serves as a model for providing medical services to the indigent in a managed care system rather than through fee-for-service arrangements. Typically, Medicaid programs have incorporated the traditional hallmarks of the U.S. health care system: namely, independent providers and fee-for-service reimbursement. In contrast, organized health plans and capitation mark the AHCCCS model.

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

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


Arizona-2

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 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.


Arizona-3

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 more than 963,000 beneficiaries, (Oct. 2003) representing 18 percent of Arizona’s population. AHCCCS has also become a model as managed care is increasingly by being implemented in other States’ Medicaid programs.

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

MEDICAL PLANS AND ADMINISTRATORS

AHCCCS Contracted Health Plans

Arizona Physicians IPA, Inc. 3141 North 3rd Avenue Phoenix, AZ 85013 602/264-1232 Care1st Health Plan of Arizona, Inc. 2355 E. Camelback Rd. Suite 300 Phoenix, AZ 85016 602/778-1800 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


Arizona-4

Phoenix Health Plan/Community Connection 1209 South 7th Avenue Phoenix, AZ 85007 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 Area Indian Health Services (IHS) Two Renaissance Square 40 N. Central Avenue Phoenix, AZ 85004-5036 602/364-5039 Tucson Area Indian Health Services (IHS) 7900 South J. Stock Road Tucson, AZ 85746 520/295-2405 Navajo Area Indian Health Services (IHS) P.O. Box 9020 Window Rock, AZ 86515-9020 928/871-5811

ALTCS Contractor List

Arizona Physicians IPA Suite A 242 West 28th Street Yuma, AZ 85364 520/783-5691 Cochise Health Systems Cochise County Health & Social Services 1415 West Melody Lane, Building A Bisbee, AZ 85603-4249 520/432-9600 DES/DDD 1789 West Jefferson, 4th Floor Phoenix, AZ 85007 602/542-0419 Evercare Select 314 N. 3rd Avenue Phoenix, AZ 85013 602/331-5100

Maricopa Long Term Care Plan Suite 125 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 Long Term Care Pima Health System Suite A-200, 5055 East Broadway Tucson, AZ 85711 520/512-5500 Pinal/Gila LTC P.O. Box 2140 971 North Pinal Parkway Florence, AZ 85232-2140 520/868-6775 Yavapai County LTC Yavapai County Department of Medical Assistance 595 White Spar Road Prescott, AZ 86303 520/771-3560 AHCCCS FFS (ALTCS) Ventilator Dependent Office of Medical Management 602/417-4370

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] Internet address: www.ahcccs.state.az.us Dell Swan Pharmacy Program Administrator AHCCCS 801 East Jefferson Street MD 4100 Phoenix, AZ 85034 612/417-4000 E-mail: [email protected]


Arizona-5


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 85282-5831 T: 480/838-3385 F: 480/838-3557 E-mail: [email protected] Internet address: www.azpharmacy.org 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 Hal Wand Executive Director 4425 W. Olive Avenue, Suite 140 Glendale, AZ 85302 T: 623/463-2727 F: 623/934-0583 E-mail: [email protected] Internet address: www.pharmacy.state.az.us Arizona Hospital and Healthcare Association John R. Rivers, FACHE President/CEO 2901 North Central Avenue Suite 900 Phoenix, AZ 85012 T: 602/445-4300 F: 602/445-4299 E-mail: [email protected] Internet address: www.azha.org


Arizona-6


Arkansas-1

ARKANSAS





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS

2001 2002** Expended Recipients Expended Recipients TOTAL $248,392,084 321,920 $273,257,660 RECEIVING CASH ASSISTANCE, TOTAL $142,811,387 111,016 Aged $18,083,097 13,278 Blind/Disabled $117,036,376 68,665 Child $4,248,875 19,495 Adult $3,443,039 9,578 MEDICALLY NEEDY, TOTAL $7,660,175 13,964 Aged $130,249 203 Blind/Disabled $2,721,983 2,036 Child $1,664,186 5,912 Adult $3,143,757 5,813 POVERTY RELATED, TOTAL $21,594,533 100,643 Aged $370,667 367 Blind/Disabled $917,628 673 Child $18,932,809 88,224 Adult $1,373,429 11,379 TOTAL OTHER EXPENDITURES/RECIPIENTS* $76,325,989 96,297

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.



Arkansas-2

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


Benefit Design

Drug Benefit Product Coverage: Products covered with restrictions: prescribed insulin; disposable needles and syringe combinations used for insulin. Products not covered: blood glucose test strips; urine ketone test strips; total parenteral nutrition, interdialytic parenteral nutrition; cosmetics; fertility drugs; experimental drugs; and vitamins (other than prenatal vitamins for pregnant women). Prior authorization required for: nitroglycerin patches; agents for impotence; Synagis; Respigam; Xenical-hyper lipidemia; Remicade; Regranex; Kineret; Enbrel; Xolair; and Humira.

Over-the-Counter Product Coverage: Products covered: digestive products (H2 antagonist). Limited coverage for: allergy, asthma and sinus products; analgesics; cough and cold preparations (under 21 years and long-term care limited needs); digestive products (non-H2 antagonist); feminine products; and topical products. Products not covered: smoking deterrent products.

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 and extended care facilities, and through physician payment when used in physicians offices.

Vaccines: Vaccines reimbursable as part of the Vaccines for Children Program.



Formulary: State covers outpatient drugs whose manufacturers have signed a rebate agreement with CMS. 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. Beneficiaries have a right to appeal prior authorization decisions. Physician must submit letter explaining medical necessity leading to the request for the medication.


Prescription Refill Limit: 5 refills within 6 months are allowed. New Rx required every 6 months.

Monthly Quantity Limit: 31-day supply.

Monthly Prescription Limit: Three prescriptions per month per recipient, except unlimited for certified LTC recipients and recipients under 21 years old. Others can receive extension of three more per month.


PRODUR system implemented in March 1997. State currently has a DUR Board with a quarterly review.


Dispensing Fee: $5.51 effective 7/1/99. Effective 3/1/02, non-MAC generics receive an additional $2.00 dispensing fee.

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

Prescription Charge Formula: Legend drugs: lower of the EAC plus a dispensing fee or CFA/state upper


Arkansas-3

limit plus a dispensing fee. Total charge may not exceed provider’s charge to the self-paying public.

Maximum Allowable Costs: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. State-specific MAC list contains 800 drugs (see www.medicaid.ar.us). Override requires physician documentation on MedWatch form as to why the generic cannot be dispensed.

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

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 275,000 Medicaid recipients are enrolled with Primary Care Physicians and approximately 70,000 children are enrolled in ArKids. Pharmaceutical benefits are provided through the State.

F. STATE CONTACTS


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


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

DUR Contact

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

DUR Board

Steve Bryant, P.D. Jason B. Hawkins, P.D. Benji Post, P.D. Debbie Hayes Ann Blaylock, A.P.N. Thomas Lewellen, D.O. Michael N. Moody, M.D. Laurence Miller, M.D. New Brand Name Products Contact

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


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


Arkansas-4

Medicaid Drug Rebate Contacts

Audits: Suzette Bridges, P.D., 501/683-4120 Dispute Resolution: Dana Boyer Rebate Analyst EDS 500 President Clinton Ave, Suite 400 Little Rock, AR 72201 T: 501/374-6608 F: 501/372-2971 E-mail: [email protected]


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


Kellie Phillips Program Administrator Medical Assistance Division of Medicaid Services Dept. of Human Services P.O. Box 1437, Slot 410 Little Rock, AR 72203 T: 501/682-8306 F: 501/682-1197 E-mail: [email protected]


None

Department of Human Services Officials

Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 201 Little Rock, AR 72203-1437 T: 501/682-8650 F: 501/682-6836 E-mail: [email protected] Internet Address: www.accessarkansas.org/dhs Roy Jeffus, Director Division of Medical Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 T: 501/682-1671 F: 501/682-1197 E-mail: [email protected]


Arkansas Hospital Association James R. Teeter President/CEO 419 Natural Resources Drive Little Rock, AR 72205 T: 501/224-7878 F: 501/224-0519 E-mail: [email protected] Internet Address: www.arkhospitals.org Arkansas Pharmacists Association Mark Riley Executive Director 417 S. Victory Street Little Rock, AR 72201-2932 T: 501/372-5250 F: 501/372-0546 E-mail: [email protected] Internet address: www.arpharmacists.org Arkansas State Board of Pharmacy Charles S. Campbell Executive Director 101 E. Capitol, Suite 218 Little Rock, AR 72201 T: 501/682-0190 F: 501/682-0195 E-mail: [email protected] Internet address: www.state.ar.us/asbp 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


California-1

CALIFORNIA





Child Adult

Prescribed Drugs





Physician Services

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

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $2,808,298,437 2,486,910 $3,591,537,830 RECEIVING ASSISTANCE, TOTAL $2,143,413,178 1,334,480 Aged $479,791,420 266,911 Blind/Disabled $1,547,024,854 579,572 Children $39,100,804 299,830 Adult $77,496,100 188,167 MEDICALLY NEEDY, TOTAL $423,154,155 279,326 Aged $198,544,758 120,346 Blind/Disabled $198,371,267 53,459 Children $11,503,750 68,297 Adults $14,734,380 37,224 POVERTY RELATED, TOTAL $54,387,618 103,247 Aged $14,257,426 11,923 Disabled $32,358,484 10,485 Children $5,572,729 51,243 Adults $2,198,979 29,596 TOTAL OTHER EXPENDITURES/RECIPIENTS* $187,343,486 769,857

*Total Other Expenditures/ Recipients include foster care children, demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.


California-2

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.


Benefit Design

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 do require prior authorization.

Physician-administered drugs: The Medi-Cal List of Contract Drugs applies to drugs dispensed from pharmacies to patients. Drugs administered directly in a physician's, dentist's, or podiatrist's office are not bound by the List of Contract Drugs.

Coverage of Injectables: Injectable medicines are reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and through physician payment when used in physician offices.

Vaccines: Vaccines are reimbursable by schedule as part of the Vaccines for Children Program. Vaccines for adults are covered through the prescription drug program or as administered in a physician's office.



Formulary: The Medi-Cal List of Contract Drugs is a preferred drug list. It contains over 600 drugs, in differing strengths and dosage forms, listed generically. Patients can get prior authorization for unlisted drugs or for listed drugs that are restricted to specific use(s), if medically justified. Manufacturers frequently petition Medi-Cal to add drugs to the List of Contract Drugs. Based on Medi-Cal’s five criteria (safety, efficacy, misuse potential, essential need, and cost), a drug may be added to the list by contractual agreement with the manufacturer to provide the State a negotiated rebate. The Medi-Cal website at: http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/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, e.g., amphetamines and methylphenidate, are restricted to attention deficit disorder in individuals between 4 and 16 years of age.

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

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

4. Some antibiotics have diagnostic and/or age restrictions.

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

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

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

8. Cancer, AIDS, and DESI Drugs: Any antineoplastic drug approved by FDA for the treatment of cancer and any drug approved by FDA for the treatment of AIDS or AIDS-related condition is covered through the Medi-Cal List of Contract Drugs; most DESI drugs rated less-than-effective by FDA are not covered.


California-3

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. An exception is allowed for refill of a reasonable quantity when prescriber is unavailable (pursuant to California law). Fee is to be pro-rated so that total fee (for partial quantity and balance of the prescription after prescriber is contacted) does not exceed the fee for the same prescription when refilled as a routine service.

Monthly Quantity Limit: This is flexible, but should be consistent with the medical needs of the patient. Limited to 100 days’ supply on most drugs. Many maintenance drugs are subject to minimum quantity or maximum frequency of billing controls.

Monthly Prescription Limit: Limited to 6 per month without prior authorization. The limit does not apply to family planning drugs, patients in nursing facilities, or to AIDS or cancer drugs.

Hospital Discharge Medications: Quantities furnished as discharge medications are limited to no more than a 10-day supply. Charges are incorporated in the hospital’s claims for inpatient services.


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 for most patients, or less $0.10 for nursing home patients.

2. Federal Upper Limit (FUL) + dispensing fee, less $0.50 for most patients, or less $0.10 for nursing home patients.

3. State Maximum Allowable Ingredient Cost (MAIC) + dispensing fee, less $0.50 for most patients, or less $0.10 for nursing home patients.

4. Pharmacy’s usual price to general public, less $0.50 for most patients, or less $0.10 for nursing home patients.

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.


California-4


Approximately 3,300,000 Medicaid recipients were enrolled in MCOs in FY 2001. Recipients receive pharmaceutical benefits through the State and managed care plans. Certain psychiatric drugs (antipsychotics, lithium, MAO inhibitors) and some anti-parkinson drugs are carved out of managed care. Most AIDS drugs are no longer carved out of managed care.

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 1240 South Loop Road Alameda, CA 94502 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 Center for Elders Independence 1955 San Pablo Ave Oakland, CA 94612 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 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 Net of California 3400 Data Drive, 1st Floor West Rancho Cordova, CA 95670 Health Plan of San Joaquin 1550 W. Fremont Street, Suite 200 Stockton, CA 95203-2643 Inland Empire Health Plan PO Box 19026 San Bernardino, CA 92423-9026 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 555 W. Fifth Street, 19th Floor Los Angeles, CA 90013-3036 Molina Healthcare Inc A Professional Corporation One Golden Shore Drive Long Beach, CA 90802 On Lok 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 92868-4220 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


California-5

San Mateo Health Commission Health Plan of San Mateo 701 Gateway Blvd., Suite 400 South San Francisco, CA 94080 Santa Barbara Regional Health Authority Santa Barbara Health Initiative 110 Castilian Drive Goleta, CA 93117-3028 Santa Clara Family Health Plan 210 E Hacienda Ave Campbell, CA 95008-6617 Santa Cruz -Monterey Managed Care Commission Central Coast Alliance for Health 375 Encinal Street, Suite A Santa Cruz, CA 95060 Scan Health Plan Senior Care Action Network 3780 Kilroy Airport Way, Suite 100 Long Beach, CA 90806-2460 Sharp Health Plan 4305 University Avenue, Suite 200 San Diego, CA 92105 Solano-Napa County Commission on Medical Care Partnership Health Plan of California 360 Campus Lane, Suite 100 Suisun City, CA 94585 Sutter Senior Care 1234 U Street Sacramento, CA 95818 UCSD Healthcare 200 West Arbor Dr. San Diego, CA 92103-8501 Universal Care 1600 E. Hill Street Signal Hill, CA 90755-3612 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 95833-97543

F. STATE CONTACTS


J. Kevin Gorospe, Pharm.D. Chief, Medi-Cal Pharmacy Policy Unit California Department of Health Services Medi-Cal Policy Division 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] Internet Address: http://www.dhs.ca.gov


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


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

DUR Contact

Vic Walker, R.Ph. B.C.P.P Senior Consulting Pharmacist Medi-Cal Policy Division 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 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


California-6

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


EDS Federal Corp. P. O. Box 13029 Sacramento, CA 95813-4029 916/636-1000


Craig Miller Chief, Medi-Cal Rebate and Vision Section Medi-Cal Policy Division 1501 Capitol Ave. P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]


EDS Federal Corp. P.O. Box 13029 Sacramento, CA 95813-4029 916/636-1000 Internet Address: www.medi-cal.ca.gov


Ronald Sanui, Pharm D. Pharmaceutical Consultant II Medi-Cal Managed Care Division 1501 Capitol Ave. P.O. Box 997413, MS 4404 Sacramento, CA 95899-7413 916-449-5138 E-mail: [email protected]


Vic Walker, R.Ph., B.C.P.P., 916/552-9500

Mail Order Drug Benefit

State currently has a mail order pharmacy capability in the Medi-Cal program. All fee-for-service beneficiaries are entitled to participate.

Health and Welfare Agency Officials

S. Kimberly Belshé 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 Stan Rosenstein Deputy Director Medical Care Services California Department of Health Services 1501 Capitol Ave., P.O. Box 997413, MS 4000 Sacramento, CA 95899-7413 T: 916/ 440-7800 F: 916/ 440-7805 E-mail: srosenst.dhs.ca.gov

Medi-Cal Contract Drug Advisory Committee

William B. Ness, M.D. 65 North 14th Street San Jose, CA 95112 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 Richard H. White, M.D. U.C. Davis Medical Center 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


California-7

Executive Officers of State Medical and Pharmaceutical Associations/Boards

California Medical Association Jack C. Lewin, M.D. CEO and Executive Vice-President 1201 J Street Sacramento, CA 95814 916/444-5532 Internet address: www.cmanet.org Osteopathic Physicians & Surgeons of California Kathleen S. Creason 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


California-8


Colorado-1

COLORADO





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $177,115,553 143,169 $189,717,036 RECEIVING CASH ASSISTANCE, TOTAL $117,978,722 76,243 Aged $38,858,494 18,832 Blind/Disabled $71,297,760 26,703 Child $2,406,437 15,586 Adult $5,416,031 15,092

MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $20,438,343 41,156 Aged $101,358 129 Blind/Disabled $15,354,288 3,802 Child $3,695,461 27,041 Adult $1,287,236 10,184 TOTAL OTHER EXPENDITURES/RECIPIENTS* $38,698,488 25,770

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Colorado-2

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.


Benefit Design

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; antihistamines; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents (given in home); contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; anti-psychotics (prior authorization required for clozoril); prescribed cough and cold medications; growth hormones; misc. GI drugs; sympathominetics (adrenergic); vitamins; acne products; leukocyte stimulants; LHRH/GnRH; injectables; plasma products; Epoetin; fluoride preparations; antisera; Oxycontin; erectile dysfunction; sympathominetics (adrenergie); 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.


Formulary: Open formulary.

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


Colorado-3

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 with explanation of medical necessity (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.


Colorado-4

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: $3.00



Over 260,000 Medicaid recipients were enrolled in managed care in FY 2001. Recipients receive pharmaceutical benefits through the Managed Care Organization.

Managed Care Organizations

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

Kaiser Permanente 10350 East Dakota Avenue Denver, CO 80905 303/344-7250

Rocky Mountain HMO 2775 Crossroads Boulevard Grand Junction, CO 81506 800/843-0719 Colorado Access

600 South Cherry Street, Suite 800 Denver, CO 80222 303/355-6707 Community Health Plan of the Rockies 400 South Colorado Boulevard, Suite 300 Denver, CO 80222 303/355-3220 United Healthcare 6251 Greenwood Plaza Boulevard, Suite 200 Englewood, CO 80111-4910 303/267/3594

F. STATE CONTACTS


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

DUR Contact

Catherine Travgott Pharmacist Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2468 F: 303/866-2578 E-mail: [email protected]

New Brand Names Products Contact

Catherine Travgott 303/866-2468


Martha Warner 303/866-3176


Colorado-5


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


ACS, Inc. 600 17th Street Suite 600 North Denver, CO 80202 T: 800/237-0757 F: 303/534-0439


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

Disease Management/Patient Education Programs

Disease/Medical State: Schizophrenia Program Name: Schizophrenia with Co-Morbid Conditions Pilot Program Program Manager: Gloria Johnson Sponsor: Eli Lilly and Company Disease/Medical State: Diabetes Program Name: Diabetes Disease Management Pilot Program Program Manager: Gloria Johnson Sponsor: Eli Lilly and Company

Disease Management/Patient Education Contact

Katie Brookler, 303/866-2416


None

Health Care Policy & Financing Department Officials

Karen K. Reinertson Executive Director Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818 T: 303/866-2993 F: 303/866-4411 E-mail: [email protected] Internet Address: www.chcpf.state.co.us Vivianne M. Chavmont, Director Medical Assistance Office Department of Healthcare Policy and Financing 1570 Grant Street Denver, CO 80203 303/866-3058

Medical Services Board

Michael Oliva, President Julie Reiskin, Vice President Mary Ellen Faules Joan M. Johnson Wendal Phillips Joe Rall Maguerite Salazar Steve Tool Mathew Dunn, M.D. Jeremy Schupbach, Coordinator

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


Colorado-6

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


Colorado Medical Society Sandra L. Maloney Executive Director 7351 Lowry Boulevard Denver, CO 80230 T: 720/859-1001 F: 303/771-8659 E-mail: [email protected] Internet address: www.cms.org Colorado Pharmacists Society

Val Kalnins, R.Ph., Executive Director 6825 E. Tennessee Avenue, Suite 440 Denver, CO 80224-1662 T: 303/756-3069 F: 303/756-3649 E-mail: [email protected] Internet address: www.copharm.org Colorado Society of Osteopathic Medicine Marie Kowalsky Executive Director 650 South Cherry Street, Suite 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: 303/894-7764 E-mail: [email protected] Internet address: www.dora.state.co.us/pharmacy Colorado Health and Hospital Association Larry H. Wall President 7335 East Orchard Road, Suite 100 Greenwood Village, CO 80111-2512 T: 720/489-1630 F: 720/489-9400 Internet address: www.cha.com


Connecticut-1

CONNECTICUT





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002* Expenditures Recipients Expenditures Recipients TOTAL $304,470,534 116,755 $357,919,257 RECEIVING CASH ASSISTANCE, TOTAL $85,509,574 29,004 Aged $14,661,696 6,146 Blind/Disabled $70,113,706 17,814 Child $176,052 2,598 Adult $558,120 2,446 MEDICALLY NEEDY, TOTAL $89,643,018 29,417 Aged $21,970,885 10,353 Blind/Disabled $67,436,637 18,548 Child $91,458 283 Adult $144,038 233 POVERTY RELATED, TOTAL $3,750,393 5,721 Aged $644,493 700 Blind/Disabled $2,152,958 1,089 Child $877,998 2,974 Adult $74,944 958 TOTAL OTHER EXPENDITURES/RECIPIENTS* $125,567,549 52,613

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable



Connecticut-2

C. ADMINISTRATION

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


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.


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.


Pro-DUR system implemented September 1996. Retro-DUR since September 1991; the State currently has a 9 member DUR Board with a quarterly review.


Dispensing Fee: $3.30, effective 10/1/03.

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. Effective 1/1/2003, the Department implemented a state MAC to include additional multi-source generic products that are not on the FUL list. The State MAC reimbursement is AWP-40%.

Patient Cost Sharing: None.



Connecticut-3


Connecticut has approximately 290,000 Medicaid recipients enrolled in managed care. Pharmaceutical benefits received through the managed care plan.


Anthem Blue Cross/Blue Shield of CT Blue Care Family Plan Paula Smyth, Director Medicaid Managed Care 370 Bassett Road North Haven, CT 06473-4201 T: 203/654-3506 F: 203/234-5310 Community Health Network of CT Sylvia Kelly, CEO 290 Pratt - 2nd Floor Meriden, CT 06450 T: 203/237-4000 F: 203/634-8411 Health Net Janice Perkins, Vice President One Far Mill Crossing, Box 904 Shelton, CT 06484-0944 T: 203/225-8630 F: 203/225-4175 First Choice of CT, Preferred One Douglas Hayward, Chief Operating Officer 23 Maiden Lane North Haven, CT 06473 T: 203/239-7444 F: 203/239-3381 F. STATE CONTACTS


Evelyn A. Dudley Pharmacy Program Manager Department of Social Services Medical Operations Unit #4 25 Sigourney Street Hartford, CT 06106 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] Internet address: www.ctmedicalprogram.com

Department of Social Services Administrative Officials

Patricia A. Wilson-Coker Commissioner Department of Social Services 25 Sigourney Street Hartford, CT 06016-5033 T: 860/424-5008 F: 860/566-2022 E-mail: [email protected] Claudette Beaulieu, Deputy Commissioner 860/424-5010 Michael Starkowski, Deputy Commissioner 860/424-5053 David Parrella, Director Medical Care Administration 860/424-5177 Rose Ciarcia, Director 25 Sigourney Street Hartford, CT 06106 860-424-5139 E-mail: [email protected] 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-4

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


Ellen Arce, R.Ph. Pharmacy Manager Electronic Data Systems 100 Stanley Street New Britain, CT 06053 860/832-5885


Mark Heuschkel Lead Planning Analyst - Pharmacy Department of Social Services Medical Operations Unit #4 25 Sigourney Street Hartford, CT 06106 T: 860/424-5347 F: 860/424-5206 E-mail: [email protected] Ellen Arce, R.Ph. (Rebates & Disputes) 860/832-5885


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


Rose Ciarcia 860/424-5139


None

Elderly Drug Coverage Program Contact

Evelyn Dudley 860/424-5654

Physician-Administered Drug Program Contact

Timothy Bowles, Medical Policy 25 Sigourney Street Hartford, CT 06106 860/424-4984

State Pharmacy Commission

William Summa, P.D., Chairman


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


Connecticut-5

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


Connecticut-6


Delaware-1

DELAWARE





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $81,623,058 85,351 $97,750,161 RECEIVING CASH ASSISTANCE, TOTAL $52,023,939 62,035 Aged $5,833,794 2,470 Blind/Disabled $27,480,662 9,724 Child $7,259,311 31,503 Adult $11,450,172 18,338 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $1,423,154 3,654 Aged $145,083 132 Blind/Disabled $533,696 282 Child $718,597 3,103 Adults $25,778 137 TOTAL OTHER EXPENDITURES/RECIPIENTS* $28,175,965 19,662

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Delaware-2

C. ADMINISTRATION

Division of Social Services, Department of Health and Social Services, through three county offices of the State agency.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; and total parenteral nutrition. Products covered with restrictions: 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 topical products. Products covered with restrictions: smoking deterrent products (prior authorization and quantity limits). Products not covered: feminine products.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: analgesics, antipyretics, and NSAIDs; anoretics; antibiotics; anti-psychotics; growth hormones; prescribed smoking deterrents; Regranex; Zyvox; Soma Accutane Cipro; Cholinesterase inhibitors; Modafanil; and Epoetin.


Vaccines: Vaccines reimbursable under the Vaccines for Children program.




Prior Authorization: State currently has a formal prior authorization procedure. Standard procedures for clients to request a fair hearing to appeal prior authorization decisions.


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.


PRODUR system implemented in August 1994. State has a DUR Board that meets bimonthly.



Ingredient Reimbursement Basis: EAC = AWP-14.0%. (AWP-16% for LTC)

Prescription Charge Formula: Payment is based on AWP-14.0% or maximum allowable cost (MAC) plus a dispensing fee, or the usual and customary cost to the general public, whichever is lower.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires completion of an FDA MedWatch form.





Delaware-3


Approximately 90,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through the State.


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


Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected] Internet address: www.dmap.state.de.us


Cynthia R. Denemark, R.Ph. 302/453-8453

DUR Contact


DUR Board

Calvin Freedman, R.Ph. Marvin H. Dorph, M.D. Richard Steele, R.Ph. Sharon Wisneski, R.N., M.S. Mark Borer, M.D. Nadia Zalusky, R.Ph. Chris Sual, R.Ph. Frank Falco, M.D.

New Brand Name Products



Dan Cohn DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224


Frank Long Contracts Manager DSS Herman Holloway Campus Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9624 F: 302/255-4425


Audits: Frank Long 302/255-9624 Disputes: Lynessa Tejeda Rebate Analyst EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/456-8453 F: 302/454-0224


Jose Tieso System Manager EDS 248 Chapman Rd, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224


Glynne Williams Health Care Cost Containment Specialist DSS Herman Holloway Campus Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9628 F: 302/255-4425


Delaware-4


None

Health and Social Services Department Officials

Vincent P. Meconi Secretary Dept. of Health & Social Services 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9040 F: 302/255-4429 E-mail: [email protected] Philip P. Soulé Deputy Director Medicaid Division Dept. of Health & Social Services 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9501 F: 302/255-4425 E-mail: [email protected]

Medical Advisory Committee Members

Susan Ebner Anne Aldridge, M.D. Caroline Vecchiolla Neil McLaughlin Richard Cherrin Kevin Sheahan Bob Welch John A. Forrest, Jr., M.D. Mark Meister Olga Ramirez Penny D. Chelucci Joseph Letnaunchyn Al Pilong George English Michael Glacken, M.D. Daniese McMullin-Powell Leonard Nitowski, M.D. Julia M. Pillsbury, D.O. Ulder Jane Tillman, M.D. Yrene E. Waldron Anne M. Allen Theodore Gregory Ellen M. Steele Kim L. Carpenter, M.D.


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 Patricia Carroll-Grant, R.Ph., CDE Executive Director P.O. Box 454 Smyrna, DE 19977-0454 T: 302/659-3088 F: 302/659-3089 E-mail: [email protected] Internet address: www.depharmacy.net 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 19903 T: 302/744-4547 F: 302/739-3071 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


District of Columbia-1

DISTRICT OF COLUMBIA


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

Disabled


Child Adult

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

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $62,292,004 35,324 $66,129,208 RECEIVING CASH ASSISTANCE TOTAL $42,750,082 22,033 Aged $3,745,744 2,262 Blind/Disabled $37,256,814 14,440 Child $358,540 2,063 Adult $1,388,984 3,268 MEDICALLY NEEDY, TOTAL $7,930,965 4,980 Aged $1,637,536 819 Blind/Disabled $5,639,520 2,399 Child $128,355 853 Adult $525,554 909 POVERTY RELATED, TOTAL $8,495,578 5,135 Aged $2,772,481 1,513 Blind/Disabled $5,511,608 1,858 Child $195,736 1,575 Adult $15,753 189 TOTAL OTHER EXPENDITURE/RECIPIENTS $3,115,379 3,176




C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; and ferrous sulfate. Products covered with restrictions: (e.g., long-term care only): total parenteral nutrition; (greater flow) Prior authorization required for: cosmetics (25 years of age); 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: anesthetics; infant formulas; cold tar preparations; ostomy products; diagnostic products; reusable needles/syringes (non-insulin); and all other non-legend items.

Over-the-Counter Product Coverage: Products covered with restrictions: oral analgesics; oral antacids; contraceptive foams and jellies; prenatal, pediatric and geriatric vitamins; and bowel preparation kits. Products not covered: allergy, asthma, and sinus products; cough and cold preparations; digestive products (H2 antagonists); feminine products; topical products; and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics; sedatives; and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; prescribed smoking deterrents; and thyroid agents. Prior authorization required for: analgesics, antipyretics, and NSAIDs; anoretics; growth hormones; misc. GI drugs; sympathominetics (adrenergic); erectile dysfunction products; multisource brands; Medicare-covered drugs; Levocamitine; Hepatitis C; and Synagis.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through physician payment when used in physicians offices’.

Vaccines: Vaccines reimbursable at cost as part of the EPSDT service.

Unit Dose: Unit dose packaging not reimbursable


Formulary: Open formulary with restrictions on use, prior authorization, and therapeutic substitution.


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. Provider/subscriber may appeal denials by writing to the District of Columbia Medicaid Program.



Ingredient Reimbursement Basis: AWP-10%.

Prescription Charge Formula: The lesser of: FUL or the AWP-10% plus the dispensing fee or usual and customary to the public.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” plus prior authorization.


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.





Approximately 80,000 Medicaid recipients were enrolled in managed care in 2002. Recipients enrolled in managed care receive pharmaceutical benefits through managed care plans.


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 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


Donna Bovell, R.Ph. Pharmacist Consultant Medical Assistance Administration Department of Health 825 North Capitol Street, NE Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected]

DUR Contact

Donna Bovell, R.Ph. 202/442-5988

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 Varnum St., NE Washington, DC 20017 202/269-7863

Prior Authorization Contacts



Technical: Ken Boni 202/965-7400 Policy: Donna Bovell, R.Ph. 202/442-5988 DUR: Donna Bovell, R.Ph. 202/442-5988





Prescription Price Updating Contact

Glenn Sharp Clinical Account Manager First Health Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7447 F: 804/273-6961 E-mail: [email protected]


Anita Martin Manager-Plan Administration First Health Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7425 F: 804/273-6961 E-mail: [email protected]




None


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] Robert Maruca Senior Deputy Director Medical Assistance Administration Department of Health 825 North Capitol Street, NE Fifth Floor Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected] Internet address: www.dchealth.dc.gov

Executive Officers of District Medical and Pharmaceutical Societies

Medical Society of the District of Columbia K. Edward Shanbacker 2175 K Street, NW, Suite 200 Washington, DC 20037 T: 202/466-1800 F: 202/452-1542 E-mail: [email protected] Internet address: www.msdc.org Washington D.C. Pharmacy Association Herbert Kwash, R.Ph., President 908 Caddington Avenue Silver Spring, MD 20901-1109 T: 301/539-3292 F: 301/539-7215 E-mail: [email protected] Osteopathic Association of the District of Columbia K. Joseph Heaton, D.O., President 2517 North Glebe Road Arlington, VA 22207 T: 703/522-8404 F: 703/522-2692 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/prof_license 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


Florida-1

FLORIDA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $1,487,935,645 1,159,155 $1,714,883,612 1,179,944 RECEIVING CASH ASSISTANCE TOTAL $893,222,135 552,401 $1,026,862,696 576,092 Aged $152,426,910 78,408 $170,850,446 79,748 Blind/Disabled $661,129,209 231,074 $750,274,442 235,685 Child $34,626,972 154,340 $46,013,540 170,004 Adult $45,039,044 88,579 $59,724,268 90,655 MEDICALLY NEEDY, TOTAL $62,753,603 24,089 $118,805,473 33,216 Aged $3,522 5 $31,545 21 Blind/Disabled $50,596,537 8,873 $120,427,359 16,970 Child $2,620,115 3,179 $2,360,440 2,997 Adult $9,533,429 12,032 $15,986,129 13,228 POVERTY RELATED, TOTAL $312,171,444 350,262 $336,992,042 397,152 Aged $116,037,164 63,790 $100,463,428 56,777 Blind/Disabled $143,969,419 43,100 $145,453,276 41,099 Child $48,125,864 217,570 $60,847,477 230,119 Adult $4,038,997 25,802 $10,227,861 69,157 TOTAL OTHER EXPENDITURE/RECIPIENTS $219,788,463 232,403 $232,223,401 173,484

*Total other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by the Florida Agency for Health Care Administration.

Source: CMS, MSIS Report, FY 2001 and Florida Medicaid Statistical Information System, FY 2002.


Florida-2

C. ADMINISTRATION

Agency for Health Care Administration. Claims processing and payment by contract with fiscal agent.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; total parenteral nutrition; and urine ketone test strips (children under age 21only). Prior authorization required for: Cytogam; Proleukin; Serostim; Albumin; Neutrexin; Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; Regranex (long term care); Botox; and nutritional supplements and non-preferred items. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products covered with restrictions: allergy, asthma, and sinus products (select products); analgesics (Tylenol); cough and cold preparations (select products); digestive products (H2 anatgonists-Prilosec OTC only); topical products (select products); and feminine products. Products not covered: digestive products (non-H2 antagonists) and smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: 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; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid agents. Partial coverage for: anoretics; prescribed cold medications. Prior authorization required for: anabolic steroids; drugs not included on the Medicaid preferred drug list; and brand name prescriptions beyond the four brand cap unless exempted. Therapeutic categories not covered: anoretics.

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.




Formulary: Preferred Drug List (PDL) with mandatory limits and exclusions. All covered drugs are available through the preferred drug process. General exclusions include excluding products based on contracting issues, restrictions on use, prior authorization 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. Direct appeal to AHCA and/or formal request for administrative hearing required to appeal prior authorization decisions.


Prescription Refill Limit:

1. Limited to four brand name RX’s per month with exceptions for specific therapeutic groups. 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.


Florida-3

4. Refills must be authorized by the prescriber andcan be made for up to one year, except that controlled substances can be refilled only in accordance with Federal and State regulations. 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 as well as State-specific limits on generic drugs. MAC override by physicians requires completed MedWatch form and prior authorization.

Incentive Fee: No incentive fee.

Patient Cost Sharing: No copayment

Cognitive Services: States pay for DUR and disease management counseling for HIV, mental health, diabetes, and hypertension services.


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 2002.


Amerigroup Florida, Inc. (FKA Physicians Health Care Plans, Inc.) 4200 W. Cypress Street, Suite 900 Tampa, Fl 33607-4173 800/600-4441 Buena Vista Medicaid Vista Health Plan, Inc. (FKA Beacon and Discovery) 300 South Park Road Hollywood, FL 33021 866/441-5501 Healthease of Florida, Inc. 6800 N. Dale Mabry Hwy., Suite 168 Tampa, FL 33614-3988 800/278-0656 Humana Family c/o Humana Medical Plan, Inc. 3501 SW 160th Street Miramar, FL 33027 800/533-5001 Jackson Memorial Health Plan 1801 NW 9th Ave., Suite 700 Miami, FL 33136 800/721-2993 Neighborhood Health Partnership, Inc. 7600 Corporate Center Dr., 2nd Floor Miami, Fl 33126-1216 800/354-0222 Personal Health Plan 324 Datura Street, Suite 401 West Palm Beach, FL 33401 561/659-1270 Preferred Medical Plan, Inc. 4950 SW 8th Street Coral Gables, FL 33134 305/447-8373 StayWell Health Plan of Florida, Inc. 6800 N. Dale Mabry Hwy., Suite 168 Tampa, FL 33614 813/935-5227


Florida-4

United Healthcare of Florida, Inc. 13621 N.W. 12th Street Sunrise, FL 33323 800/910-3224 Vista South Florida (FKA Foundation Health Plan) 300 South Park Road Hollywood, FL 33021 800/441-5501

F. STATE CONTACTS


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] Internet address: www.fdhc.state.fl.us

Agency for Health Care Administration Officials

Vacant Secretary Agency for Health Care Administration 2727 Mahan Drive, MS 1 Tallahassee, FL 32308 T: 850/922-3809 F: 850/488-0043 E-mail: [email protected] 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]


Bruce McCall, Pharm.D. Pharmacy Program Manager Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected]

DUR Contact

Linda G. Barnes Senior Pharmacist Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/487-4441 F: 850/922-0685 E-mail: [email protected]

Medicaid DUR Board

Arijit Aichbhaumik Plant City, FL Lois Adams, R.Ph. Orlando, FL Bryan Bognar, M.D. Lutz, FL Leanne Lai, Ph.D. Ft. Lauderdale, FL David Levine, DPM, D.O. Ft. Lauderdale, FL Earlene Lipowski, Ph.D., R.Ph. Gainesville, FL Larry Mattingly, D.O. Orange Park, FL Jeane McCarthy, M.D., Ph.D. St. Petersburg, FL Richard Roberts, Pharm.D. Jacksonville, FL Robert Taymans, R.Ph. Safety Harbor, FL

Pharmaceutical and Therapeutics Committee

Robert Blackburn, D.O. (Chair) Spring Hill, FL James Brookins, M.D. Tampa, FL Leanne Lai, Ph.D. Ft. Lauderdale, FL Jeane McCarthy, M.D., Ph.D. St. Petersburg, FL


Florida-5

Lorianne McElheney, R.Ph. Palmetto, FL Douglas Nee, Pharm.D. Fort Meyers, FL Dorinda Segovia, Pharm.D. Hialeah, FL Jerry Jean Stambaugh, Pharm.D. Lantana, FL Craig A. Trigueiro, M.D. Bradenton, FL


Jerry F. Wells 850/487-4441


First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578


Jason Ottinger Rebate Coordinator Agency for Health Care Administration 2727 Mahan Drive, MS 38 Tallahassee, FL 32308 T: 850/922-7794 F: 850/922-0685 E-mail: [email protected]


Kevin Whittington Clinical Program Coordinator ACS 9040 Roswell Road Roswell, GA 850/201-1418


Christina Lopez Manager, Health Systems Development Agency for Health Care Administration 2727 Mahan Drive, MS 8 Tallahassee, FL 32308 850/487-2355 E-mail: [email protected]


State has a mail order pharmacy benefit under its diabetes demonstration waiver.


Melanie Brown-Woofter Program Administrator Agency for Health Care Administration 2727 Mahan Drive, MS 50 Tallahassee,FL 32308 T: 850/487-2355 F: 850/410-1676 E-mail: [email protected]

Disease Management /Patient Education

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]


Florida Medical Association, Inc. Sandra B. Mortham CEO 113 East College Avenue Tallahassee, FL 32301 T: 850/224-6496 F: 850/222-8030 E-mail: [email protected] Internet address: www.fmaonline.org Florida Pharmacy Association Michael Jackson, R.Ph. Executive Director 610 North Adams Street Tallahassee, FL 32301-1114 T: 850/222-2400 F: 850/561-6758 E-mail: [email protected] Internet address: www.pharmview.com Florida Osteopathic Medical Association


Florida-6

Stephen R. Winn Executive Director The Hull Building 2007 Apalachee Parkway Tallahassee, FL 32301 T: 850/878-7364 F: 850/942-7538 E-mail: [email protected] Internet address: www.foma.org State Board of Pharmacy John D. Taylor Executive Director 4052 Bald Cypress Way, Bin C04 Tallahassee, FL 32399-3254 T: 850/487-1257 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


Georgia-1

GEORGIA


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

DisabledChild Adult Aged Blind/

Disabled Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $655,515,772 856,797 $873,703,133 RECEIVING CASH ASSISTANCE, TOTAL $422,797,389 368,161 Aged $49,961,732 31,775 Blind/Disabled $323,103,058 156,568 Child $22,633,229 112,507 Adults $27,099,370 67,311 MEDICALLY NEEDY, TOTAL $15,484,179 8,446 Aged $5,802,403 3,606 Blind/Disabled $9,681,639 4,837 Child $137 3 Adults $0 - POVERTY RELATED, TOTAL $63,048,028 309,147 Aged $3,524,685 2,335 Blind/Disabled $3,102,251 2,047 Child $44,949,926 230,198 Adults $11,471,166 74,567 TOTAL OTHER EXPENDITURES/RECIPIENTS* $154,186,176 171,043




Georgia-2

C. ADMINISTRATION

Department of Community Health, Division of Medicaid


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 (total parenteral nutrition (21 and younger) and interdialytic parenteral nutrition (21 and younger). Products requiring prior authorization: Marinol; Betaseron, Avonex, Rebif, Leukine, Crinone 8%, Forteo, growth hormone, immune globulin, Fuzeon, Penlac, Epoetin; interferons; lactulose; Neupogen; top.vit.A derivatives; Toradol; Regranex; Viagra; Cialis, Levitra, Oral Diflucan 50mg, 100mg & 200mg , Panretin Gel,, Vfend, Zetia, topical testosterone, Insulin Pen Delivery Systems and Cartridges for adults, PPIs; Oral Lamisil; ESRD drugs; Oral Sporanox; Botox; Oxycontin; brand-names and multi-source. Products not covered: cosmetics; fertility drugs; experimental drugs; prescription vitamins and minerals (except for prenatal and fluorides not in combination with other vitamins); barbituates (except Seconal & Mebaral ); DESI drugs; and Miralax;( covered for 21 and younger) 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; Lice-B- Gone 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: 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.

Drug Utilization Review On-line PRODUR system implemented in October 2000. State has a 20 member DUR Board (4 meetings per year).


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 as well as 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.


Georgia-3

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


Jerry Dubberly, RPh 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: www.dch.state.ga.us

Department of Community Health

Tim Burgess, Commissioner Department of Community Health 2 Peachtree Street, NW, Suite 4043 Atlanta, GA 30303-3159 T: 404/656-4507 F: 404/651-6880 E-mail: [email protected] 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]


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]

DUR Contact

Pat Zeigler-Jeter, M.P.A., R.Ph. 404-657-9181

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 L. Dianne Bradford, Ph.D. Morehouse School of Medicine Departments of Psychiatry and Medicine 720 Westview Drive, SW Atlanta, GA 30310-1495 Daniel Gallina, M.D. Emory University School of Medicine Grady Health System Diabetes Unit 69 Butler Street Atlanta, GA 30303-3033 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


Georgia-4

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, GA 30602 Cynthia O’Steen-Piela, R.Ph. District Manager Wal-Mart Pharmacy 1350 Arborwood Ridge Bishop, GA 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


Etta L. Hawkins, R. Ph. 404/656-4044


Andrew Shim, Pharm.D. Clinical Program Manager Express Scripts, Inc. 6625 W. 78th Street, BL-0420 Bloomington, MN 55439 T: 952/837-5326 F: 952/837-7184 E-mail: [email protected]


Pat Zeigler-Jeter, M.P.A., R.Ph. 404-657-9181


Scott Percival Account Manager Express Scripts, Inc. 6625 W. 78th St., BL-0420 Bloomington, MN 55439 T: 952/837-7744 F: 952/837-7741 E-mail: [email protected]


Kathy Driggers Director, Managed Care Department of Community Health 2 Peachtree Street, NW Atlanta, GA 30303 T: 404/657-7793 F: 404/656-8366 E-mail: [email protected]


Charmaine Heard, M.D. Medical Director Department of Community Health 2 Peachtree Street, NW, 37th Floor Atlanta, GA 30303 T: 404/463-7638 F: 404/656-8366 E-mail: [email protected]

Mail Order Pharmacy Benefits

None

Medical Assistance Advisory Committee

Representatives from each of the following groups: Medical Association of Georgia Georgia Pharmaceutical Association Atlanta Medical Association Georgia Health Care Association Georgia Hospital Association Georgia Dental Association Georgia Osteopathic Medical Association National Pharmaceutical Association


Georgia-5

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


Medical Association of Georgia David Cook, Executive Director 1330 W. Peachtree Street, NW, Suite 500 Atlant, GA 30309 T: 404/876-7535 F: 404/881-5021 E-mail: [email protected] Internet address: www.mag.org Georgia Pharmacy Association Oren “Buddy” Harden, Jr. Chief Executive Officer 50 Lenox Pointe, NE Atlanta, GA 30324-3170 T: 404/231-5074 F: 404/237-8435 E-mail: [email protected] Internet address: www.gpha.org 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: [email protected] Internet address: www.goma.org State Board of Pharmacy Sandy Bond Executive Director 237 Coliseum Drive Macon, GA 31217-3858 T: 478/207-1686 F: 404/656-0513 E-mail: [email protected] Internet address: www.sos.state.ga.us/plb/pharmacy/ Georgia State Medical Association 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-6

Georgia Hospital Association Joseph A. Parker President 1675 Terrell Mill Road Marietta, GA 30067 T: 770/249-4522 F: 770/955-5801 E-mail: [email protected] Internet address: www.gha.org


Hawaii-1

HAWAII





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001* 2002** Expenditures Recipients Expenditures Recipients TOTAL $74,869,859 $88,256,904 RECEIVING CASH ASSISTANCE TOTAL Aged Blind/Disabled Child Adult MEDICALLY NEEDY, TOTAL Aged Blind/Disabled Child Adult POVERTY RELATED, TOTAL Aged Blind/Disabled Child Adult TOTAL OTHER EXPENDITURES/RECIPIENTS*

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2001 and 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, CMS-64 Report, FY 2001 and FY 2002.


Hawaii-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered as DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products requiring prior authorization: total parenteral nutrition (for home infusion); interdialytic parenteral nutrition (for home infusion); Clorazil; Procardia XL; Norvasc; brand products on FUL price list; Betaseron; and Oxycontin. Products not covered: cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered: allergy, asthma, and sinus products; analgesics; and digestive products (non-H2 antagonists). Products covered with restrictions; cough and cold preparations (select products, others require prior authorization); digestive products (H2 antagonists-cimatidine and ranitidine, others require prior authorization); topical products (for non-cosmetic purposes only); and smoking deterrent products (Xyban only, others require prior authorization).

Therapeutic Category Coverage: Products covered: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antilipemic agents; anxiolytics; sedatives; and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; estrogens; hypotensive agents; misc. GI drugs; sympathominetics (adrenergic); and thyroid agents Prior authorization required for: anabolic steroids; anorectics; non-sedating antihistamine drugs; atypical anti-psychotics; prescribed cold medications; proton pump inhibitors; growth hormones; and prescribed smoking deterrents.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care 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 EPSDT service, CHIP, and the Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable

Formulary/Prior Authorization Formulary: Open formulary managed through prior authorization. Preferred drug list to be implemented in 2004.

Prior Authorization: State currently has a formal prior authorization procedure. A fair hearing may be requested for appeal of prior authorization decisions.


Monthly Quantity Limit: Physicians are encouraged to prescribe a 30-day supply or 100 units. State has implemented maximum doses for certain drugs, including Epogen, Liptor, Zofran, and Zomig.


PRODUR system implemented in September 1997. State currently has a DUR board with a quarterly review.


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 prior authorization.


Patient Cost Sharing: No copayment.



Hawaii-3


Approximately 135,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive most of their pharmaceutical benefits through managed care plans. State has specific guidelines for the pharmacy benefit for Medicaid recipients enrolled in managed care plans. Drugs prescribed by dentists are “carved out” of managed care and provided through the State.


AlohaCare, Inc. Mr. John McComas 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI 96814 808/973-1650 Hawaii Medical Service Association (HMSA) QUEST Administration 818 Keeaumoku Street Honolulu, HI 96808 808/948-5250 Kaiser Foundation Health Plan, Inc. Ms. Virginia Vierra 1441 Kapiolani Blvd, Suite 1600 Honolulu, HI 96814 808/944-0261 Behavioral Health Services Andreas Carvalho Community Care Services (CCS) 810 N. Vineyard Blvd. Honolulu, HI 96817 808/948-5250

F. STATE CONTACTS


Lynn S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Boulevard, Suite 506B Kapolei, HI 96707 T: 808/692-8116 F: 808/692-8131 Internet address: www.med-quest.us


Lynn S. Donovan, R.Ph. 808/692-8116

DUR Contact

Kathleen Kang-Kaulupali Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Blvd., Room 506-B Kapolei, HI 96707 T: 808/692-8065 F: 808/692-8131

Medicaid DUR Board

Myron Shirasu, M.D. (Internal Medicine) 321 North Kuakini Street, Suite 200 Honolulu, HI 96817 808/523-8611

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


Hawaii-4




First Data Bank 111 Bayhill Drive San Bruno, CA 94066 800/633-3453


Policy: Lynn S. Donovan, R.Ph. 808/692-8116 Audits: Martha Kessinich Drug Rebate Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 800/358-2381


Heather Bodiford Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Attn: Hawaii Medicaid T: 800/358-2381 F: 770/730-5198 E-mail: [email protected]

Disease Management/Patient Education Contact



None


Lillian Koller Director Department of Human Services 1390 Miller Street, Room 209 Honolulu, HI 96813 T: 808/586-4997 F: 808/586-4890 E-mail: [email protected]

Aileen Hiramatsu Administrator, Med-Quest Division Department of Human Services P.O. Box 399 Kapolei, HI 96809-0339 T: 808/692-8050 F: 808/586-4890 E-mail: [email protected]


Hawaii Medical Association Paula Arcena Executive Director 1360 S. Beretania Street, Suite 200 Honolulu, HI 96814-1520 T: 808/536-7702 F: 808/528-2376 E-mail: [email protected] Internet address: www.hmaonline.net Hawaii Pharmacist Association 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


Idaho-1

IDAHO





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $105,473,425 112,357 $119,177,013 RECEIVING CASH ASSISTANCE, TOTAL $64,871,126 22,489 Aged $4,947,969 2,016 Blind/Disabled $59,411,640 19,271 Child $280,234 963 Adult $231,283 239 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $10,152,018 55,312 Aged $139,939 93 Blind/Disabled $160,823 132 Child $8,806,102 48,702 Adult $1,045,154 6,385 TOTAL OTHER EXPENDITURES/RECIPIENTS* $30,450,281 34,556

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report FY 2002.


Idaho-2

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.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations for insulin and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; and interdialytic parenteral nutrition. Note: blood glucose test strips and urine ketone test strips 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; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents;sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anabolic steroids; analgesics; antipyretics, and NSAIDs; antihistamines; prescribed cold medications; growth hormones misc. GI drugs; amphetamines; Provigil; Aldara; Synagis; Regranex; Retinoids; Androgel; Prolastin; Klonopin Wafer; Zetia; Xanax XR; 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, the Vaccines for Children Program, and the State Vaccine Program.

Unit Dose: Unit dose packaging reimbursable when used in unit dose systems.

Formulary Authorization

Formulary: Open formulary. Pharmacy program is managed through an enhanced prior authorization program, therapeutic substitution, preferred products, physician profiling, and generic substitution for multi-source products.

Prior Authorization: State currently has a formal prior authorization procedure and a prior authorization committee. Informal reconsideration of denied prior authorization requests followed by a formal appeal process Written “notice of appeal” required for fair hearing.


Monthly Quantity Limit: Prescription drugs are limited to a 34-day supply. Limits on the number of refills per script and early refills. The following drugs are limited to a 100-day supply: 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.


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 as well as State-specific limits on generic drugs. Override requires failure of two generic formulations and submission of a MedWatch form. Incentive Fee: None. Patient Cost Sharing: No copayment.


Idaho-3



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.

F. STATE CONTACTS


Shawna L. Kittridge, R.Ph., M.H.S. Pharmacy Services Supervisor Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1956 F: 208/364-1864 E-mail: [email protected] Internet address: www.idahohealth.org


Shawna L. 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 3232 Elder Boise, ID 83705 T: 208/364-1821 F: 208/364-1864 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.


Shawna Kittridge, R.Ph., M.H.S. 208/364-1956


Katie Ayad Technical Records II Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1970 F: 208/364-1864 E-mail: [email protected]


Mary Wheatly Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1832 F: 208/364-1864 E-mail: [email protected]


EDS P.O. Box 23 Boise, ID 83707 T: 208/395-2000 F: 208/395-2030


Shawna Kittridge, R.Ph., M.H.S. 208/364-1956


State currently has a mail order pharmacy program. Pharmacy must be a registered Idaho Medicaid provider.

Health and Welfare Department Officials

Karl Kurtz, Director Dept. of Health & Welfare 450 West State Street PO Box 83720 Boise, ID 83720-0036 T: 208/334-5500 F: 208/334-6558 E-mail: [email protected]


Idaho-4

Joe Brunson, Administrator Department of Health and Welfare Division of Medicaid Americana Building P.O. Box 83720 Boise, ID 83720-0036 T: 208/364-5747 F: 208/334-1811 E-mail: [email protected]


JoAn Condie Idaho State Pharmacy Association Greg Dickerson Mental Health Providers Association 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


Idaho Medical Association Robert Seehusen, CEO P.O. Box 2668 305 West Jefferson Boise, ID 83701 T: 208/344-7888 F: 208/344-7903 E-mail: [email protected] Internet address: www.idmed.org 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 State Board of Pharmacy Richard K. Markuson Executive Director P.O. Box 83720 Boise, ID 83720-0067 T: 208/334-2356 F: 208/334-3536 E-mail: [email protected] Internet address: www.state.id.us.bop Idaho Hospital Association Steven A. Millard President 615 North Seventh Street P.O. Box 1278 Boise, ID 83701 T: 208/338-5100 F: 208/338-7800 E-mail: [email protected] Internet address: www.teamiha.org


Illinois-1

ILLINOIS1





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002**

Expenditures Recipients Expenditures Recipients TOTAL $934,241,252 1,068,535 $1,293,435,797 RECEIVING CASH ASSISTANCE TOTAL $330,543,572 241,552 Aged $39,704,574 19,211 Blind/Disabled $270,163,357 120,773 Child $9,670,272 71,473 Adult $11,005,369 30,095 MEDICALLY NEEDY, TOTAL $458,879,265 294,472 Aged $128,710,263 61,247 Blind/Disabled $271,010,968 93,079 Child $620,940 784 Adult $58,537,094 139,362 POVERTY RELATED, TOTAL $84,314,675 456,821 Aged $3,621,119 2,432 Blind/Disabled $9,302,549 3,668 Child $64,771,300 404,568 Adult $6,619,707 46,153 OTHER EXPENDITURES/RECIPIENTS* $60,503,740 75,690

1 The State of Illinois did not respond to the 2001, 2002, or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Illinois Medicaid program to assess the accuracy and currency of the information included.

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.


Illinois-2

C. ADMINISTRATION Illinois Department of Public Aid, Division of Medical Assistance.


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.


Prescription Refill Limit: Maximum of eleven refills.

Monthly Quantity Limit: As medically appropriate. Also edit for maximum daily quantities.


PRODUR system implemented in January 1993. State currently has a DUR board which meets as needed.


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 2003. Recipients receive pharmaceutical benefits through managed care plans.


Illinois-3


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 2600 Chicago, IL 60606-4402 Harmony Health Plan 23 Public Square, Suite 340 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


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/


Pharmacy Unit Staff 217/782-5565

DUR Contact

Marvin L. Hazelwood 217/524-5565


Marvin L. Hazelwood

217/524-5565


First DataBank 111 Bayhill Dr. San Bruno, CA 94066 650/588-5454


Brandley Wallner, Manager Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62704 217/785-6114 E-mail: [email protected]


Bureau of Managed Care Illinois Department of Public Aid 201 S. Grand Avenue East Springfield, IL 62763 T: 217/524-7478 F: 217/524-7535 E-mail: [email protected]


None

Elderly Expanded Drug Coverage Program

Susan Coombe, Supervisor, Circuit Breaker Program Illinois Department of Revenue 101 W. Jefferson, Level 3 - 250 Springfield, IL 62794 217/785-2097


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]


Illinois-4

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: 217/782-1200 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 Street 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


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-5

Illinois Pharmacists Association Terri McEntaffer, R.Ph., CAE Executive Director 204 West Cook Street Springfield, IL 62704-2526 T: 217/522-7300 F: 217/522-7349 E-mail: [email protected] Internet address: www.ipha.org Illinois Osteopathic Medical Society 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 E-mail: [email protected] Internet address: www.ihatoday.org


Illinois-6


Indiana-1

INDIANA



Aged Blind/Disabled


Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients

TOTAL $562,120,344 464,879 $636,346,098 490,260 RECEIVING CASH ASSISTANCE, TOTAL $277,174,243 188,399 $315,484,522 200,489 Aged $47,951,486 16,531 $52,184,587 16,691 Blind/Disabled $190,763,506 56,296 $217,167,920 59,727 Child $15,067,039 69,054 $17,736,334 70,416 Adult $23,392,212 46,518 $28,395,681 53,655 MEDICALLY NEEDY, TOTAL $0 - $0 - Aged $0 - $0 - Blind/Disabled $0 - $0 - Child $0 - $0 - Adult $0 - $0 - POVERTY RELATED, TOTAL $48,080,747 146,488 $55,897,050 155,896 Aged $304,966 378 $400,906 482 Blind/Disabled $535,916 566 $1,018,867 777 Child $46,038,486 136,278 $53,085,594 145,439 Adult $1,201,379 9,266 $1,391,683 9,198 TOTAL OTHER EXPENDITURES/RECIPENTS* $236,865,354 129,992 $264,964,526 133,875

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by the Indiana Medicaid Program’s Office of Medicaid Policy and Planning. Source: CMS, MSIS Report, FY 2001 and Indiana Medicaid Statistical Information System, FY 2002.


Indiana-2

C. ADMINISTRATION

Office of Medicaid Policy and Planning *NOTE WELL—All requests for information by,

or on behalf of, drug manufacturers must be made ONLY to: [email protected]

Phone requests will not be accepted.


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: Covered.

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: None.


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.


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 AmeriChoice 333 N. Alabama Suite 350 Indianapolis, IN 46204


Indiana-3

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: 317/232-4307 F: 317/232-7382 E-mail: [email protected] *NOTE WELL—All requests for information by,

or on behalf of, drug manufacturers must be made ONLY to: [email protected]

Phone requests will not be accepted.

DUR Contact

Karen Clifton DUR Board Secretary Office of Medicaid Policy & Planning Room W382, Indiana Sate Government Center South, 402 West Washington Street Indianapolis, IN 46204 T: 317/232-4307 F: 317/232-7382 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


Martha Kessenich Rebate Accounting Manager 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 770/730-3292 F: 866/759-4100 E-mail: [email protected]


Ulka Pandya 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866-322-5960 x4032 F: 866/759-4100 E-mail: [email protected]


John Barth Managed Care Director Office of Medicaid Policy and Planning 402 W. Washington Street Room W382, MS07 Indianapolis, IN 46204 T: 317/233-0237 F: 317/232-7382 E-mail: [email protected]


None

Administration Officials

Melanie Bella Assistant Secretary Medicaid Policy & Planning Indiana Family & Social Services Administration 402 W. Washington Street, Room W382 Indianapolis, IN 46204 T: 317/234-2407 F: 317/232-7382 John Barth Managed Care Director 317/233-4697 Pat Nolting, Director


Indiana-4

Medicaid Program Operations – Acute Care 317/232-4318

Medicaid Advisory Committee

Indiana Council of Community Mental Health Centers James F. Jones Indiana Hospital Association L. Richard Gohman Indiana Dental Association Ed Popcheff Indiana State Osteopathic Association Edward A. White, D.O. Indiana State Nurses Association Ernest C. Klein Indiana State Podiatry Association Kirk S. Holston, D.P.M. Indiana Optometric Association Marjorie Knotts, O.D. Indiana Pharmaceutical Association Monica Foye Indiana Psychological Association Paul Schneider, Ph.D. Indiana State Chiropractic Association Michael Gallagher Indiana Association for Home Care Todd Stallings Indiana Academy of Ophthalmology Kim Williams Indiana Speech and Hearing Association Susan Holbert Business and Industrial Interests Lula E. Baxter Labor Interests Donald Mulligan, Sr.


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 E-mail: [email protected] Internet address: www.inha.org


Iowa-1

IOWA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $230,430,967 221,691 $285,467,642 RECEIVING CASH ASSISTANCE TOTAL $114,379,584 106,099 Aged $14,750,173 6,734 Blind/Disabled $81,135,611 32,484 Child $7,586,771 39,126 Adult $10,907,029 27,755 MEDICALLY NEEDY, TOTAL $13,202,042 6,191 Aged $3,922,542 2,287 Blind/Disabled $7,976,548 2,034 Child $154,791 278 Adult $1,148,161 1,592 POVERTY RELATED, TOTAL $8,996,176 46,728 Aged $513,385 843 Blind/Disabled $740,862 756 Child $6,629,188 37,819 Adult $1,112,741 7,310 TOTAL OTHER EXPENDITURES/RECIPIENTS* $93,853,165 62,673

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and Iowa Medicaid Statistical Information System, FY 2002.


Iowa-2

C. ADMINISTRATION

State Department of Human Services, Bureau of Long Term Care.


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.



Iowa-3

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.


PRODUR system implemented in July 1997. State currently has a DUR Board with a monthly review.



Ingredient Reimbursement Basis: EAC = AWP-12%.

Prescription Charge Formula: Payment will be based on the pharmacist's usual, customary and reasonable charge, but payment may not exceed EAC plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires “Brand Medically Necessary,” completion of a MedWatch form, and prior authorization.


Patient Cost Sharing: Copayment of $0.50-$3.00 for brand products, depending on the cost of the drug.



Approximately 285,000 Medicaid beneficiaries were enrolled in managed care organizations in 2002. Iowa Medicaid recipients enrolled in managed care receive pharmaceutical benefits through the State.


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


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]


Sandy Pranger, R.Ph. ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1329 F: 515/327-0945


Iowa-4

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

Richard Rinehart, M.D. Connie Connolly, R.Ph. Ronald Miller, M.D., M.B.A. Bruce Alexander, R.Ph., Pharm. D. Sandi Birchem, D.O. George Kappos, M.D. Dan Murphy, R.Ph. Julie Kuhle, R.Ph., Project Coordinator Cheryl Clark, R.Ph. Janalyn Phillips, R.Ph. Susan Parker, Pharm.D.


Susan L. Parker, Pharm.D. 515/281-3002


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


Technical: Rocco Russo, 515/327-0950 ext. 1114 Audits: Rocco Russo, 515/327-0950 ext. 1114 DUR: Julie Kuhle 515/270-0713 PA: Sandy Pranger, 515/327-0950 ext. 1329


Mindy Ruby Claims Manager ACS P.O. Box 14422 Des Moines, IA 50306-3422 T: 515/327-0950 ext. 1108 F: 515/327-0945


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]


State currently has a mail order pharmacy program. Participating pharmacies must be enrolled as an Iowa Medicaid provider.

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


Iowa-5

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

Kevin W. Concannon, Director Dept. of Human Services Hoover State Office Bldg., 5th Floor Des Moines, IA 50319-0014 T: 515/281-5452 F: 515/281-7791 E-mail: [email protected] Eugene Gessow Medicaid Director Department of Human Services Hoover State Office Building, 5th Floor Des Moines, IA 50319-6242 T: 515/281-6249 F: 515/281-8512 E-mail: [email protected]

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


Iowa-6

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 Street 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


Iowa-7

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 Street 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


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 address: 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 Street 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 Street, Suite E Des Moines, IA 50309-4688 T: 515/281-5944 F: 515/281-4609 E-mail: [email protected] Internet address: www.state.ia.us/ibpe


Iowa-8

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] Internet address: www.ihaonline.org


Kansas-1

KANSAS





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $189,290,260 158,515 $213,145,382 156,832 RECEIVING CASH ASSISTANCE TOTAL $85,089,631 58,792 $91,842,893 34,917 Aged $8,618,107 4,187 $14,301,443 6,006 Blind/Disabled $70,087,687 29,828 $68,219,151 22,560 Child $2,774,647 14,115 $9,322,299 6,405 Adult $3,609,190 10,662 $0 - MEDICALLY NEEDY, TOTAL $11,665,933 8,314 $94,149,457 30,715 Aged $2,421,349 1,362 $56,071,896 19,501 Blind/Disabled $8,335,032 2,898 $37,779,501 9,870 Child $331,900 1,946 $146,766 829 Adult $577,652 2,108 $151,294 515 POVERTY RELATED, TOTAL $10,333,897 49,242 $9,970,767 77,451 Aged $484,846 470 $248 1 Blind/Disabled $1,460,600 867 $0 - Child $7,711,591 41,266 $9,415,709 72,996 Adult $676,860 6,639 $554,810 4,454 TOTAL OTHER EXPENDITURES/RECIPIENTS* $82,200,799 42,167 $17,182,265 13,695 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2002 data provided by the Health Care Policy Division, Kansas Department of Social and Rehabilitation Services. Source: CMS, MSIS Report, FY 2001 and Kansas Medicaid Statistical Information System, FY 2002. Note: Kansas estimates 2003 drug expenditures to be approximately $237 million and the number of Medicaid drug recipients to be 200,000.


Kansas-2

C. ADMINISTRATION

State Department of Social and Rehabilitation Services.


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 (patches covered for limited time period); and topical products Products not covered: allergy, asthma and sinus products; digestive products (non-H2 antagonists); feminine 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: State currently maintains a formulary along with a Preferred Drug List (PDL). (See www.srskansas.org/hcp/medicalpolicy/pharma for a listing of PDL categories.) 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


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, Cialis, Levitra, Ketorolac, Toradol and Relenza have other specific limits.


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


Kansas-3

allowable cost (MAC) limits on generic drugs. Override requires “Dispense as Written.”


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 45,000 Medicaid Recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through both the State and managed care plans. Hemophilia drugs and certain other specific compounds are carved out of managed care.


First Guard 3801 Blue Pkwy Kansas City, MO 64130

F. STATE CONTACTS


Mary H. Obley, Pharmacist Pharmacy Program Manager 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.eds.com


Mary H. Obley, Pharmacist 785/296-8406


Mary H. Obley, Pharmacist 785/296-8406

DUR Contact

Vicki L. Schmidt, Pharmacist Health Care Policy Division Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-S Topeka, KS 66612-1570 T: 785/274-4287 F: 785/296-4813 E-mail: [email protected]

DUR Board

Michael Burke, M.D., Ph.D. Barry Sarvis, R.Ph. Kevin Waite. Pharm.D. John Lowdermilk, R.Ph. R. Kevin Bryant, M.D., C.M.D Brenda Shewe, M.D. John Whitehead, D.O. Linda Kroeger, ARNP, FNP


Mary H.Obley, Pharmacist 785/296-8406


Policy: Mary H. Obley, Pharmacist Pharmacy Program Manager 785/296-8406

Technical: Cindy LaClair Drug Rebate Specialist, EDS 3600 SW Topeka Boulevard, Suite 204 Topeka, KS 66611 785/274-5987 E-mail: [email protected]


EDS 3600 SW Topeka Boulevard, Suite 204 Topeka, KS 66611 785/274-4200


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]


Kansas-4


None

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] Robert Day, Ph.D., Director Adult and Medical Services Department of Social and Rehabilitation Services 915 SW Harrison Topeka, KS 66612-1570 T: 785/296-3981 F: 785/296-4813 E-mail: [email protected]

Medical Care Advisory Committee Contact

Nialson Lee, B.S.N., M.H.A Administrator, Health Care Systems and Policy/ Medical Department of Social and Rehabilitation Services 915 SW Harrison, Rm. 651-S Topeka, KS 66612-1570 T: 785/296-4753 F: 785/2964813 E-mail: [email protected]


Kansas Medical Society Dan Suiter, 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 Sherry Denton, Interim Executive Director 1020 SW Fairlawn Road Topeka, KS 66604-2275 T: 785/228-2327 F: 785/228-9147 E-mail: [email protected] Internet address: www.kansaspharmacy.org

Kansas Association of Osteopathic Medicine Charles Wheeler, 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 Debra Billingsley, Secretary Landon State Office Building 900 Jackson, Room 560 Topeka, KS 66612-1231 T: 785/296-4056 F: 785/296-8420 E-mail: [email protected] Internet address: www.accesskansas.org Kansas Hospital Association Don Wilson President 215 Southeast Eighth Street Topeka, KS 66603 T: 785/233-7436 F: 785/233-6955 E-mail: [email protected] Internet address: www.kha-net.org


Kentucky-1

KENTUCKY





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $598,093,343 475,365 $652,904,065 RECEIVING CASH ASSISTANCE, TOTAL $424,804,782 235,058 Aged $37,547,483 16,692 Blind / Disabled $355,245,438 137,989 Child $12,748,175 51,834 Adult $19,263,686 28,543 MEDICALLY NEEDY, TOTAL $19,756,137 24,343 Aged $4,859,165 2,018 Blind / Disabled $3,736,659 1,645 Child $3,032,751 11,256 Adult $8,127,562 9,424 POVERTY RELATED, TOTAL $40,038,880 160,513 Aged $557,666 595 Blind / Disabled $1,299,771 941 Child $35,140,791 140,715 Adult $3,040,652 18,262 TOTAL OTHER EXPENDITURES/RECIPIENTS* $113,493,544 55,451 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Kentucky-2

C. ADMINISTRATION

Department for Medicaid Services, within the Cabinet for Health Services.


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; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; and thyroid agents. Prior authorization required for: anabolic steroids; analgesics, antipyretics, NSAIDs; anoretics; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; prescribed cold medications; growth hormones; hypotensive agents; misc. GI drugs; topical steroids; erectile dysfunction products; Leukotriene inhibitors; Synagis; Respigam; Zetia; CNS stimulants for ADHD and other disorders; Avodart; Proscar; anti-fungals for nails; Serotonin 5HT1 Receptor Agonosts; GCSF products; Recombinant Human Erythropoietin agents; and Xolair. Therapeutic categories not covered: prescribed smoking deterrents; agents for cosmetic purposes or hair growth and agents to promote fertility.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities, and through both the Prescription Drug Program and physician payment when used in physician offices. Reimbursement is limited to antineoplastic drugs with “J” codes in physician offices, several antibiotics, Depo-Provera for birth control.

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: Closed Formulary. The Kentucky Medicaid Program maintains a closed formulary and covers all rebated products. The State manages the formulary through a variety of techniques including the exclusion of products based on contracting issues, restrictions on use, prior authorization, algorithms, and preferred products. Prior authorization required for many brand name products with generic equivalents.

Prior Authorization: State currently has a prior authorization procedure. A formal appeals process is available if a request is denied.


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.


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, or (4), SMAC if any, plus a dispensing fee.

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


Kentucky-3

“Brand Medically Necessary,” or Prior Authorization.


Patient Cost Sharing: $1.00



Approximately 153,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through both the State and managed care plans. Medications prescribed by a board certified psychiatrist are carved out of managed care.

Managed Care Organization

Passport Health Plan Joyce Schifano, Executive Director

F. STATE CONTACTS


Dan Yeager, R.Ph. Interim Pharmacy Director Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected] Internet address: www.chs.ky.us/dms


Dan Yeager, R.Ph. 502/564-7940

Pharmacy and Therapeutics Advisory Committee

Robert C. Hughes, M.D. (Chair) Truman Perry, M.D. Dale E. Toney, M.D. Christopher A. Cunha, M.D. Carol Lee Steltenkamp, M.D., M.B.A. Connie Gayle White, M.D. (Vice-Chair) Naren N. James, M.D. Carmel Wallace, M.D. Andrew T. Cooley, M.D.

Janet Poe Wright, Pharm.D. R. Michael Cayce, R.Ph. Garry A. Hamm. R.Ph. Dan Yeager, R.Ph. (non-voting)

DUR Contact

Debra Bahr, R.Ph. Pharmacy Services Program Manager Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: [email protected]

Drug Management Review Advisory Board

Richard Arnold, M.D. (Chair) Phillip Bressoud, M.D. Phillip Baier, O.D. Patricia Freeman, R.Ph., Ph.D. James S. Davis, M.D. Karen Barnes, M.D. Janice Sullivan, M.D. Madonna H. Ringswald, D.O. John Spencer, Pharm.D. Sandra Thornbury Jacob Hutti, Pharm.D. Misha Glendening, A.R.N.P. Pam Koob, Ph.D. A.R.N.P. Scott Moody, Pharm.D. (non-voting)


Debra Bahr, R.Ph. 502/564-7940

Prescription Price Updating UNYSIS Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860


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]


Kentucky-4


Unisys Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860


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]


Sate currently has a mail order pharmacy program. Mail order pharmacy program is open to all Medicaid recipients. Must use a pharmacy that participates in the Kentucky Medicaid Program.

Department for Medicaid Services Officials

James W. Holsinger, Jr., M.D., Secretary Cabinet for Health and Family Services CHR Building, 5 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-6786 F: 502/564-0274 Mike Robinson, Commissioner Department for Medicaid Services Sixth Floor 275 East Main Street Frankfort, KY 40621 T: 502/564-4321 F: 502/564-0509

State Advisory Council on Medical Assistance

Frank Butler Elvin E. Dodson Bob Gray William P. Mattingly Marsha Mercer Marcia Morgan Chester A. Nava Jr., D.P.M. (chair) Kristin V. Paul, R.N. Vickie L. Prichard William K. Rich, D.M.D Leslie Rogers

Nancy Steele Suzanne Watkins, O.D. William T. Watkins, M.D. Bettie Speicher Weyler Donnie Wilhite John Withrow


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 E-mail: [email protected] 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 E-mail: [email protected] 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 E-mail: [email protected] 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 T: 859/433-3641 F: 859/257-7297 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 E-mail: [email protected] Internet address: www.koma.org


Kentucky-5

Kentucky Hospital Association Michael T. Rust President 2501 Nelson Miller Parkway Louisville, KY 40223 T: 502/426-6220 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


Kentucky-6


Louisiana-1

LOUISIANA





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $554,670,701 628,571 $714,107,841 RECEIVING CASH ASSISTANCE, TOTAL $351,387,693 259,405 Aged $91,902,271 41,683 Blind/Disabled $227,169,789 114,935 Child $15,071,139 64,596 Adult $17,244,494 38,191 MEDICALLY NEEDY, TOTAL $7,085,668 5,470 Aged $2,977,860 1,238 Blind/Disabled $2,574,449 1,411 Child $61,884 215 Adult $1,471,475 2,606 POVERTY RELATED, TOTAL $67,020,934 260,160 Aged $1,987,183 1,371 Blind/Disabled $1,481,920 1,336 Child $59,094,838 228,683 Adult $4,456,993 28,770 TOTAL OTHER EXPENDITURES/RECIPIENTS* $129,176,406 103,536

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Louisiana-2

C. ADMINISTRATION

Department of Health and Hospitals.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Products covered as DME: total parenteral nutrition and interdialytic parenteral nutrition. Products not covered: cosmetics; DESI drugs; fertility drugs; experimental drugs; and cough and cold preparation.

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

Therapeutic Category Coverage: Therapeutic categories/ products covered: all except cosmetics, cough and cold preparations, DESI drugs and experimental drugs. Prior authorization required for: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; and sympathominetics (adrenergic). Partial coverage for: anoretics.

Coverage of Injectables: Injectable medicines reimbursable under the Prescription Drug Program and through physician payment when used in physician offices.

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



Formulary: Open formulary. General management techniques include restrictions on use, 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.


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.


PRODUR system implemented in April 1996. State has a DUR Board that meets quarterly.


Dispensing Fee: $4.45 on average to $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.”


Louisiana-3


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


Mary J. Terrebonne, P.D. Pharmacy Director Department of Health & Hospitals 1201 Capital Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected] Internet address: www.lamedicaid.com

Department of Health and Hospital Administration Officials

Frederick P. Cerise, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821 T: 225/342-9500 F: 225/342-9508 E-mail: [email protected]

Ben A. Bearden, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-3891 F: 225/342-9508 E-mail: [email protected]

DUR Contact

Mary J. Terrebonne, P.D. 225/342-9768

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 401½ 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




Louisiana-4


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]


Technical: Timothy Williams, 225/342-5194 Policy: Mary J. Terrebonne, 225/342-9768 Disputes: Katie Landry, 225/342-0427


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]


State has a voluntary mail order pharmacy program open to all Medicaid recipients.

Medical Managed Care Contact


Medical Care Advisory Committee

Sandra C. Adams (Chairperson) Brenda Armstrong Ralph D. Balentine Dr. Donnie Batie Francine Boyles Dr. Floyd A. Buras Jennifer Canaday Marcia Daigle Sen. John L. “Jay” Dardenne, Jr. Partricia DeMichele Daily Dupre, Jr. Wanda Ellis Warren Hebert Paul Hildreth Robert D. Horneman Amelia Lafont Rep. Jerry L. “Luke” LeBlane Dr. Charles Clinton Lewis Kay Marcel

Dr. Robert L. Marier June Peach Dr. Keith M. Perrin Ms. Bea Piker Tawana Pounders Sean Prados Willa Rawls Sen. J. “Tom” Schedler Greg Scott Mary Scott Richard “Andy” Soileau Mary Tonore Dr. Leonard Weather, Jr. Linda Welch Ms. Ann Williamson

Medicaid Pharmaceutical and Therapeutics Committee

Mr. Joe Adams Mandeville, LA State Representative Rodney Alexander Jonesboro, LA Dr. Donnie Batie Baton Rouge, LA Mr. Ben Bearden Baton Rouge, LA Dr. Vincent Culotta Metairie, LA Dr. Richard Doskey River Ridge, LA Dr. Blackwell B. Evans, Jr. New Orleans, LA Dr. Conchetta Fulton New Orleans, LA Mr. David Hood Baton Rouge, LA Charles Jastram New Orleans, LA Dr. Ernest Kinchen Lafayette, LA Dr. Michael Kudla Lake Charles, LA Dr. W. Chapman Lee Baton Rouge, LA


Louisiana-5

James Lowery Pineville, LA Dr. Brobson Lutz New Orleans, LA Dr. Catherine A. McDonald Lafayette, LA Mr. Marty McKay Alexandria, LA Dr. Phillip J. Medon Monroe, LA Dr. John B. Pope Shreveport, LA Ms. Carolyn Tackett Hammond, LA Dr. Henderson Tilton New Orleans, LA Dr. Leonard Weather New Orleans, LA Dr. Lolie C. Yu New Orleans, LA

Pharmacy Advisory Committee

Ken Ardoin Michelle Wolf-Selfo Scott Napoli William Bouren Allan Brinkhaus Clovis Burch Horace Bynum Wayne T. Harris Tim Jacks Ruth “Cookie” Jean Ricky Guidry Carl Aron Amy Soileau Marty McKay Jerry Wallace Kirt Soileau


Louisiana State Medical Society Dave L. Tarver Executive Vice President 6767 Perkins Road, Suite 100 Baton Rouge, LA 70808 T: 225/763-8500 F: 225/763-6122 E-mail: [email protected] Internet address: www.lsms.org Louisiana Osteopathic Medical Association (Inactive) Nancy Bellemare, D.O. President 215 Friedrichs Avenue Metairie, LA 70005-4516 800/621-1773, ext. 8188 E-mail: [email protected] Internet address: www.loma-net.org State Board of Pharmacy Malcolm J. Broussard Executive Director 5615 Corporate Boulevard, Suite 8E Baton Rouge, LA 70808-2537 T: 225/925-6496 F: 225/925-6499 E-mail: [email protected] Internet address: www.labp.com Louisiana 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 David Lofton 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-6

Louisiana Hospital Association Lynn B. Nicholas President & CEO 9521 Brookline Avenue Baton Rouge, LA 70898-0720 T: 504/928-0026 F: 225/923-1004 E-mail: [email protected] Internet address: www.laha.org


Maine-1

MAINE





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $203,693,259 192,833 $220,420,714 RECEIVING CASH ASSISTANCE, TOTAL $99,156,442 63,650 Aged $9,742,927 4,469 Blind/Disabled $75,144,561 28,041 Child $3,038,840 13,637 Adults $11,230,114 17,503 MEDICALLY NEEDY, TOTAL $3,381,341 1,253 Aged $2,428,720 912 Blind/Disabled $916,215 281 Child $8,041 24 Adults $28,365 36 POVERTY RELATED, TOTAL $42,571,202 49,911 Aged $10,445,319 5,441 Blind/Disabled $22,747,950 7,758 Child $9,021,432 34,767 Adult $356,501 1,945 TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,584,274 78,019

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report FY 2001 and CMS-64 Report, FY 2002.


Maine-2

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); 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; analgesics; digestive products (non H2 antagonists); topical products; and feminine products. Products covered with restrictions: H2 antagonists (limited coverage after 1/1/01); smoking deterrent products (by Rx only). Products not covered: cough and cold preparations.

Therapeutic Category Coverage: Therapeutic categories covered: (prior authorization required): anabolic steroids; analgesics, antipyretics, and NSAIDs; anoretics; antibiotics anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamine drugs; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; sympathominetics (adrenergic); thyroid agents; injectable arthritis medications; acute migraine medications; Synvisc; antifungals; EPO; Synagis, and erectile dysfunction products.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and in physician offices.

Vaccines: Vaccines reimbursable based on cost as part of the EPSDT service (admin. fees), as part of the Children’s Health Insurance Program, and as part of the Vaccines for Children Program.



Formulary: Closed formulary with restrictions on use, prior authorization, and preferred products. (The Maine Care Preferred Drug List can be seen at www.ghsinc.com.) Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization may be obtained in the case of necessary exceptions. Fair hearing appeal of denials through the Office of Administrative Hearings. State has no formal prior authorization committee.

Prescribing or Dispensing Limitations Monthly 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 12 times per year.


Dispensing Fee: $3.35 - $12.50 (Effective 1/20/2004)

Ingredient Reimbursement Basis: EAC = AWP -15%.

Prescription Charge Formula: Lowest of usual and customary, FUL, AWP-15%, or Maine MAC. Maine MAC includes 1,232 drug products in addition to FUL products.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Override requires prior authorization.


Patient Cost Sharing: $2.50 per script up to a maximum of $25.00 per month.

Cognitive Services: State does not pay for cognitive services.

E. USE OF MANAGED CARE About 110,000 Medicaid recipients are enrolled in managed care in 2002. Medicaid recipients enrolled in managed care receive pharmaceutical benefits through the State.


Maine-3

F. STATE CONTACTS

State Drug Program Administrator Jude Walsh, Director Health Care Management Division Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1815 F: 207/287-6533 E-mail: [email protected] Internet address: www.maine.gov/bms


Jude Walsh 207/287-1815

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

Jude Walsh 207/287-1815

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 207/822-7627 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


Jude Walsh 207/287-1815


Jude Walsh 207/287-1815


Rossi Rowe Insurance Recovery/ Drug Rebate Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1838 F: 207/287-1788 E-mail: [email protected]


Maine-4


Marcia Pykare Manager of Data Processing Goold Health Systems P.O. Box 1090 Augusta, ME 04332-1090 T: 207/622-7153 F: 207/623-5125 E-mail: [email protected]


Jude Walsh 207/287-1815

Mail Order Pharmacy Program State has a mail order Medical Assistance pharmacy program.


Jude Walsh 207/287-1815

Human Services Department Officials

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.maine.gov/dhs Chris Zukus Lessard, 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] Internet address: www.maine.gov/bms


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 Christopher R. Gauthier, President 127 Pleasant Hill Road Scarborough, ME 040704 T: 207/396-5340 F: 207/396-5341 E-mail: [email protected] Internet address: www.mparx.com Maine Osteopathic Association Kellie Miller, M.S. Executive Director 693 Western Avenue, #1 Manchester, ME 04351 T: 207/623-1101 F: 207/623-4228 E-mail: [email protected] Internet address: www.mainedo.org Maine 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.maine.gov/prf/olr/ Maine Society of Health-System Pharmacists Carl Grove, President 25 June Street Sanford, ME 04073 207/324-4310 E-mail: [email protected] 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


Maryland-1

MARYLAND





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $417,080,496 413,755 $297,291,733 RECEIVING CASH ASSISTANCE, TOTAL $250,086,652 146,902 Aged $32,434,284 16,402 Blind / Disabled $195,329,917 69,078 Child $8,287,280 40,807 Adult $14,035,171 20,615 MEDICALLY NEEDY, TOTAL $86,459,198 53,223 Aged $46,136,023 18,138 Blind / Disabled $29,821,999 11,626 Child $4,769,778 13,221 Adult $5,731,398 10,238 POVERTY RELATED, TOTAL $59,823,561 186,809 Aged $11,344,463 7,589 Blind / Disabled $14,225,876 5,162 Child $31,413,643 154,271 Adult $2,839,579 19,787 TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,711,085 26,821 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Maryland-2

C. ADMINISTRATION State Department of Health and Mental Hygiene.


Benefit Design

Drug Benefit Product Coverage: Products covered: legend drugs; prescribed insulin; disposable needles and syringe combinations used for insulin. Covered under DME: blood glucose test strips; urine ketone test strips total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; DESI drugs; 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 extended care facilities, and through both the Prescription Drug Program and physician payment when used in physician offices.




Formulary: Open formulary with a preferred drug list (PDL). Prior authorization required for non-PDL products.

Prior Authorization: State currently has a Prior Authorization procedure. A general appeals procedure is available when a physician can provide additional information to justify the medical necessity of a particular product.

Preauthorization is needed for any prescription with a usual and customary charge exceeding $400. Prior authorization is also needed for early refills, nutritional supplements, brand medically necessary and excessive quantities.


Prescription Refill Limit: Maximum of eleven refills. The original prescription and its refills may not exceed a 360-day supply.

Monthly Quantity Limit: The amount of medication to be dispensed on a prescription at one time is limited to a less than 34-day supply except for specific maintenance drugs for chronic conditions, where up to a 100-day supply may be dispensed at one time.


PRODUR system implemented January 1993. State currently has a DUR Board with a quarterly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.69 - $5.65 as of November 2002. $3.69 - non-PDL Brand. $4.69 - PDL Generic $4.65-Nursing Home non-PDL

Brand $5.65 - Nursing Home PDL or Generic Ingredient Reimbursement Basis: Estimated Acquisition Cost (EAC) equals/lowest of: 1. Wholesale Acquisition Cost (WAC) plus 9%.

2. Direct cost plus 9%.

3. Distributor's price plus 9%.

4. Average Wholesale Price (AWP) minus 11%.


Maryland-3

Prescription Charge Formula: Reimbursement will be the lower of: (1) the calculated ingredient cost plus a dispensing fee; (2) the usual and customary fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. Approximately 1,000 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary” and a reason.

Incentive Fee: $1.00 higher for dispensing a lower cost multisource product.

Patient Cost Sharing: Copayment = $2.00 for Brands not on the PDL. Does not apply to managed care, family planning, nursing home residents, recipients under 21 years old, or generic drugs.



Approximately 444,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through the State and managed care plans. (Mental health drugs are “carved out” of managed care.)


United Healthcare Family First Lyndwood Executive Center 6095 Marshalee Drive Elkridge, MD 21075 410/277-6000 Helix Family Choice, Inc. 8094 Sandpiper Circle Baltimore, MD 21236 410/933-3021 Jai Medical Systems, Inc. 5010 York Road Baltimore, MD 21212 410/433-2200 Maryland Physicians Care MCO 7104 Ambassador Road Suite 100 Baltimore, MD 21244 410/277-9710

Priority Partners MCO Bay Meadow Industrial Park 6704 Curtis Court Glen Burnie, MD 21060 410/424-4400 Ameri Group 857 Elkridge Landing Road, #300 Linthicum, MD 21090 410/859-5800

F. STATE CONTACTS


Mr. Joseph L. Fine Director Maryland Pharmacy Program DHMH, Office of Operation and Eligibility 201 West Preston Street Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 E-mail: [email protected] Internet address: www.dhmh.state.md.us


Frank T. Tetkoski Manager Services and Preauthorization DHMH, Division of Pharmacy Services 201 West Preston Street, Room 409 Baltimore, MD 21201 T: 410/767-1460 F: 410/333-5398 E-mail: [email protected]


Tuong Nguyen, P.D. Pharmacist Consultant DHMH-Office of Operations and Eligibility Division of Pharmacy Services 201 W. Preston St. Baltimore, MD 21201 T: 410/767-8701 F: 410/333-5398 E-mail: [email protected]


Maryland-4

DUR Contact

Judy Geisler, P.D. Pharmacist Consultant DHMH-Office of Operations and Eligibility Division of Pharmacy Services 201 W. Preston Street Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 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.


First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 415/588-5454 F: 415/827-4578


Technical: Ed Ellis, 410/767-1455 Policy: Jeffrey Gruel, 410/767-1455 Disputes: Alex Taylor, 410/263-7048

Claims Submission Contact First Health Services Corporation Division of Claims Processing James Demery Manager, Pharmacy Services 201 W. Preston St. Baltimore, MD 21201 T: 410/767-1460 F: 410/333-5398 E-mail: [email protected]

Medicare Managed Care Contact

Jim Gardner Chief Division of Health Choice Management 201 W. Preston St., Room 208 Baltimore, MD 21201 410/767-1482


None

Expanded Drug Coverage Program

Paul Roeger, Chief Division of Eligibility Services Montgomery Park Business Center 1800 Washington Boulevard, Suite 400 Baltimore, MD 21230 T: 443/263-7031 F: 443/263-7065 E-mail: [email protected]

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] Joseph Davis Executive Director Office of Operations and Eligibility 201 W. Preston Street Baltimore, MD 21201 Joseph Fine Director Maryland Pharmacy Program 201 W. Preston Street Baltimore, MD 21201 Jeffrey Gruel,Chief Division of Pharmacy Services Office of Operations and Eligibility 201 W. Preston Street Baltimore, MD 21201 410/767-1455 Paul Roeger Program Manager - Eligibility Pharmacy Assistance Program PO Box 386 Baltimore, MD 21203

Medical Assistance Staff Committee Members

Judy Geisler, P.D. Division of Pharmacy Services 201 W. Preston Street Baltimore, MD 21201


Maryland-5

Mr. Frank Tetkoski, P.D., Manager Services and Preauthorization Division of Pharmacy Services 201 W. Preston Street, Room 409 Baltimore, MD 21201 Phil Cogan Preferred Drug List Division of Pharmacy Services 201 W. Preston Street Baltimore, MD 21201 Tuong Nguyen, P.D. Division of Pharmacy Services 201 W. Preston St. Baltimore, MD 21201


Maryland State Medical Society T. Michael Preston Executive Director 1211 Cathedral Street Baltimore, MD 21201 T: 410/539-0872 F: 410/547-0915 E-mail: [email protected] Internet address: www.medchi.org Maryland Association of Osteopathic Physicians 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 E-mail: [email protected] Internet address: www.marylandpharmac.street.org Maryland Society of Health-System Pharmacists David A. Kotzin, President 8480-M Baltimore National Pike, Ste. 252 Ellicott City, MD 21042 T: 410/465-9975 F: 410/465-7073 E-mail: [email protected] Internet address: www.mshp.org

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 Association of Maryland Hospitals and Health Systems Calvin M. Pierson, President 6820 Deerpath Road Elkridge, MD 21075-6234 T: 410/379-6200 F: 410/379-8239 E-mail: [email protected] Internet address: www.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


Maryland-6


Massachusetts-1

MASSACHUSETTS





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $795,309,302 664,891 $958,972,520 RECEIVING CASH ASSISTANCE TOTAL $398,769,692 233,547 Aged $43,882,222 27,199 Blind/Disabled $325,512,115 126,497 Child $9,394,346 50,397 Adult $19,981,009 29,454 MEDICALLY NEEDY, TOTAL $33,106,079 16,380 Aged $13,532,409 8,577 Blind/Disabled $19,573,670 7,823 Child $0 - Adult $0 - POVERTY RELATED, TOTAL $222,673,963 225,206 Aged $57,479,842 29,452 Blind/Disabled $133,146,461 46,414 Child $30,025,642 144,510 Adult $2,022,018 4,830 TOTAL OTHER EXPENDITURES/RECIPIENTS* $140,759,568 189,758 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Massachusetts-2

C. ADMINISTRATION

Executive Offices of Health and Human Services, Division of Medical Assistance, Office of Medicaid.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered (except in LTC facilities): disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips. Products covered with restrictions: total parenteral nutrition (prior authorization required). 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- not covered in LTC facilities): allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products; feminine products and topical products. Products not covered: smoking deterrent products.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; chemotherapy agents; contraceptives; and thyroid agents. Prior authorization required for: growth hormones; Erythropoeitin; and selected biotech drugs. Partial coverage for: prescribed cold medications. Partial coverage with prior authorization required for: analgesic, antipyretics, and NSAIDs; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; ENT anti-inflammatory agents; hypotensive agents; misc. GI drugs; andsympathominetics (adrenergic). Therapeutic categories not covered: anoretics; prescribed smoking deterrents; weight loss or gain medications; medications to treat sexual dysfunction; experimental or investigational drugs; and less than effective drugs.

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 managed through restrictions on use, prior authorization, and physician profiling.

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: $3.00 (basic) plus $1.00-$2.00 additional for compounded Rx’s, effective 1/1/2004.

Ingredient Reimbursement Basis: EAC = WAC + 6%.

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.


Massachusetts-3

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

Patient Cost Sharing: Copayment = $3.00 (Brands) and $1.00 (Generics), effective 2/1/2004.

Institutionalized patients

− Children under age 19

− Pregnant and postpartum women

− Hospice care

− Family planning items



E. USE OF MANAGED CARE Approximately 238,000 Medicaid recipients in MCOs were enrolled in MCOs in FY 2002 with another 411,000 enrolled in pre-paid health plans (PHPs). Recipients receive pharmaceutical benefits through managed care plans. Enrollees in the PCCM program receive pharmaceutical benefits from the State.

Managed Care Organization

Primary Care Clinician Plan Boston Medical Center HealthNet Plan Fallon Community Health Plan Neighborhood Health Plan Network Health

F. STATE CONTACTS

State Drug Program Administrator Paul L. Jeffrey Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210-5865 E-mail: [email protected] Internet Address: www.state.ma.us/dma


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.

New Brand Name Products Contact Christopher T. Burke Policy Analyst Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5592 F: 617/210-5597 E-mail: [email protected]

Prescription Price Updating First Data Bank 111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578

Medicaid Drug Rebate Contacts Martha Kessenich Rebate Analyst ACS State Health Care 365 North Ridge Road, Suite 400 Atlanta, GA 30350 800/358-2381


ACS State Health Care 365 North Ridge Road, Suite 400 Atlanta, GA 30350 800/358-2381


Massachusetts-4


Kate Willrich-Nordahl, Director Massachusetts Health MCO Program Department of Public Health 250 Washinton Street, 6th Floor Boston, MA 02108 T: 617/624-5693 F: 617/624-5698 E-mail: [email protected]


None

Disease Management Program/Initiative Contact N/A

Executive Offices of Health and Human Services Ronald Preston, Secretary Executive Office of Health and Human Services One Ashburton Place, Room 1109 Boston, MA 02108 T: 617/727-0077 F: 617/727-5134 E-mail: [email protected] Internet address: www.masscares.org Beth Waldman, Director Office of Medicaid One Ashburton Place, Room 1109 Boston, MA 02108 T: 617/573-1770 F: 617/573-1894 E-mail: [email protected] Internet address: www.state.ma.us/dma


Massachusetts Medical Society Corrine Broderick Executive Vice President 860 Winter Street Waltham Woods Corporate Center Waltham, MA 02451-1411 T: 781/893-4610 F: 781/893-9136 E-mail: [email protected] Internet address: www.massmed.org

Massachusetts 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. William Seeglitz President P.O. Box 487 Winchester, MA 01890 781/721-9900 E-mail: [email protected] Internet address: www.northeastosteo.org Massachusetts Board of Registration in Pharmacy Charles R. Young Executive Director 239 Causeway Street, Suite 500 Boston, MA 02114 T: 617/727-9953 F: 617/727-2197 E-mail: [email protected] Internet address: www.state.ma.us/reg/boards/ph Massachusetts Society of Health-Systems Pharmacists Martin Goldberg President 500 West Commings Park, Suite 3475 Woburn, MA 01801 T: 781/937-0175 F: 781/937-0176 E-mail: [email protected] Internet address: www.mashp.org Massachusetts Hospital Association Ronald M. Hollander President Five New England Executive Park Burlington, MA 01803 T: 617/272-8000 F: 781/272-8000 E-mail: [email protected] Internet address: www.mhalink.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


Michigan-1

MICHIGAN A. BENEFITS PROVIDED AND GROUPS ELIGIBLE




Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $604,759,491 551,593 $674,222,281 RECEIVING CASH ASSISTANCE TOTAL $278,471,171 199,600 Aged $34,781,401 18,971 Blind/Disabled $232,639,786 127,875 Child $3,532,094 24,915 Adult $7,517,890 27,839 MEDICALLY NEEDY, TOTAL $33,663,061 48,285 Aged $8,419,629 5,074 Blind/Disabled $14,322,748 5,269 Child $2,043,913 10,523 Adult $8,876,771 27,419 POVERTY RELATED, TOTAL $33,072,967 114,030 Aged $1,984,861 1,503 Blind/Disabled $14,408,432 5,343 Child $13,531,563 85,310 Adult $3,148,111 21,874 TOTAL OTHER EXPENDITURES/RECIPIENTS* $259,552,292 189,678



Michigan-2

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 (prior authorization for equipment and supplies) and interdialytic parenteral nutrition (prior authorization required for self administration). Prior authorization required for: brand name products equivalent to MACs; Accutane & Retin-A; Dexedrine and Adderall; Persantine; Lactulose (Cephulac); Methylphenidate (selected ages); selected benzodiazepines; Epogen administered in the home setting; dietary formulas; and drugs not listed on the formulary. Products not covered: cosmetics; fertility drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products covered with restrictions (only selected products in each category): allergy, asthma and sinus products (antihistamines); analgesics (payment limits, considered part of nursing home per diem reimbursement); non-H2 antagonists (payment limits, considered part of nursing home per diem reimbursement); H2 antagonist (payment limits); feminine products (payment limits); topical products; and smoking deterrent products (tablets, patches and gum-quanity limits per beneficiary per year). Products not covered: cough and cold preparations.

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

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 cost plus a fee/or vaccine replacement as part of the EPSDT service the Children Health Insurance Program, and the Vaccines for Children Program.


Formulary/Prior Authorization Formulary: Closed formulary and a preferred drug list (PDL). (See www.michigan.fhsc.com for listing of drugs on the PDL.) Formulary managed through restrictions on use, prior authorization requirements, age/gender editing; and clinical editing for “first line” therapy.

Prior Authorization: State currently has a formal prior authorization procedure. Beneficiaries have a right to appeal prior authorization decisions on the basis of medical necessity. Informal review of additional information can be conducted at any time. Beneficiaries also have fair hearing rights to appeal denial of coverage for an excluded product.

Prescribing or Dispensing Limitations Prescription Refill Limit: None

Monthly Quantity Limit: Prescribed quantities should be limited to an amount necessary to keep the recipient supplied during the therapy regimen. Quanity limits for selected pharmaceuticals (e.g., sedative hypnotics). In certain cases and conditions, more than a month’s supply will be appropriate. However, in no instance may more than 100 days supply be dispensed per prescription.

Drug Utilization Review PRODUR system implemented in July 2000. State currently has a DUR Board with a quarterly review.


Dispensing Fee: $3.77, (included in annual Appropriations Act.)

Ingredient Reimbursement Basis: 1-4 stores = AWP-13.5%, 5 or more stores = AWP-15.1%.


Michigan-3

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. Override requires “Brand Medically Necessary” 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 800,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans. Psychotropics, antidepressants, anti-mania, central nervous system stimulants, and other select classes of drugs are administered by managed care organizations but paid for by the State.


Botsford Health Plan 28050 Grand River Farmington Hills, MI 48336 800/479-5122 Internet address: www.botsfordhealthplan.org Cape Health Plan 26711 Northwestern Highway, Suite 300 Southfield, MI 48034 248/386-3000 888/354-2273 Internet address: www.capehealth.com Community Choice Michigan 2369 Woodlake Drive Okemos, MI 48864 517/349-9922 800/390-7102 Internet address: www.ccmhmo.org Great Lakes Health Plan, Inc. 17117 W. Nine Mile, Suite 1600 Southfield, MI 48075 248/559-5656 800/903-5253 Internet address: www.glhp.com Health Plan of Michigan, Inc. 17515 W. Nine Mile, Suite 650 Southfield, MI 48075 248/557-3700 888/437-0606 Internet address: hpmich.com HealthPlus Partners, Inc. 2050 S. Linden Road P.O. Box 1700 Flint, MI 48501-1700 810/230-2132 800/322-9161 Internet address: www.healthplus.com M-Caid 2301 Commonwealth Blvd. Ann Arbor, MI 48105-1573 800/527-5549 Internet address: www.mcare.org McLaren Health Plan G 3245 Beacher Road, Suite 200 Flint, MI 48532 888/327-0671 Internet address: www.mclaren.org


Michigan-4

Midwest Health Plan 5050 Schaefer Road Dearborn, MI 48126 313/581-3700 888/654-2200 Internet address: www.midwesthealthplan.com Molina Healthcare of Michigan 100 W. Big Beaver Road, Suite 600 Troy, MI 48084 248/925-1700 888/898-7969 Internet address: www.molinahealthcare.com OmniCare Health Plan 1155 Brewery Park Blvd. Suite 250 Detroit, MI 48207 313/259-4000 800/955-4578 Internet address: www.ochp.com PHP of Mid-Michigan, Inc. P.O. Box 30377 Lansing, MI 48909-7877 517/364-8400 800/661-8299 Internet address: www.phpmm.org PHP of Southwest Michigan, Inc. 106 Farmers Alley, Suite 300 Kalamazoo, MI 49007 269/341-7200 800/261-0084 Internet address: www.ibahealthplans.com Priority Health, Government Programs, Inc. 1231 E. Beltline, NE Grand Rapids, MI 49525-4501 616/942-0954 888/975-8102 Internet address: www.priority-health.com Total Health Care 3011 W. Grand Blvd., Suite 1600 Detroit, MI 48202 313/871-2000 800/826-2862 Internet address: totalhealthcareonline.com Upper Peninsula Health Plan 228 W. Washington Street Marquette, MI 49855 906/225-7500 800/835-2556 Internet address: www.uphp.com

The Wellness Plan 7700 Second Avenue Detroit, MI 48202 313/202-8500 800/875-9355 Internet address: www.wellplan.com

F. STATE CONTACTS

State Drug Program Administrator Giovannino A. Perri, M.D. Chief Medical Consultant MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Internet address: www.michigan.gov/mdhc

New Brand Names Products Contact

Donna Hammel Office of Medical Affairs MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]


First Health Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696

DUR Contact

Deberah Eggleston, M.D. MDCH- Medical Services Administration 400 S. Pine St. P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]


Michigan-5

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


First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696


Technical: Dawn Parsons Pharmacy Consultant

MDCH/ Medical Services Administration

400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Audits: First Health Services Corporation

877/864-9014


First Health Services Corp T: 877/864-9014 F: 888/603-7696

Medicaid Managed Care Contact Sue Moran, Chief Bureau of Medicaid Operations and Quality MDCH- Medical Services Administration 400 S. Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]


Giovannino A. Perri, M.D. 517/335-5181


None

Elderly Expanded Drug Coverage Contact

Thomas Chisnell MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]


Michigan-6

Michigan Dept. of Community Health (MDCH) Janet Olszewski, Director MCDH/ Lewis Cass Building 320 South Walnut Street Lansing, MI 48913 T: 517/335-0267 F: 517-373-4288 E-mail: [email protected] Patrick Barrie, Deputy Director Health Programs Administration Michigan Department of Community Health 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 Ernst, M.D. Jonathan G.A. Henry, M.D. Edward J. Keating, R.Ph. Giovannino A. Perri, M.D. Max Robins, D.O. Sandra Campbell, 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: 517/337-1315 F: 517/337-2490 E-mail: [email protected] Internet address: www.msms.org

Michigan Pharmacists Association Larry D. Wagenknecht, CEO 815 N. Washington Avenue Lansing, MI 48906-5198 T: 517/484-1466 F: 517/484-4893 E-mail: [email protected] Internet address: www.michigan pharmacists.org Michigan Osteopathic Association Dennis Paradis, Executive Director 2445 Woodlake Circle Okemos, MI 48864 T: 800/657-1556 F: 517/347-1566 E-mail: [email protected] Internet address: www.moa-do.com State Board of Pharmacy Roberta Armstrong, Chairperson Licensing Manager 611 W. Ottawa, First Floor P.O. Box 30670 Lansing, MI 48909-8170 517/335-0918 Internet address: www.michigan.gov/cis/ Michigan Health and Hospital Association Spencer C. Johnson, President 6215 West St. Joseph Highway Lansing, MI 48917 T: 517/323-3443 F: 517/323-0946 E-mail: [email protected] Internet address: www.mha.org Health Care Association of Michigan Reginald Carter, Ph.D. President & 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


Minnesota-1

MINNESOTA





Child Adult

Prescribed Drugs





Physician Services

Dental Services B. EXPENDITURES FOR DRUGS

2001 2002**

Expenditures Recipients Expenditures Recipients TOTAL $265,240,353 188,566 $310,174,144 RECEIVING CASH ASSISTANCE, TOTAL $148,264,320 78,475 Aged $7,108,479 4,018 Blind / Disabled $129,186,438 46,033 Child $5,008,680 16,345 Adult $6,960,723 12,079 MEDICALLY NEEDY, TOTAL $17,151,129 6,590 Aged $4,624,706 2,823 Blind / Disabled $12,502,998 3,665 Child $22,225 92 Adult $1,200 10 POVERTY RELATED, TOTAL $1,456,490 1,725 Aged $695,335 1,177 Blind / Disabled $753,128 472 Child $7,795 61 Adult $232 15 TOTAL OTHER EXPENDITURES/RECIPIENTS* $98,368,414 101,776

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Minnesota-2

C. ADMINISTRATION Minnesota Department of Human Services, Health Care Management Division, Medical Assistance Program.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; syringe combinations used for insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: drugs used for cosmetic purposes; drugs used for hair growth; fertility drugs; appetite supressants; and experimental drugs; disposable needles used for insulin; blood glucose test strips; and urine ketone test strips. Products covered with limitations: sildenafil, methylphenidate (including d-methylphenidate), Adderall, pemoline, dextroamphetamine, vitamins, and cough and cold preparations. Prior authorization required for: alglucerase; Interferon Alfa N-3; Interferon Gamma-1B; Ondansetron; Granisetron; omeprazole (including s-omeprazole); sertraline 25mg and 50mg tablets; Butulinum Toxin Types A & B; valdecoxib; Esomeprazole; dolasetron; celecoxib; rofecoxib; escitalopram 10mg; citalopram 10mg and 20mg; paroxetine 10mg; modafinil 100mg; trandolapril; trandolapril/verapamil combination; quinapril; quinapril/HCTZ; amlodipine/benazepril; benazepril/HCTZ; benazepril; fosinopril; and fosinopril/HCTZ. (For a complete list of products requiring prior authorization, contact the Pharmacy Program at The Minnesota Department of Human Services, Health Care Management Division, Medical Assistance Program.)

Over-the-Counter Product Coverage: Products covered: smoking deterrent products. Products covered with limitations: allergy, asthma and sinus products; analgesics; cough and cold preparations; digestive products (H2 and antagonist); feminine products (antifungals covered); topical products; and smoking deterrent products; vitamins; ocular lubricants; pediculocides; and activated charcoal and ipecac.

Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; 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; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; prescribed smoking

deterrents; sympathominetics (adrenergic); thyroid agents; and prescribed cold medications. Prior authorization required for: analgesics, antipyretics, and NSAIDS; antidepressants; cardiac drugs; and misc. GI drugs. Therapeutic categories not covered: anoretics; DESI drugs.

Coverage of Injectables: Injectable medicines reimbursable through the pharmacy benefit when dispensed by a pharmacy and through physician payment when used in physician offices.

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


Formulary/ Prior Authorization Formulary: Open formulary with general exclusions, restrictions, and preferred products.

Prior Authorization: State currently has a prior authorization procedure and a Drug Formulary Committee. Recipient has the right to appeal prior authorization decisions and coverage of an excluded product by appeals referee followed by an appeal in court.

Prescribing or Dispensing Limitations Monthly Quantity Limit: 3 month supply. Minimum 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.



Ingredient Reimbursement Basis: EAC = AWP – 11.5%.

Prescription Charge Formula: Reimbursement is based on the lesser of submitted AWP minus 11.5% plus a dispensing fee, MAC plus a dispensing fee, or usual and customary. Special rules for IV admixtures.


Minnesota-3

Maximum Allowable Cost: State imposes a combination of Federal Upper Limits and State-specific MAC on generic drugs. Override requires or “dispense as written.” No pre-printed DAW allowed.


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

Cognitive Services: State pays for professional services (e.g., clozaril monitoring).


Approximately 370,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans.


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 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


Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet address: www.dhs.state.mn.us


Cody C. Wiberg, Pharm.D., R.Ph. 651/296-8515

DUR Contact

Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator 444 Lafayette Road North 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


Minnesota-4

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 C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator

New Brand Names Product Contact


Prescription Drug Updating

First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588/4003


Dwaine Voas MMIS Unit Supervisor Minnesota Department of Human Services 800 Minnehaha Avenue St. Paul, MN 55155


Jarvis Jackson, R.Ph. Drug Rebate Coordinator Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/282-5881 F: 651/282-6744 E-mail: [email protected]

Disease Management Program/Initiative Contact Mary Claire Wohtetz Clinical Pharmacist Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/215-1632 F: 651/282-6744 E-mail: [email protected]


None

Elderly Expanded Drug Coverage Program Contact



Kevin Goodno Commissioner Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3815 T: 651/297-7515 F: 651/297-3230 E-mail: [email protected] Mary Kennedy Medicaid Director Department of Human Services 444 Lafayette Road St. Paul, MN 55155-3852 T: 651/297-7515 F: 651/297-3230 E-mail: [email protected]

Drug Formulary Committee

Al Heaton, Pharm.D., R.Ph. Senior Director Prime Therapeutics 1020 Discovery Road, No. 100 Eagan, MN 55121


Minnesota-5

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 Robert K. Meiches Chief Executive Officer 1300 Godward Street, NE, Suite 2500 Minneapolis, MN 55413-1878 T: 612/378-1875 F: 612/378-3875 E-mail: [email protected] Internet address: www.mnmed.org

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 Scott Marin Executive Director 13911 Ridgedale Drive, Suite 260 Minnetonka, MN 55305 T: 952/541-9499 F: 952/541-9684 E-mail: [email protected] Internet address: www.mnshp.org Care Providers of Minnesota Rick E. Carter President & CEO 7851 Metro Parkway Suite 200 Bloomington, MN 55425 T: 612/854-2844 F: 612/854-6214 E-mail: [email protected] Internet address: www.careproviders.org


Minnesota-6


Mississippi-1

MISSISSIPPI





Child Adult

Prescribed Drugs




Skilled Nursing Home Services

Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $494,805,247 478,404 $567,313,801 RECEIVING CASH ASSISTANCE TOTAL $273,269,878 214,993 Aged $40,460,923 21,661 Blind/Disabled $206,625,503 105,509 Child $12,577,330 59,540 Adult $13,606,122 28,283 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $163,081,425 238,963 Aged $57,308,548 28,431 Blind/Disabled $65,540,551 24,427 Child $35,839,110 161,784 Adult $4,393,216 24,321 TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,453,944 24,448 **Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Mississippi-2

C. ADMINISTRATION

Division of Medicaid, Office of the Governor.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; total parenteral nutrition; and interdialytic parenteral nutrition. Prior authorization required for: brand name multisource products; Sandimmune; oral erectile dysfunction agents; enteral feeding products; nutritional products; immunosuppressant agents; Clozaril (must be prescribed by Board Certified or Board Eligible Psychiatrist); * Xenical, Benzodiazepines, NSAD, Protropin and Humatrope; * all Antihemophilic Factors including VIII and IX; * Synagis; Enbrel; Brand SR opioid agonists; and all Home IV drug therapies. Products not covered: cosmetics; fertility drugs; experimental drugs; disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips.

* These products are covered only for children ages 0-21 years through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT).

Over-the-Counter Product Coverage: Products covered with restrictions; (i.e.must be on limited formulary, requires a prescription, and counts against monthly service limits): allergy, asthma, and sinus products (Benadryl); analgesics (ASA, generic Tylenol); cough and cold preparations (generic Robitussin); digestive products (non-H2 antagonist); feminine products; topical products; smoking deterrent products; certain vitamins (prenatal and dialysis). Products not covered: H2 antagonists.

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

weight loss drugs; fertility drugs; vitamins and minerals (except prenatal); and DESI drugs.


Unit Dose: Unit dose packaging is reimbursable.

Vaccines: Vaccines reimbursable as part of the Vaccine for Children Program.

Formulary/Prior Authorization Formulary: Open formulary with preferred drug list (PDL). General exclusions include:

1. Drugs used for anorexia or weight gain.

2. Drugs when used for the symptomatic relief of cough and colds (except quaifenesin syrup 100 mg/5 ml, iodinated glycerol tablets 30 mg, which are covered).

3. Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations, which are covered).

4. Covered outpatient drugs for which the manufacturer requires (as a condition of sale) that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

5. Barbiturates (except amobarbital, butabarbital, mephobarbital, pentobarbital, phenobarbital, secobarbital, which are covered).

6. Benzodiazepines (except Klonopin, Lorazapam, Diazepam and Temazepam which are covered).

7. DESI drugs (those drugs that are designated less than effective by the FDA).

Prior Authorization: State currently has a prior authorization procedure. A written request (including medical justification for beneficiaries under age 21) must be made within 30 days of denial to appeal a prior authorization decision. Review and determination made within 3 days of receipt. All parties notified in writing within 24 hours of decision.


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.


Mississippi-3

Monthly Prescription Limit: Total prescriptions dispensed per month per recipient are limited to 5. Two additional prescriptions per month may be allowed with prior authorization. Beneficiaries under age 21 years old or in long term care facilities are exempt from monthly prescription limits.

Drug Utilization Review PRODUR system implemented in 1993. State has a 12 member DUR Board that meets quarterly.


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-12%, effective July 1, 1990.

Prescription Charge Formula: Reimbursement for legend drugs will be at the lessor of AWP-12% plus a dispensing fee or usual and customary charge. OTC drugs will be paid at lessor of AWP plus a dispensing fee, usual and customary price, or estimated shelf price plus a dispense fee.

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs. Override requires “Brand Medically Necessary” or prior authorization 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 Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: www.dom.state.ms.us

Division of Medicaid Official

Warren A. Jones, M.D., Executive Director Division of Medicaid Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 T: 601/359-6050 F: 601/359-6048 E-mail: [email protected] DUR Contact

Judith P. Clark, R.Ph. 601/359-5253

Mississippi DUR Board

Sara Weisenberger, M.D. UMC-Department of Pediatrics 2500 North State Street Jackson, MS 39216 Tim Alford, M.D. (Chair) 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 Andrea Phillips, M.D. Phillips Medical Services P.O. Box 21214 Jackson, MS 39289 Joe McGuffee, R.Ph. McGuffee Drugs 102 North Main Street Mendenhall, MS 39114


Mississippi-4

D. Montez Carter, Pharm.D. P.O. Box 1414 Greenwood, MS 38935 Leigh Ann Ramsey, Pharm.D. 231 Winged Foot Circle Jackson, MS 39211 Diana McGowan, R.Ph., M.B.A 328 Dover Lane Madison, MS 39110 Clarence DuBose, R.Ph. (Vice-Chair) Medi-Mart Pharmacy 3737 Main Street Moss Point, MS 39563 Bob Broadus, R.Ph. 7147 Creekwood Drive Mandeville, LA 70471

New Brand Names Product Contact





Robert Reedy, C.Ph.T. DRAMS Business Analyst ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/206-2936 F: 601/206-3119 E-mail: [email protected]

Claims Submission Contact Bob Parenteu, PBM Account Manager ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/296-2934 F: 601/296-3119 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 K. Crowder, R.N., M.P.H. Director of Medical Services Division of Medicaid Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201 T: 601/359-5243 F: 601/359-5252 E-mail: [email protected]


Pilot Program


Melzana Fuller Director of Provider and Beneficiary Relations Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Jackson, MS 39201 T: 601/359-6063 F: 601/359-4185 E-mail: [email protected]

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


Mississippi-5

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.msmaonline.com Mississippi Pharmacists Association Bo Dalton, R.Ph. Executive Director 341 Edgewood Terrace Drive Jackson, MS 39206-6217 601/981-0416 E-mail: [email protected] Internet address: www.mspharm.org

Mississippi State Board of Pharmacy Leland “Mac” McDivitt Executive Director 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 E-mail: [email protected] Internet address: www.moma-net.org Mississippi Hospital Association Sam W. Cameron President/CEO P.O. Box 16444 6425 Lakeover Road Jackson, MS 39236-6444 T: 800/289-8884 F: 601/368-3200 E-mail: [email protected] Internet address: www.mhanet.org Mississippi Society of Health-System Pharmacists Dianna McGowan Association Manager 328 Dover Lane Madison, MS 39110 T: 601/856-9273 F: 601/856-8539 E-mail: [email protected] Internet address: www.pharmd.org/mshp Mississippi Health Care Association Vanessa P. Henderson Executive Director 114 Marketridge Drive Ridgeland, MS 39157 T: 601/956-3472 F: 601/977-0273 E-mail: [email protected] Internet address: www.mshca.com


Mississippi-6


Missouri-1

MISSOURI





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $680,574,899 472,624 $790,853,387 RECEIVING CASH ASSISTANCE TOTAL $302,169,328 173,944 Aged $52,969,010 21,219 Blind/Disabled $220,471,969 71,356 Child $12,427,726 46,893 Adult $16,300,623 34,476 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $46,561,919 108,561 Aged $6,632,609 3,988 Blind/Disabled $14,729,020 4,105 Child $23,680,913 87,976 Adult $1,519,377 12,492 TOTAL OTHER EXPENDITURES/RECIPIENTS* $331,843,652 190,119 **Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Missouri-2

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; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Limited coverage (limited to OTC formulary) for: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products (non-H2 antagonists); and topical products. Prior authorization required for: amphetamines; barbiturates; Isotretinoin; and Retinoic Acid. Products not covered: cosmetics; fertility drugs; experimental drugs; smoking deterrent products and feminine products.

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

(For additional information on products and/or category coverage, see the pharmacy provider bulletin at www.medicaid.state.mo.us.)

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in physician offices, home health care settings, and extended care facilities.




Formulary: Open formulary with exclusions and restrictions, including preferred products, physician profiling, prior authorization, clinical edits, and step therapy.

Prior Authorization: State currently has a prior authorization procedure and a Drug Prior Authorization Committee composed of 9 members who meet quarterly. Fair hearing process to appeal prior authorization decisions.

Prescribing or Dispensing Limitations Prescription Refill Limit: None

Monthly Quantity Limit: Physician encouraged to prescribe 34-day or 100 dose supply but may, at own discretion, prescribe up to a maximum 90-day supply.

Dose Limit: Prescriptions for the following must be dispensed for at least 200 units per prescriptions: 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.


PRODUR system implemented in 1993. State currently has a 13 member DUR Board with a quarterly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.09 (out-of-state), $8.04 (in-state), $8.19 (long-term care pharmacies).

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 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.


Missouri-3

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific limits on generic drugs. 910 drugs are listed on the State-specific MAC list. Override requires prior authorization and a MedWatch form.


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 asthma, diabetes, heart failure, and depression education.


Approximately 402,000 Medicaid recipients are enrolled in managed care organizations in 2002. All receive pharmacy services through managed care. Protease inhibitors are carved out of 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 Boulevard Columbia, MO 65203 573/441-2100

F. STATE CONTACTS


George L. Oestreich, Pharmacy Program Director Department of Social Services Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected] Internet address: www.dss.mo.gov/dms

Social Services Department Officials Steve Roling, Director Department of Social Services Broadway State Office Building 221 West High Street P.O. Box 1527 Jefferson City, MO 65102 T: 573/751-4815 F: 573/751-3203 E-mail: [email protected]


Missouri-4

Christine Rackers, Director Department of Social Services 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]


Rhonda A. Driver Clinical Pharmacist Department of Social Services Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102- 6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected]

Prior Authorization Contact Rhonda A. Driver 573/751-6961

DUR Contact Jayne Zemmer DUR Coordinator Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-1612 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


Missouri-5

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 Boulevard Jefferson City, MO 65109


First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 650/588-5454 F: 650/872-4510


Lynn Hebenheimer Medicaid Unit Supervisor Division of Medicaid Services Drug Rebate Unit P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/526-5664 F: 573/522-2594 E-mail: [email protected]

Claims Submission Contact Diane Twehous Claims Process Administrator Verizon Data Services 905 Weathered Rock Road Jefferson City, MO 65109 573/635-2434


Judy Muck Assistant Deputy Director Division of Medical Services Managed Care Unit P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/526-2886 F: 573/526-3946 E-mail: [email protected]

Mail Order Pharmacy Program None

Disease Management/ Patient Education Programs Disease Medical States: Asthma Cardiovascular Disease Depression Diabetes Program Manager: Jennifer Cornelious Program Sponsor: State of Missouri

Disease Management Initiatives Contact

George Oestreich 573/781-6961

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


Missouri State Medical Association C. C. Swarens Executive Secretary 113 Madison Street, P.O. Box 1028 Jefferson City, MO 65102 T:573/636-5151 F: 573/636-8552 E-mail: [email protected] Internet address: www.momed.net/momed/index.htm


Missouri-6

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 3605 Missouri Boulevard P. O. Box 625 Jefferson City, MO 65102 T: 573/751-0091 F: 573/526-3464 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 T: 573/893-3700 F: 573/893-2809 E-mail: [email protected] Internet address: www.mhanet.com


Montana-1

MONTANA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $69,552,397 63,338 $77,845,461 67,341 RECEIVING CASH ASSISTANCE, TOTAL $33,656,590 25,847 $37,412,054 28,190 Aged $2,737,151 1,546 $2,999,604 1,524 Blind / Disabled $26,502,817 10,510 $28,765,236 10,729 Child $1,528,685 8,838 $2,074,230 9,751 Adult $2,887,937 4,953 $3,572,984 6,186 MEDICALLY NEEDY, TOTAL $19,932,987 7,701 $22,229,084 7,821 Aged $11,577,514 5,327 $12,853,926 5,336 Blind / Disabled $8,337,077 2,318 $9,364,165 2,449 Child $18,336 55 $10,665 34 Adult $60 1 $328 2 POVERTY RELATED, TOTAL $1,798,235 11,913 $2,534,084 13,561 Aged $0 - $14 1 Blind / Disabled $0 - $0 - Child $1,509,510 9,980 $2,079,724 11,322 Adult $288,725 1,933 $454,346 2,238 TOTAL OTHER EXPENDITURES/RECIPIENTS* $14,164,585 17,877 $15,670,239 17,769 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by Montana Department of Public Health and Human Services, Medicaid Services Bureau. Source: CMS, MSIS Report, FY 2001 Montana Medicaid Statistical Information System, FY 2002.


Montana-2

C. ADMINISTRATION

Department of Public Health and Human Services, Medicaid Services Bureau.


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); allergy, asthma, and sinus products (Loratadine only); insulin; laxatives; antacids; head lice treatment; H2 antagonist GI products; bronchosaline; and smoking deterrent products. Products not covered: 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: prescribed cold medications. Prior authorization required for: anorectics; antihistamines; anxiolytics, sedatives, and hypnotics; analgesics, antipyretics, NSAIDs; and growth hormones.

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 EPSDT service, the Children Health Insurance Program, and the Vaccines for Children Program.



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: 34-day supply.


PRODUR system implemented in September 1994. State DUR Board (DUE Care Program) has 6 members and meets monthly.


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%.

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.



Montana-3

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.



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


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] Chuck Hunter, Administrator Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4458 F: 406/444-1861 E-mail: [email protected] John Chappuis Medicaid Director 406/444-4084 Duane Pershinger, Bureau Chief Acute Services Section 406/444-4144

Mary Angela Collins, Bureau Chief Managed Care Section 406/444-4146 Brett Williams, Bureau Chief Hospital and Clinic Section 406/444-9614

Prior Authorization Contact Mark Eichler, R.Ph., FASCP 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., FASCP T: 406/443-4020

Montana DUR Board

Mark Eichler, R.Ph., FASCP DUR Coordinator V. Lee Harrison, M.D. Richard Sargent, M.D. Marcella Barnhill, R.Ph. Lori Fitzgerald, Pharm. D.

Prescription Price Updating First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578


Betty DeVaney, Drug Rebate Coordinator Department of Public Health & Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2591 T: 406/444-3457 F: 406/444-1861 E-mail: [email protected]


Montana-4


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]


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/Medical State: Asthma Program Name: Nurse First Asthma Program Program Manager: Ted Weldon Program Sponsor: Mckesson Health Solutions Disease/Medical State: Cardiovascular disease Program Name: Nurse First Asthma Program Program Manager: Ted Weldon Program Sponsor: Mckesson Health Solutions Disease/Medical State: Diabetes Program Name: Nurse First Asthma Program Program Manager: Ted Weldon Program Sponsor: Mckesson Health Solutions Disease/Medical State: Chronic Pain Program Name: Nurse First Asthma Program Program Manager: Ted Weldon Program Sponsor: Mckesson Health Solutions


Jacklynn Thiel, Quality Assurance Program Officer Dept. of Public Health and Human Services Medicaid Services Bureau P.O. Box 202951 1400 Broadway Helena, MT 59620-2951 T: 406/444-1834 F: 406/444-1861 E-mail: [email protected]

Mail Order Pharmacy Benefit None

Executive Officers of State Medical and Pharmaceutical Societies Montana Medical Association G. Brian Zins Executive Vice President/CEO 2021 11th Avenue, Suite 1 Helena, MT 59601-4890 T: 406/443-4000 F: 406/443-4042 E-mail: [email protected] Internet address: www.mmaoffice.com Montana Pharmacy Association Jim E. Smith Executive Director P. O. Box 1569 34 West 6th Avenue, Suite 2E Helena, MT 59601-5074 T: 406/449-3843 F: 406/443-1592 E-mail: [email protected] Internet address: www.rxmt.org State Board of Pharmacy Rebecca Deschamps, R.Ph. Executive Director P.O. Box 200513 301 South Park, 4th Floor Helena, MT 59620-0513 T: 406/841-2355 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 Carmen Bell Executive Director 1600 2nd Avenue, SW, Suite 120 Minot, ND 58701 701/852-8789 E-mail: [email protected] Montana Hospital Association Dick Brown Sr. Vice President/Executive Director P.O. Box 5119 Helena, MT 59604 406/442-1911, Ext. 26 E-mail: [email protected] Internet address: www.medassets.com/mtha.htm


Nebraska-1

NEBRASKA





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $161,577,499 178,365 $196,409,250 194,714 RECEIVING CASH ASSISTANCE TOTAL $58,978,402 45,490 $69,279,614 48,501 Aged $8,756,182 3,959 $9,843,626 3,983 Blind/Disabled $42,225,001 15,234 $49,388,569 15,517 Child $3,734,776 17,651 $4,534,213 19,350 Adult $4,262,443 8,646 $5,513,206 9,651 MEDICALLY NEEDY, TOTAL $40,152,899 30,671 $48,643,338 33,381 Aged $25,640,472 9,676 $29,632,049 9,808 Blind/Disabled $5,365,283 1,463 $6,684,567 1,527 Child $1,810,841 6,569 $2,260,713 6,761 Adult $7,336,303 12,963 $10,066,009 15,285 POVERTY RELATED, TOTAL $50,564,381 78,571 $65,092,478 90,996 Aged $13,567,579 6,293 $15,871,572 6,505 Blind/Disabled $22,577,439 7,496 $29,727,730 8,077 Child $13,960,793 60,808 $18,756,628 71,240 Adult $458,570 3,974 $736,548 5,174 TOTAL OTHER EXPENDITURES/RECIPIENTS* $11,881,817 23,633 $13,393,820 21,836 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division. Source: CMS, MSIS Report, FY 2001 and Nebraska Medicaid Statistical Information System, FY 2002.


Nebraska-2

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 25+ 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: anxiolytics, 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 (ICF/MR) patients;

8. Over-the-counter (OTC) drugs not listed on the Department’s Drug Name/License Number Listing microfiche;

9. Baby foods or metabolic agents (Lofenalac, etc.,) normally supplied by the Nebraska Department of Health;

10. Drugs distributed or manufactured by certain drug manufacturers or labelers that have not agreed to participate in the drug rebate program.

Drugs, items, or manufacturers that are identifiable as non-covered are so designated on the NE-POP system, and on the Department’s Drug Name/License Number Listing microfiche or website.

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.


Nebraska-3


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.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.27 - $5.00. The Nebraska Department of Health and Human Services assigns a dispensing fee to each individual pharmacy based on location, services, volume, and other third-party participation. The fee is calculated from information obtained through the Department’s Prescription Survey.

Ingredient Reimbursement Basis: EAC = AWP -11%.

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 1,400 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.



Approximately 156,000 unduplicated Medicaid recipients were enrolled in managed care in 2002. Recipient enrolled in MCOs receive pharmaceutical services through the State.


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


Dyke Anderson, R.Ph Pharmacy Consultant Department of Health and Human Services Finance and Support Medicaid Division 301 Centennial Mall South, 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected] Internet address: www.hhs.state.ne.us

Health and Human Services Department Officials Stephen Curtiss, Director Department of Health and Human Services Finance and Support P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-8553 F: 402/471-9449 E-mail: [email protected]


Nebraska-4

Robert J. Seiffert, Administrator Medicaid Division Department of Health and Human Services Finance and Support P.O. Box 95026 301 Centennial Mall South, 5th Floor Lincoln, NE 68509-5026 T: 402/471-9223 F: 402/471-9092 E-mail: [email protected] Richard Raymond, M.D., Chief Medical Official Department of Health and Human Services 402/471-9105 Kris Azimi Utilization Review Consultant 402/471-7620 Christine Wright, M.D., Medical Director Medicaid Division 402/471-9136


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 Contact Beth Wilson DUR Director Nebraska Pharmacists Association 6221 South 58th, Suite A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

Nebraska DUR Board Pharmacist Members: Kevin Borcher, R.Ph. Elissa Carney, R.Ph. Patty Gollner, R.Ph. David Hutsell, R.Ph. John Franklin, R.Ph. Kim Hamik, R.Ph. Shannon Nelson, R.Ph. Phillip Vuchetich, R.Ph.

Physician Members: Kay Anderson, M.D. Fred Ayers, M.D. Kirk Muffly, M.D. Thomas B. Murray, M.D. Sam Perry, M.D.


Dyke Anderson, R.Ph. 402/471-9379


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 Steve Smith Account Representative ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/901-5002 F: 770/730-5198 E-mail: [email protected]


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]


Nebraska-5


None

Medical Advisory Committee

Marlene Brondel League of Human Dignity 1701 P Street Lincoln, NE 68508 Tim Bruner Director of Fiscal Services Lincoln General Hospital 2300 South 16th Street Lincoln, NE 68502 Joni Cover, J.D. Executive Vice President Nebraska Pharmacists Association 6221 South 58th Street, Suite A Lincoln, NE 68502 Karen Miller Health Insurance Specialist Room 227, Federal Building 601 East 12th Street Kansas City, MO 64106 Edmund A. Schneider, O.D. Lincoln Vision Clinic 810 North 48th Street Lincoln, NE 68504 Steven Lorenzen Director, Federal Programs Blue Cross/Blue Shield of NE Main P.O. Station Box 3248 Omaha, NE 68180 John Milligan Legal Services of Southeast Nebraska 825 Terminal Building Lincoln, NE 68508 Joan Penrod, Ph.D. Department of Preventive and Social Medicine UNMC Box 984350, 600 S. 42nd Street Omaha, NE 68198 Larry Rennecker NAHHS 1640 L Street, Suite D Lincoln, NE 68508

Sandy Johnson Executive Secretary Nebraska Medical Association First Bank Bldg., Suite 1512 Lincoln, NE 68508 Pat Snyder Executive Director Nebraska Health Care Association 421 South 9th Street, Suite 137 Lincoln, NE 68508 James Walker, D.D.S. 1640 South 70th, Suite 200 Lincoln, NE 68506


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 A. 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-6

Nebraska Association of Hospitals and Health Systems Laura J. Redoutey, FACHE President 1640 L Street, Suite D Lincoln, NE 68508-2509 T: 402/458-4900 F: 402/475-4091 E-mail: [email protected] Internet address: www.nhanet.org


Nevada-1

NEVADA





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $62,849,319 55,580 $86,929,536 RECEIVING CASH ASSISTANCE TOTAL $45,602,458 29,090 Aged $9,830,256 5,917 Blind/Disabled $34,597,803 16,240 Child $588,847 4,156 Adult $585,552 2,777 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $1,863,191 10,403 Aged $97,513 157 Blind/Disabled $259,384 255 Child $806,164 5,859 Adult $700,130 4,132 TOTAL OTHER EXPENDITURES/RECIPIENTS* $15,383,670 16,087 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Note: Nevada estimates 2003 drug expenditures to be approximately $102.8 million. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Nevada-2

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.


Vaccines: Vaccines reimbursable at cost plus an administration fee ($3.83) as part of the EPSDT service.


Formulary/Prior Authorization 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.


State currently has a DUR Board with a quarterly review by a PRODUR contractor. PRODUR system implemented in 2003.


Nevada-3

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.76, effective 10/1/98. IV dispensing fee is $16.80 for first ingredient; $5.60 for other ingredients.


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 61,000 Medicaid recipients are enrolled in MCOs in 2002; all receive pharmacy benefits through their managed care plan.


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


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

Steve Espy, R.Ph. Director of Drug Utilization Health Information Design, Inc. 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531

DUR Contact

Dionne Coston, R.N. 775/684-3775

DUR Board

Joseph W. Johnson, M.D. 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


Nevada-4


Dionne Coston, R.N. 775/684-3775




Technical: Anita Sheard, 775/684-3749 Policy: Dionne Coston, R.N., 775/684-3755 Rebate: Anita Sheard, 775/684-3749


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 Street, Suite 204 Carson City, NV 89701 775/684-3697 E-mail: [email protected]


None


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 Health officer, Health Division


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: www.state.nv.gov/pharmacy Nevada Hospital Association Bill M. Welch President/CEO 5250 Neil Road Suite 302 Reno, NV 89502 T: 775/827-0184 F: 775/827-0190 E-mail: [email protected] Internet address: www.nvha.net


New Hampshire-1

NEW HAMPSHIRE





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $90,927,579 73,489 $99,682,997 RECEIVING CASH ASSISTANCE, TOTAL $25,669,473 18,137 Aged $3,216,921 1,436 Blind/Disabled $18,263,975 5,335 Child $1,567,158 7,533 Adult $2,621,419 3,833 MEDICALLY NEEDY, TOTAL $24,027,775 9,047 Aged $10,097,853 4,233 Blind/Disabled $11,643,790 2,676 Child $328,662 819 Adult $1,957,470 1,319 POVERTY RELATED, TOTAL $6,948,883 26,834 Aged $421,825 293 Blind/Disabled $437,532 257 Child $5,787,235 24,563 Adult $302,291 1,721 TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,281,448 19,471




New Hampshire-2

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; 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; erectile dyfunction products; PPIs; Cox IIs; Oxycontin; CNS stimulants; anti-fungals for nail fungus; and rheumatoid arthritis agents. Brand approval overrides required for NSAIDs, controlled substances, and GI drugs for which there are therapeutically equivalent (A-rated) generics available.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home healthcare and extended care facilities, and through physician payment when used in physicians’ offices.

Vaccines: Vaccines reimbursable as part of the EPSDT, CHIP, and VCP service. Childhood immunization vaccine is provided to all children through the Division of Public Health Services. The Medicaid program does not reimburse 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. Management of formulary includes prior authorization and quantity limits on certain products (e.g., anti-emetics, anti-migraine agents, etc.).

Prior Authorization: State currently has a formal prior authorization procedure with an associated grievance and appeal procedure.

Prescribing or Dispensing Limitations Monthly Quantity Limit: Limited to 30-day supply Maintenance Medications: Limited to 90-day Supply


Drug Utilization Review PRODUR system implemented in July 1995. State currently has a DUR Board with a quarterly review.




Prescription Charge Formula: Lesser of usual and customary charge or AWP-16%, 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.”


Patient Cost Sharing: Copayment – Generics: $1.00; Brand: $2.00, effective 3/1/04. Copayments apply to all recipients except nursing home patients in SNF or ICF facilities; home and community based care waived recipients holding form 949; pregnant women; children under 18 years; and prescriptions for family planning drugs.



None as of June 2003.


New Hampshire-3

F. STATE CONTACTS

State Drug Program Administrator Margaret A. Clifford Pharmacy Administrator Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4210 F: 603/271-8701 E-mail: [email protected] Internet address: www.dhhs.state.nh.us

Department of Health and Human Services Officials

John Stephen Commissioner Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-4331 F: 603/271-4912 E-mail: [email protected]

Stephen Norton Acting Director Office of Health Planning & Medicaid 129 Pleasant Street Concord, NH 03301 603/271-4297 [email protected]

DUR Contact

Lisè Farrand, R.Ph. Pharmaceutical Services Specialist Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 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. John Zinka, R.Ph.

New Brand Name Products Contact Lisé Farrand, R.Ph. 603/271-4419


Sherrill Bryant Plan Administrator First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]


John Cox Rebate Pharmacist First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965/7647 E-mail: [email protected]

Claims Submission Contact Sherrill Bryant 800/884-2822

Medicaid Managed Care Contact Margaret A. Clifford 603/271-4210

Mail Order Pharmacy Benefit None

Disease Management/Patient Education Contact Doris Lotz, M.D. Medicaid Medical Director Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-8166 F: 603/271-8701 E-mail: [email protected]


New Hampshire-4

Pharmacy & Therapeutics Advisory Committee William Kassler, M.D., M.P.H. Stephen Bartels, M.D. Doris Lotz, M.D. Bryan King, M.D. Steven Paris, M.D. Richard Lafleur, M.D. Eric Pollak, M.D., M.P.H.Lenny Parker, R.Ph. Margaret Clifford, R.Ph. Roger Hebert, R.Ph. Paul Santos, Pharm.D. Robert Lenza, R.Ph.

Executive Officers of State Medical and Pharmaceutical Services

New Hampshire Medical Society Palmer P. Jones Executive Vice President 7 N. State Street Concord, NH 03301-4018 T: 603/224-1909 F: 603/226-2432 E-mail: [email protected] Internet address: www.nhms.org

New Hampshire Pharmacists Association David Minnis Executive Director 2 Eagle Square, Suite 400 Concord, NH 03301-8905 T: 603/229-0292 F: 603/224-7769 E-mail: [email protected] Internet address: www.newhampshirepharmacistree.org

New Hampshire Osteopathic Association, Inc. Robert Soucy, D.O. President 7 North State Street Concord, NH 03301 603/224-1909 E-mail: [email protected] Internet address: www.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


New Jersey-1

NEW JERSEY 1





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $649,274,352 307,798 $694,669,924 RECEIVING CASH ASSISTANCE, TOTAL $364,861,677 165,644 Aged $66,082,464 30,760 Blind / Disabled $291,316,345 96,878 Child $1,682,939 14,742 Adult $5,779,929 23,264 MEDICALLY NEEDY, TOTAL $8,848,818 3,531 Aged $7,865,157 3,213 Blind / Disabled $948,839 230 Child $34,822 88 Adult $0 - POVERTY RELATED, TOTAL $100,274,542 57,346 Aged $32,401,984 14,695 Blind / Disabled $64,930,600 16,665 Child $2,513,691 20,113 Adult $428,267 5,873 TOTAL OTHER EXPENDITURES/RECIPIENTS* $175,289,315 81,277 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.

1 The State of New Jersey did not respond to the 2002 or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid program to assess the accuracy and currency of the information included.


New Jersey-2

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; cough and cold preparations for children under age 21; contraceptive devices and supplies; family planning supplies (e.g., pregnancy test kits); and smoking deterrent products (inhaler or nasal spray). Products not covered: digestive products; feminine products; contraceptives; pregnancy test kits; 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.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care and extended care facilities and through physician payment when used in physician offices.

Vaccines: Vaccines reimbursable at AWP 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”.



New Jersey-3


Cognitive Services: State pays for cognitive services.


Approximately 460,000 Medicaid recipients received pharmacy benefits through managed care in 2001. All receive pharmaceutical benefits from MCOs.


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


Edward J. Vaccaro, R.Ph. Assistant Director, Office of Utilization Management Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625 T: 609/588-2726 F: 609/588-3889 E-mail: [email protected]


Gwendolyn L. Harris, Commissioner Department of Human Services Capitol Place One CN-700, 5th Floor P.O. Box 700 Trenton, NJ 08625 T: 609/292-3717 F: 609/292-3824 E-mail: [email protected] Ann Clemency Kohler, Director Division of Medical Assistance and Health Services Department of Human Services P.O. Box 712 Trenton, NJ 08625-0712 T: 609/588-2600 F: 609/588-3583 E-mail: [email protected]

DUR Contact Edward J. Vaccaro, R.Ph. T: 609/588-2726

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.


Edward J. Vaccaro, R.Ph. T: 609/588-2726


First DataBank 1111 Bayhill Dr. San Bruno, CA 94066 415/588-5454


Technical: Daniel Upright, 609/588-2792 Policy: Edward J. Vaccaro, 609/588-2726 PA: Carl Tepper, 609/588-2744


New Jersey-4


Peter Ringel Deputy Project Director Unisys 3705 Quakerbridge Road, Suite 101 Trenton, NJ 08619 T:609/588-6000 F: 609/584-8270 E-mail: [email protected]


Edward J. Vaccaro 609/588-2726

Mail Order Benefit Program

State currently has a mail order benefit program. All Medicaid recipients are entitled to participate. 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


Edward J. 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 Frank Cagliari 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 Remi Erdos Executive Director P.O. Box 45013 Newark, NJ 07101 973/504-6450 E-mail: [email protected] Internet address: www.state.nj.us/lps/ca/brief/pharm.htm New Jersey Hospital Association Gary S. Carter, FACHE President & CEO 760 Alexander Road, P.O. Box 1 Princeton, NJ 08543-0001 609/275-4000 E-mail: [email protected] Internet address: www.njha.com


New Mexico-1

NEW MEXICO





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS

2001 2002*

Expenditures Recipients Expenditures Recipients TOTAL $70,147,344 75,669 $73,877,785 RECEIVING CASH ASSISTANCE TOTAL $38,536,342 33,554 Aged $7,975,843 6,366 Blind/Disabled $29,447,155 15,664 Disabled $350,900 5,397 Child $762,444 6,127 Adult $0 - MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $2,087,207 23,345 MEDICALLY NEEDY, TOTAL $96,973 176 Aged $342,469 425 Blind/Disabled $1,478,634 19,624 Child $169,131 3,120 Adult TOTAL OTHER EXPENDITURES/RECIPIENTS* $29,523,795 18,770 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.


New Mexico-2

C. ADMINISTRATION

Human Services Department (HSD), Medical Assistance Division.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Prior Authorization required for: amphetamines and stimulants for ADD (adults only); nutritional supplements. Products not covered: drugs for treatment of tuberculosis; cosmetics; experimental drugs; fertility drugs; drugs and immunizations available from any other source; medications supplied by the New Mexico State Hospital to clients on convalescent leave from hospital; hormones; stimulants; drugs classified by FDA as “ineffective;” hypnotic drugs (barbiturates); and drugs without Medicaid rebate participation agreement.

Over-the-Counter Product Coverage: 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 (prior authorization required); 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 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, the Children’s Health Insurance Program, and the Vaccine for Children Program. Unit Dose: Does not reimburse for unit dose packaging.

Formulary/Prior Authorization Formulary: Open formulary

Prior Authorization: State currently has a formal prior authorization procedure screening for drug classes.

Prescribing or Dispensing Limitations 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.


Dispensing Fee: $3.65, effective 6/12/02. State currently has a DUR Board that meets at least quarterly.

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 $2.00 for CHIP clients and working disabled clients.



New Mexico-3


Approximately 250,000 Medicaid recipients enrolled in are MCOs in FY 2002. Recipients receive pharmaceutical benefits through managed care plans.

F. STATE CONTACTS


Neal Solomon, M.P.H., R.Ph. Pharmacist, Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]

DUR Contact Neal Solomon, M.P.H., R.Ph. 505/827-3174

DUR Board Denise Cuellar, Pharm.D. Greg D’Armour, Pharm.D. Gregory Toney, R.Ph., Ph.C. John Piper, Pharm.D. John Lauriello, M.D. Gayle Chacon, M.D. John Seibel, M.D. Judy Romero, Pharm.D. Manual Archuleta, M.D.


Neal Solomon, M.P.H., R.Ph. 505/827-3174


Delfinia Dandoval, Human Services Department ASD 729 St. Michaels Drive Santa Fe, NM 87504-2348 T: 505/476-8920 F: 505/827-1147 E-mail: [email protected]



Prescription Price Updating Contact


Claims Submission

ACS, Inc. 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/352-8592 F: 770/730-5198

Medicaid Managed Care Contact Alana Reeves Human Services Department P.O. Box 2348 Santa Fe, NM 85705-2348 T: 505/827-3131 F: 505/827-3185 E-mail: [email protected]


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 New Mexico Department of Human Services Medicaid Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3100 F: 505/827-3185 E-mail: [email protected]

Medical Advisory Committee Members

Linda Sechovec Executive Director NM Health Care 6400 Uptown Boulevard, NE, Suite 520-W Albuquerque, NM 87110


New Mexico-4

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 Drive, Bldg. D Santa Fe, NM 87501 Michelle Lujan-Grisham New Mexico State Agency on Aging 228 East Palace Avenue Santa FE, NM 87501 Sam Cata, Commissioner Office of Indian Affairs 224 E. Palace Avenue Santa FE, NM 87501 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 Boulevard, 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] Internet address: www.nm-pharmacy.com New Mexico Osteopathic Medical Association Elizabeth “Betty” Barrett Executive Director P. O. Box 53098 Albuquerque, NM 87153-3098 T: 505/332-2146 F: 505/332-4861 E-mail: [email protected] Internet address: www.nmoma.org


New Mexico-5

State Board of Pharmacy Jerry Montoya Chief Inspector/Director 111 Lomas Boulevard, Suite 412 Albuquerque, NM 87102 T: 505/222-9130 F: 505/222-9145 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: www.nmhsa.org


New Mexico-6


New York-1

NEW YORK





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2002** 2003*** Expenditures Recipients Expenditures Recipients TOTAL $3,660,427,024 $3,949,177,519 2,567,097 RECEIVING CASH ASSISTANCE, TOTAL $2,340,874,399 840,496 Aged $419,244,725 140,438 Blind/Disabled $1,799,235,899 450,143 Child $47,920,289 181,271 Adult $74,473,486 68,544 MEDICALLY NEEDY, TOTAL $1,021,426,022 1,030,106 Aged $265,858,105 113,314 Blind/Disabled $478,087,980 114,547 Child $140,836,085 553,923 Adult $136,643,853 248,322 POVERTY RELATED, TOTAL $552,607,313 635,184 Aged $1,914 28 Blind/Disabled $0 - Child $68,148,436 289,938 Adult $484,456,964 345,218 TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,269,785 61,311 * Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. ***2003 data provided by the New York State Department of Health, Office of Medicaid Management.

Source: CMS, CMS-64 Report, FY 2002 and New York State Medicaid Statistical Information System, FY 2003.


New York-2

C. ADMINISTRATION

State Department of Health, Office of Medicaid Management.


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); second generation antihistamines; growth hormones; (serostim) medical/surgical supplies; orthopedic shoes; compression stockings; and some DME items. Therapeutic categories not covered: anorectics and agents used for hair growth.

Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care facilities and through physician payment when used in physician offices. In extended care facilities reimbursement for non-self administered injectable medicines is included in the facility rate. No special coverage policies exist for self-administered injectable medicines. Vaccines: Vaccines are reimbursable under the EPSDT service, CHIP, and the Vaccines for Children program.


Formulary/Prior Authorization Formulary: Open formulary. Utilization managed through restrictions on use, prior authorization, and quantity limits. General Exclusions: New York State follows OBRA '90 guidelines in the reimbursement of prescription drugs.

Prior Authorization: State currently has a formal prior authorization procedure and a Pharmacy and Therapeutics Committee that meets quarterly. Although there is no formal method for appealing a prior authorization decision, the ordering prescriber may call the voice interactive system until the system issues a prior authorization number. All requests are approved. Beginning in November 2002, all brand name drugs with A-rated generics require prior authorization.


Prescription Refill Limit: Maximum of 5 refills within 6 months. Also, annual limits on number of prescriptions and prescription and nonprescription drugs without an override. Monthly Dollar Limits: None.

Drug Utilization Review PRODUR system implemented in March 1995. State currently has a DUR Board which meets bimonthly.


Dispensing Fee: $3.50 for brand name drugs, $4.50 for generic drugs. Effective 8/1/98.

Ingredient Reimbursement Basis: EAC = AWP-12% (effective 7/1/03)

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.


New York-3

Maximum Allowable Cost: State imposes Federal Upper Limits on generic drugs must get prior authorization for most brand name products. (see www.health.state.ny.us/nysdoh/medicaid/ ptcommittee/mandatorggen.htm)

Incentive Fee: $1.00 for dispensing a lower cost multi- source product.

Patient Cost Sharing: Copayment is $2.00 for brand name drugs, $0.50 for generic and OTC drugs. Exceptions include psychotropic drugs as well as drugs FDA approved for the treatment of tuberculosis and family planning drugs.



Approximately 1.1 million Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through the State.

Health Maintenance Organizations

− ABC Health Plan − Affinity Health Plan − AmeriChoice of New York − Broome MC − Buffalo Community 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 − HealthSource/Hudson Health Plan − HIP − IHA − Manhattan PHSP/CenterCare − Metropolitan Plus Health Plan − Neighborhood Health Providers − NY Hospital Community PHSP − NYPS Select Health − NYS Catholic Health − PCMP − Preferred Care − Primary Health − Southern Tier − St. Barnabas/Partners in Health

− Suffolk Co PHSP − Total Care/Syracuse PHSP − United Healthcare Plan of NY, Inc. − United Healthcare of Upstate − VitaCare, Inc. − 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 Avenue, 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. John Navarra, R.Ph. (Chairman) Dilip Patel, R.Ph. Mohammed Saleh, R.Ph. John Westerman, R.Ph.

Formulary Contact

Mark-Richard A. Butt, M.S., R.Ph. 518/474-9219




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.


New York-4

DUR Contact

Lydia Kosinski, R.Ph. DUR Manager Office of Medicaid Management NYS Department of Health 99 Washington Avenue, 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.




Carl T. Cioppa, R.Ph. Manager, Pharmacy Operations Pharmacy Policy and Operations NYS Dept. of Health, Office of Medicaid Management 99 Washington Avenue, Suite 606 Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Sally Nelson, R.Ph. E-mail: [email protected]


Audit & Policy: Mark-Richard Butt, 518/474-9219 Disputes: Joseph Maiello, 518/474-9219 PRODUR: Dennis Pidgeon, 518/474-6866

Claims Submission Contact eMedNY Computer Sciences Corporation (CSC) One CSC Way Rensselaer, NY 12144 800/343-9000 E-mail: [email protected]


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/Medical State: AIDS/HIV Program Name: Aids Intervention Management Program Program Sponser: AIDS Institute, NYSDOH Disease/Medical State: Asthma Program Name: Asthma Quality Improvement Project Program Sponser: NYSDOH Disease/Medical State: Diabetes Program Name: Diabetes Quality Improvement Project Program Sponser: NYSDOH Disease/Medical State: Smoking Cessation Program Name: Smokers’ Quit Line Program Sponser: Roswell Park

Disease Management Program/Initiative Contacts

Karen A. Fuller, Ph.D. Director, Bureau of Program Guidance NYS Department of Health Office of Medicaid Management 99 Washington Avenue, Suite 606 Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] Donna Haskin E-mail: [email protected] Denise Spor E-mail: [email protected]



New York-5

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 Avenue Albany, NY 12203 T: 518/452-6828 F: 518/452-6882 E-mail: [email protected] Internet address: www.health.state.ny.us/nysdoh/epic/faq.htm

Department of Health Officials

Antonia C. Novello, M.D, M.P.H., Dr. Ph. Commissioner NYS Department of Health Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, NY 12237 T: 518/474-2011 F: 518/474-5450 E-mail: [email protected] Kathryn Kuhmerker, Deputy Commissioner Office of Medicaid Management NYS Department of Health Corning Tower The Governor Nelson A. Rockefeller Empire State Plaza Albany, NY 12237 T: 518/474-3018 F: 518/486-6852 E-mail: [email protected] Karen A. Fuller, Ph.D. Assistant Director, Bureau of Program Guidance Division of Policy and Program Guidance/Office of Medicaid Management 99 Washington Avenue, Suite 606 Albany, NY 12210 518/474-9219 Mark-Richard A. Butt, MS, R.Ph. Assistant Director, Pharmacy Policy and Operations 518/474-9219 E-mail: [email protected] Carl T. Coppa, R.Ph. Manager, Pharmacy Operations 518/474-9219 E-mail: [email protected]

Anita Murray, R.Ph. Manager, Pharmacy Policy E-mail: [email protected] Joseph Maiello, R.Ph. Manager, Pharmacy Rebates 518/474-9219 E-mail: [email protected]


Ruben P. Cowart, D.D.S., (Chairman) John Angerosa, M.D. Steven E. Barnes, D.O. Russel N. Cecil, M.D. David Cerniglia, D.C. Stoner E. Horey, M.D. Mary K. Lashomb Norman R. Loomis, M.D. Hugo M. Morales, M.D., P.C. Tanton Mustapha, M.D. Leon Nadrowski, M.D. Dennis P. Norfleet, M.D. Elena Padilla, Ph.D. Carl P. Sahler, M.D., Ph.D. Robert A. Schwartz, M.D. Gavin Setzen, M.D. Kathleen Benson Smith Patricia Stevens, Deputy Commissioner, NYS Office of Temporary and Disability Assistance (DSS Representative) Roger W. Trifthauser, D.D.S., M.S.


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: 516-488-6136 E-mail: [email protected] Internet address: www.mssny.org Pharmasists Society of the State of New York Craig Burridge, M.S., CAE Executive Director 210 Washington Avenue Extension Albany, NY 12203 T: 518/869-6595 F: 518/464-0618 E-mail: [email protected] Internet address: www.pssny.org/index_new.htm


New York-6

New York State Osteopathic Medical Society, Inc. Martin Diamond, D.O. Executive Director 1855 Broadway, Suite 1102A New York, NY 10023 T: 212/261-4137 F: 312/202-1786 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 One Empire Drive Rensselaer, NY 12114 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


North Carolina-1

NORTH CAROLINA





Child Adult

Prescribed Drugs





Physician Services

Dental Services B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $971,066,103 907,413 $1,100,822,176 RECEIVING CASH ASSISTANCE TOTAL $558,673,839 432,859 Aged $154,115,092 65,618 Blind/Disabled $315,225,407 127,822 Child $27,022,573 121,937 Adult $62,310,767 117,482 MEDICALLY NEEDY, TOTAL $64,926,538 28,652 Aged $44,433,190 17,372 Blind/Disabled $16,408,373 6207 Child $614,556 899 Adult $3,470,419 4,174 POVERTY RELATED, TOTAL $327,242,251 402,313 Aged $135,848,480 60,081 Blind/Disabled $128,536,123 50,197 Child $56,963,937

255,320

Adult $5,893,711 36,715 TOTAL OTHER EXPENDITURES/RECIPIENTS*

$20,223,475 43,589



North Carolina-2

C. ADMINISTRATION

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


Benefit Design

Drug Benefit Product Coverage: Products covered: select OTC products; 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 not listed on the selected coverage list; and those products mentioned below under “Therapeutic Category Coverage” section.

Over-the-Counter Product Coverage: North Carolina covers a select list of OTC products. (see www.dhhs.state.nc.us/dma/mp/mpindex.htm)

Therapeutic Category Coverage: North Carolina provides coverage for all therapeutic categories except products used for cosmetic purposes; fertility drugs; diaphragms; IV fluids(Dextrose 500ml or greater) and irrigations fluids used in an inpatient facility; Drugs on DESI list; any drug manufactured by a company who has not signed the federal rebate agreement; and experimental drugs. Prior authorization required for: Drugs used to treat ADHD; Procrit/Epogen; Neupogen; Aransep; OxyContin; Growth Hormones;Provigil; Rebetron; Vioxx; Celebrex; Bextra; Enbrel; Botox; Mybloc; Zyban, Nicotrol, Nicotine Patch; Synagis; and RespiGam. (see www.ncmedicaidpbm.com for additional information.)

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: Formal prior authorization process can be found at: ww.ncmedicaidpbm.com. A prescriber’s written justification is required to appeal a prior authorization decision.

Prescribing or Dispensing Limitations Monthly Quantity Limit: 34-day supply maximum. Except birth control tablets and hormonal replacement therapy dial packs: 3 months; maintenance non-controlled medications, tied with the FUL and/or SMAC after a prior successful fill may receive a 3 month supply upon the prescribers discretion.

Monthly Prescription Limit: Six prescriptions per month per recipient.

Prescription Dollar Limits: None.

Drug Utilization Review 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 plus a dispensing fee or usual and customary, whichever is lowest. The pharmacist filling the original prescription will not be reimbursed for refills for the same drug within a calendar month.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits generic drugs. 367 drugs are listed on the State-specific MAC list. Override requires “Brand Medically Necessary” written on the face of the prescription by the prescriber.


Patient Cost Sharing: $1.00 copayment/Rx (includes refills) for generic prescriptions; $3.00 copayment/Rx for brand name prescriptions.



North Carolina-3


Approximately 30,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through the State.

Managed Care Organizations SouthCare/Coventry 2815 Coliseum Center Drive Charlotte, NC 28217

F. STATE CONTACTS


Sharman C. Leinwand, R.Ph., M.P.H. Pharmacy Program Manager Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/857-4034 F: 919/715-1255 E-mail: [email protected] Internet address: www.dhhs.state.nc.us/dma


Sharman C. Leinwand, R.Ph., M.P.H. 919/857-4034

DUR Contact


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.




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]


Audits: Sharman C. Leinwand, R.Ph., M.P.H. 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, R.Ph., M.P.H. 919/857-4034

Department of Human Resources Officials Gary Fuquay, 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


North Carolina-4

Office of Research Demonstration and Rural Health Development Torlen Wade 311 Ashe Avenue Raleigh, NC 27606 919/857-4267

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 Jeffrey J. LeBoeuf Executive Director 8311 Brier Creek Parkway Raleigh, NC 27617 T: 888/626-6248 F: 910/763-4666 E-mail: [email protected] Internet address: www.ncoma.org State Board of Pharmacy David R. Work Executive Director P.O. Box 4560 Chapel Hill, NC 27515-4560 T: 919/942-4454 F: 919/967-5757 E-mail: [email protected] Internet address: www.ncbop.org North Carolina 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


North Dakota-1

NORTH DAKOTA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $43,288,363 39,758 $52,495,878 RECEIVING CASH ASSISTANCE, TOTAL $20,469,921 18,113 Aged $4,465,220 1,978 Blind/Disabled $12,892,102 5,031 Child $1,238,624 7,216 Adult $1,873,975 3,888 MEDICALLY NEEDY, TOTAL $19,371,705 10,427 Aged $12,570,047 5,815 Blind/Disabled $6,083,620 2,136 AFDC-Child $318,364 1,577 AFDC-Adult $399,674 899 POVERTY RELATED, TOTAL $586,363 3,898 Aged $5,838 21 Blind/Disabled $7,750 25 AFDC-Child $481,791 3,324 AFDC-Adult $90,984 528 TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,860,374 7,320 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


North Dakota-2

C. ADMINISTRATION

North Dakota Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; and total parenteral nutrition. Products not covered: cosmetics; fertility drugs; urine ketone test strips; interdialytic parenteral nutrition; drugs used for hair growth; prescription vitamins (except prenatal vitamins); and DESI drugs. Prior authorization required for: nutritional supplements; and orlistat.

Over-the-Counter Product Coverage: Products covered: antacids; analgesics; iron supplements; artificial tears; digestive products; and anti-ulcer medications. Products covered with restriction: allergy, asthma, and sinus products; smoking deterrent products (lifetime limits). Products not covered: cough and cold preparations; feminine products; and topical products.

Therapeutic Category Coverage: Categories covered: anabolic steroids; antibiotics; anticoagulants; anticouvulsants; 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); thyroid agents; and prescribed smoking deterrents. Prior authorization required for: brand name NSAIDs, anoretics (orlistat); antihistamines; and PPIs. 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.



Formulary: Open formulary

Prior Authorization: State currently has a formal prior authorization procedure. Beneficiary can request a fair hearing to appeal a prior authorization decision.

Prescribing or Dispensing Limitations Prescription Refill Limit: 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. Limits on the number of refills by class (e.g., 0 for C-IIs; 5 for C-IIIs, IVs, and Vs).



Drug Utilization Review PRODUR system implemented in July 1996. State has a DUR Board that meets quarterly.


Dispensing Fee: $5.60 for generic, $4.60 for brand effective 8/1/03.


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


Approximately 600 Medicaid recipients were enrolled in managed care organizations in 2002. Recipients enrolled in MCO’s receive pharmacy benefits through the State.


North Dakota-3

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: 701/328-1544 F: 701/328-1544 E-mail: [email protected] Prior Authorization Contact

Brendan K. Joyce, Pharm.D., R.Ph. 701/328-1544

DUR Contact


DUR Board

Mark Biel, RPh Term Expires: 06/30/2005 Patricia Churchill, RPh Term Expires: 06/30/2004 Leann Ness, PharmD Term Expires: 06/30/2004 Greg Pfister, PharmD Term Expires: 06/30/2006 John Savageau, RPh Term Expires: 06/30/2006 Robert Treitline, RPh Term Expires: 06/30/2005 Kamille Sherman, MD Term Expires: 06/30/2005 Ronald Burd, MD Term Expires: 06/30/2006 Norman Byers, MD Term Expires: 06/30/2006 Albert Samuelson, MD Term Expires: 06/30/2004

Robert Thompson, MD Term Expires: 06/30/2005 John Windsor, DO Term Expires: 06/30/2004 Ex-Officio Members Gary Betting, M.D. Medical Consultant, DHS Brendan K. Joyce, Pharm.D., R.Ph. Medical Services, DHS Mary Koenecke, RPH PHRMA Term Expires: 06/30/2004










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., R.Ph. 701/328-41544


North Dakota-4

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.


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 Lynn Blakeman St. Vincent’s Care Center Alison Fallgater, D.D.S. Amy Fleck, O.D. Howard Anderson, R.Ph. Terry Johnson, MD David Peske ND Medical Association Gary Betting, M.D. DHS-Medical Consultant 2 Medicaid Recipients

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


North Dakota-5

Donald R. Lamb, M.D. 100 4th Street, S., Suite 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, Suite 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 Carmen Christianson Bell President Director 1600 2nd Avenue, SW, Suite 20 Minot, ND 58701 701/852-8798 Internet address: www.ndoma.org North Dakota Pharmaceutical Association Wade B. Bilden 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 5807-7340 T: 701/328-9535 F: 701/224-9529 E-mail: [email protected]


North Dakota-6

North Dakota Hospital Association Arnold R. Thomas, President 3205 E. Thayer Avenue Bismarck, ND 58501 701/224-9732 E-mail: [email protected]


Ohio-1

OHIO





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $1,087,552,923 904,380 $1,333,992,298 RECEIVING CASH ASSISTANCE, TOTAL $540,895,726 292,077 Aged $84,684,721 32,916 Blind/Disabled $430,791,473 161,509 Child $11,864,467 66,278 Adult $13,555,065 31,374 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $35,401,852 148,249 Aged $2,188,262 1,883 Blind/Disabled $5,157,289 2,989 Child $24,761,193 122,129 Adult $3,295,108 21,248 TOTAL OTHER EXPENDITURES/RECIPIENTS* $511,255,345 464,054



Ohio-2

C. ADMINISTRATION

Ohio Department of Job and Family Services, Bureau of Health Plan Policy.

D. PROVISIONS RELATING TO DRUGS Benefit Design

Drug Benefit Product Coverage: Products covered: most drugs including prescribed insulin; total parenteral nutrition products; and interdialytic parenteral nutrition products. 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. Products covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. 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: analgesics, antipyretics, and NSAIDS; anticoagulants; anticonvulsants; anti-depressants; anti-psychotics; anxiolytics, sedatives and hypnotics; chemotherapy agents; contraceptives; estrogens; and thyroid agents. Prior authorization required for: antibiotics; antidiabetic agents; antihistamines; antilipemic agents; cardiac drugs; prescribed cold medications; ENT-anti-inflammatory agents; hypotensive agents; misc. GI drugs; prescribed smoking deterrents; and sympathominetics (adrenergic). Therapeutic categories not covered: anbolic steroids; anorectics; growth hormones; innovator multi-source drugs; 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 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. ADL managed by excluding products based on contracting issues, restrictions on use, and prior authorization.

Prior Authorization: State currently has a formal prior authorization procedure. Prior authorization is needed for certain individual drugs (see examples above) A beneficiary may appeal a prior authorization decision and be granted an administrative hearing.


State does not impose prescribing or dispensing limits on prescriptions.


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. ($0.50 fee for flu vaccine.) Ingredient Reimbursement Basis: EAC = WAC + 9% (eff. 5/1/02). Prescription Reimbursement Formula: Reimbursement for legend drugs and selected OTC products based on the lowest of:

1. 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.


Ohio-3


Approximately 400,000 Medicaid recipients were enrolled in managed care in 2002. All received pharmacy services through managed care plans.

Managed Care Organizations Buckeye Community health Plan 175 South Third Street Suite 520 Columbus, OH 43215 866/246-4356 Dayton Area Health Plan One South Main Street One Dayton Center Dayton, OH 45402 937/224-3300 PrimeTime Medical Insurance Company P.O. Box 6907 Canton, OH 44706 330/451-0934 Paramount Care, Inc. P.O. Box 928 Toledo, OH 43697-0928 419/887-2550 QualChoice Health Plan 6000 Parkland Boulevard Cleveland, OH 44124 440/460-0093 SummaCare P.O. Box 3620 Akron, OH 44309 330/996-8410

F. STATE CONTACT

State Program Drug 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 Street, 27th Floor Columbus, OH 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]


Robert P. Reid, R.Ph. 614/466-6420


Drugs: Robert P. Reid, R.Ph. 614/466-6420 DME/Nutritions: Bonnie Brownlee 614/466-6065

DUR Contact

Jan Lawson DUR Administrator 255 East Main Street Columbus, OH 43215 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.




Robert P. Reid, R.Ph. 614/466-6420


First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7696


Cynthia Burnell, Chief Bureau of Managed Health Care Ohio Department of Job and Family Services 255 E. Main Street Columbus, OH 43215 614/466-4693

Mail Order Pharmacy Benefit State has mail order providers.


Ohio-4


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 Court Columbus, OH 43220 Susan Baker, APN 2288 Kings Corners East Lexington, OH 44904 Mary Jo Welker, M.D. 2231 North High Street Columbus, OH 43201 Jennifer Christner, M.D. 2262 Parkwood Toledo, OH 43620 Sandra Hrometz, R.Ph, Ph.D. 740 E. College Avenue Bluffton, OH 43209 Tammie J. Stroup, R.Ph. 30 E. Broad Street, 27th Floor Columbus, OH 43215-3414

Department of Job and Family Services Officials 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: 614/466-0140 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

Medical Care Advisory Committee

Jerry Friedman, Chair Cindy Norwood Ed Lentz Hubert Wirtz Robert Logan Eugene King, J.D. Pamela Morris Frank Giganti Walter Clark, M.D. Eileen Cooper Reed Robert Staib Jack Cera Art Schlesinger Randall Garland William Sawyer, M.D. Virginia Haller, M.D. Maureen Mitchell, R.N., Ed.D. Richard Tuck, M.D. Christopher Moore Nancy Lee Kathleen Anderson Katherine Kuck Donna Skoda, M.S., R.D., L.D. T. Clifford Deveny, M.D. Randy Runyon Brian Tilow


Ohio State Medical Association Brent Mulgrew Executive Director 3401 Mill Run Drive Hilliard, OH 43026 T: 800/766-6762 F: 614/527-6763 E-mail: [email protected] Internet address: www.osma.org


Ohio-5

Ohio Pharmacists Association Ernest “Ernie” Boyd Executive Director 6037 Frantz Road, Suite 106 Dublin, OH 43017 T: 614/798-0037 F: 614/798-0978 E-mail: [email protected] Internet address: www.ohiopharmacists.org 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, Room 1702 Columbus, OH 43215-6126 T: 614/466-4143 F: 614/752-4836 E-mail: [email protected] Interent address: www.state.oh.us/pharmacy/ Ohio Hospital Association James Castle, CEO 155 E. Broad Street, 15th Floor Columbus, OH 43215-3620 T: 614/221-7614 F: 614/221-4771 E-mail: [email protected] Internet address: www.ohanet.org


Ohio-6


Oklahoma-1

OKLAHOMA1





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $215,717,760 249,678 $285,068,869 RECEIVING CASH ASSISTANCE, TOTAL $71,737,280 62,218 Aged $21,886,460 21,329 Blind/Disabled $48,377,145 35,113 Child $903,823 4,161 Adult $569,852 1,615 MEDICALLY NEEDY, TOTAL $296,233 562 Aged $13,911 31 Blind/Disabled $149,640 137 Child $61,257 210 Adult $71,425 184 POVERTY RELATED, TOTAL $26,864,537 129,023 Aged $85,695 170 Blind/Disabled $134,217 149 Child $24,942,717 114,054 Adult $1,701,908 14,650 TOTAL OTHER EXPENDITURES/RECIPIENTS* $116,819,710 57,875 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002. 1 Note: As of January 1, 2004, (after the survey was conducted) the Oklahoma Medicaid program, according to its website, underwent changes regarding managed care. These changes will be reflected in the 2004 compilation. Please contact the State for information on the changes in managed care.


Oklahoma-2

C. ADMINISTRATION Oklahoma Health Care Authority.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered (DME benefit): disposable needles and syringe combinations for insulin; blood glucose test strips; and urine ketone test strips. Products covered with restrictions: total parenteral nutrition (reimburse single most costly ingredient, not reimbursed through pharmacy program). Products not covered: cosmetics; fertility drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered: birth control products. Products covered with restrictions: allergy, asthma, and sinus products (Claritin OTC only for children < 21 years. PA required for adults. Rx required for all ages.); digestive products (non-H2 antagonists-Prilosec OTC only, Rx required); smoking deterrent products (PA and Rx required). Products not covered: analgesics; cough and cold preparations; H2 antagonists; feminine products; topical products. Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidepressants; antidiabetic agents; antilipemic agents; anti-psychotics; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anoretics (partial coverage); analgesics, antipyretics, NSAIDs; antihistamine drugs (partial coverage); anxiolytics, sedatives, and hypnotics; cardiac drugs; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents (partial coverage) stimulants for ADHD; clopidigrel; and montelukast. Therapeutic categories not covered: anabolic steroids; and prescribed cold medications. OBRA ’90 drugs identified as "coverage optional." Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and physician payment when used in home health care and extended care facilities, and through physician payment when used in physician offices. Vaccines: Vaccines reimbursable as part of EPSDT services and the Vaccines for Children Program. Unit Dose: Unit dose packaging not reimbursable.


Formulary: Open formulary with the preferred drug list (PDL). PDL managed through restrictions on use, prior authorization, therapeutic substitution, use of preferred products, and step therapy. 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.


PRODUR system implemented in 2000. State currently has a DUR Board with a monthly review.


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, 414 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.


Oklahoma-3


Approximately 185,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive benefits through both the State and managed care plans. Effective 1/1/2004, there will be no fully capitated managed care plans in Oklahoma. The Primary Care/Care Management System will remain in place.

F. STATE CONTACTS


Nancy Nesser, D.Ph., J.D. Pharmacy Director Oklahoma Health Care Authority 4545 N. Lincoln, 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

Prior Authorization Contact Ronald Graham, D.Ph. Manager, Operations/DUR University of Oklahoma, College of Pharmacy P.O. Box 26901 Oklahoma City, OK 73109 T: 405/271-6614 F: 405/271-2615 E-mail: [email protected]

DUR Contact Ronald Graham, D.Ph. 405/271-6614

Medicaid DUR Board

Rick Crensaw, D.O. Dick Robinson, R.Ph. (Vice-Chair) Dorothy Gourley, D.Ph. Cliff Meece, D.Ph. Greg Tarasoff, M.D. Cathy E. Hollen, D.Ph. Thomas Kuhls, 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 Internet address: www.firstdatabank.com


Tom P. Simonson Drug Rebate Manager 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]


Rodney Ramsey Pharmacy Claims Specialist Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7492 F: 405/530-3238 E-mail: [email protected]

Claims Submission Contact EDS 2401 N.W. 23rd Street, Suite 11 Oklahoma City, OK 73107 405/416-6794


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.


Kathe Eastham, R.N Nurse Case Manager III Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105-9901 T: 405/522-7155 F: 405/522-7378 E-mail: [email protected]


Oklahoma-4

Oklahoma Health Care Authority Officials

Michael Fogarty, J.D. Chief Executive Officer Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7300 F: 405/522-7187 E-mail: [email protected] Lynn Mitchell, M.D. State Medicaid Director Oklahoma Health Care Authority 4545 N. Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/530-7365 F: 405/530-3218 E-mail: [email protected]

Advisory Committee on Medical Care for Public Assistance Recipients

Frank Wilson, III, M.D., Chairman 4545 N. Lincoln, Suite 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, Ph.D., Executive Director P.O. Box 18731 Oklahoma City, OK 73154 T: 405/528-3338 F: 405/528-1417 E-mail: [email protected] Internet address: www.opha.com Oklahoma Osteopathic Association Lynette C. McLain Executive Director 4848 N. Lincoln Boulevard Oklahoma City, OK 73105-3321 T: 405/528-4848 F: 405/528-6102 E-mail: [email protected] Internet address: www.okosteo.org

State Board of Pharmacy Janis K. McAllister President 4545 N. Lincoln Boulevard, Suite 112 Oklahoma City, OK 73105-3488 T: 405/521-3815 F: 405/521-3758 E-mail: [email protected] Internet address: www.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


Oregon-1

OREGON





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $222,018,784 220,711 $279,029,096 RECEIVING CASH ASSISTANCE TOTAL $81,943,856 59,881 Aged $8,775,572 7,674 Blind/Disabled $66,610,479 31,564 Child $1,293,366 10,333 Adult $5,264,439 10,310 MEDICALLY NEEDY, TOTAL $32,193,369 7,442 Aged $5,225,676 1,960 Blind/Disabled $26,967,693 5,482 Child $0 - Adult $0 - POVERTY RELATED, TOTAL $5,834,456 37,267 Aged $446,133 404 Blind/Disabled $1,288,996 622 Child $3,452,072 31,426 Adult $647,255 4,815 TOTAL OTHER EXPENDITURES/RECIPIENTS* $102,047,103 116,121 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. ** 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Oregon-2

C. ADMINISTRATION

Office of Medical Assistance Programs (OMAP), Department of Human Services.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin. Products covered under DME: disposable needles and syringe combinations used for insulin; blood glucose test strips; and urine ketone test strips. Prior authorization required for: isotretinon; acute anti-ulcer drugs; cosmetics; total parenteral nutrition; interdialytic parenteral nutrition; retinoic acid; nasal inhalers; coal tar preparations; and topical testosterone. Products not covered: cosmetics; fertility drugs; experimental drugs.

Over-the-Counter Product Coverage: Products requiring prior authorization and physician prescription (limited to 3 claims per month in each therapeutic class): 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: analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anti-depressants; antidiabetic drugs; antilipemic agents; antipsychotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; estrogens; hypotensive agents; prescribed smoking deterrents; sympathominetics (andrenergic); and thyroid agents. Therapeutic categories requiring prior authorization: anabolic steroids; anticonvulsants; antihistamine drugs; anxiolytics, sedatives, and hypnotics; ENT anti-inflammatory agents; growth hormones; misc. GI drugs; antifungals; legend laxatives; oral nutrionals; topical antibiotics; topical antivirals; weight reduction drugs; and any other drug products for which the only indication is for a non-funded condition. Therapeutic categories not covered: anoretics. (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.



Formulary: Open formulary with a preferred drug list (PDL). PDL managed through physician profiling.

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.


34 days for chronic drugs. (Limits on initial prescription for chronic medications to 15 days to prevent wasting if drug is changed due to intolerance, side effects, etc.) Therapy duration limits on selected drugs.




Dispensing Fee: $3.50, $3.80, effective 10/01/01. 1) $3.50 (retail); 2) $3.90 (institutional/SNF: providers operating a

True or Modified Dose Delivery System). Ingredient Reimbursement Basis: EAC = AWP-15% (Retail), AWP-11% (Institutional)

Prescription Charge Formula: Estimated acquisition cost (EAC) defined as the lesser of: (1) AWP-15% (2) Federal Upper Limits for multiple source drugs or (3) state MAC, or (4) the usual and customary charge plus a dispensing fee.

Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific maximum allowable cost (MAC) limits on generic drugs. Override requires or “Brand Medically Necessary” plus documentation of patient intolerance to generic.


Patient Cost Sharing: $2.00 (generic); $3.00 (brand)



Oregon-3


Approximately 265,000 Medicaid Recipients were enrolled in MCOs in FY 2002. Recipients enrolled in MCOs receive pharmaceutical benefits through managed care plans. Mental health drugs are carved out of managed care. Care Oregon, Inc 522 SW Fifth Avenue, Suite 200 Portland, OR 97204 800/224-4840 Cascade Comprehensive Care, Inc. 900 Main Street, Suite A P.O. Box 217 Klamath Falls, OR 97601-0368 541/883-2947 Central Oregon Independent Health Services, Inc. 2650 NE Courtney Drive P.O. Box 5729 Bend, OR 97708-5729 800/431-4155 Doctors of The Oregon Coast South (DOCS) 750 Central, Suite 202 P.O. Box 1096 Coos Bay, OR 97420 541/269-7400 Douglas County IPA 500 SE Cass, Suite 210 Roseburg, OR 97470 541/677-3453 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 Street, 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 P.O. Box 925 Hillsboro, OR 97123-0925 800/681-1901

F. STATE CONTACTS


Thomas Drawbaugh Pharmacy Program Manager Office of Medical Assistance Programs (OMAP) Department of Human Resources 500 Summer Street, NE, E-35 Salem, OR 97301-1077 T: 503/945-6492 F: 503/373-7689 E-mail: [email protected] Internet address: www.dhs.state.or.us/healthplan


Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected]


Oregon-4

DUR Contact

Kathy L. Ketchum, R.Ph., M.P.A.: H.A. 503/494-1589

Medicaid DUR Board

Rickland G. Asai, D.M.D. Patrick Bowman, R.Ph. Gerald D. Fairbanks, R.Ph. Dean Haxby, Pharm.D. Christina Heinrich, Pharm.D. (Vice-Chair) Robert Ingle, Jr., M.D., M.P.H. Gregory Johnson, M.D. (Chair) Raymond S. Lee, D.O. Sharon Leigh, Pharm.D. John Muench, M.D., M.P.H. Clifford Singer, M.D.

New Brand Name Products Contact Kathy L. Ketchum, R.Ph., M.P.A.: H.A. 503/494-1589

Prescription Price Updating Jim Rowland Account Manager First Health Services Corporation 925 Commercial Street Salem, OR 97301-2460 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

Medicaid Drug Rebate Contacts Jim Rowland 503/391-1980

Claims Submission Contact Jim Rowland 503/391-1980


Joyce Riggi Delivery Systems Manager Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97310 T: 503/945-6497 F: 503/947-5221

Disease Management Program/Initiative Contact Chris Barber Case Management Coordinator Office of Medical Assistance Programs 500 Summer Street, NE Salem, OR 97301 503/945-6588 E-mail: [email protected]

Disease Management/Patient Education Programs Disease States/Medical Conditions: asthma, cardiovascular disease, diabetes Program Name: Care Enhance Program Manager: McKesson

Mail Order Pharmacy Program State has a Mail Order Pharmacy Program. All non-institutionalized beneficiaries are entitled to participate.

Office of Medical Assistance Officials

Jean Thorne Director Department of Human Services 500 Summer Street, NE, E-15 Salem, OR 97301 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] 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 Michael Garland John Hogan Kelley Kaiser Noel Larson, D.M.D. Amy Malone Rick Wopat, M.D.


Oregon-5

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 Stephanie Munoz Director of Operations 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: 503/222-2779 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 Street, #9 Portland, OR 97232 T: 503/731-4032 F: 503/731-4067 E-mail: [email protected] Internet address: www.pharmacy.state.or.us Oregon Association of Hospitals and Health Systems Ken Ballantyne Senior Vice President 4000 Kruse Way Place Building 2, Suite 100 Lake Oswego, OR 97035-2543 T: 503/636-2204 F: 503/636-8310 E-mail: [email protected] Internet address: www.oahhs.org


Oregon-6


Pennsylvania-1

PENNSYLVANIA





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $690,558,773 461,114 $718,210,352 RECEIVING CASH ASSISTANCE, TOTAL $295,061,741 162,880 Aged $63,115,582 25,318 Blind / Disabled $210,975,578 76,006 Child $8,864,185 39,509 Adult $12,106,396 22,047 MEDICALLY NEEDY, TOTAL $68,796,845 36,604 Aged $60,348,380 23,250 Blind / Disabled $4,759,422 1,278 Child $2,469,233 7,645 Adult $1,219,810 4,431 POVERTY RELATED, TOTAL $146,089,558 155,466 Aged $47,997,255 19,730 Blind / Disabled $79,066,222 33,769 Child $17,670,812 92,287 Adult $1,355,269 9,680 TOTAL OTHER EXPENDITURES/RECIPIENTS* $180,610,629 106,164 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.



Pennsylvania-2

C. ADMINISTRATION

Office of Medical Assistance Programs, Department of Public Welfare.


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: Open formulary. Prior Authorization: State currently has a prior authorization procedure screening for drug classes and individual drugs. Products that require PA include BMN brand name drugs that have A-rated generics, H2 antagonists used >90 days, and drugs for erectile dysfunction. Also, Oxycontin prescriptions with doses in excess of 3 tablets per day, or being on more than 2 different strengths concurrently and COX-2 drugs if the patient is taking another NSAID, the prescribed dose is higher than the FDA recommended dose, or the patient is under 70 years of age and is not taking an anticoagulant.

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


PRODUR system implemented in June 1993. DUR Board has 10 members and meets quarterly.


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” or “Brand Necessary,” plus prior authorization. Incentive Fee: None.


Pennsylvania-3

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.


Approximately 936,000 unduplicated Medicaid recipients were enrolled in managed care in 2002. All receive pharmacy services, depending on their category of assistance, through managed care.


AmeriHealth HMO/Mercy Health Plan 65,312 1901 Market Street, 45th Floor Philadelphia, PA 19103 Keystone Mercy Healthplan 246,609 200 Stevens Drive, Suite 900 Philadelphia, PA 19113-1570 Americhoice of PA 103,240 The Wanamaker Building 100 Penn Square East, Suite 900 Philadelphia, PA 19107 Health Partners of Philadelphia 126,060 841 Chestnut Street, Suite 900 Philadelphia, PA 19107 Three Rivers Health Plans/MedPlus+ 135,525 300 Oxford Drive Monroeville, PA 15146 UPMC Health Plan, Inc./Best 63,823 Healthcare of Western PA One Chatam Center 112 Washington Place Pittsburgh, PA 15219 Gateway Health Plan 195,723 Two Chatam Center, Suite 500 Pittsburgh, PA 15219

F. STATE CONTACTS

State Drug Program Administrator Joseph E. Concino, R.Ph., Chief 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 B. Richman Secretary Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-2600 F: 717/772-2062 E-mail: [email protected] David S. Feinberg Deputy Secretary for Medical Assistance Programs Department of Public Welfare Health and Welfare Building P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-1870 F: 717/787-4639 E-mail: [email protected] Gwendolyn A. Poles, D.O. Clinical Management Consultant Teresa Shuchart Director Division of Data and Claims Management Richard M. Wallace Acting Director Bureau of Program Integrity Donald R. Yearsley Acting Director Bureau of Policy, Budget, and Planning Patricia S. Jacobs Acting Director Bureau of Fee-for-Service Programs Michael Jacobs Acting Director Bureau of Managed Care Operations


Pennsylvania-4

Andrew Major Director Bureau of Long Term Care Programs 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


Joseph E. Concino, R.Ph. 717/772-6341


First DataBank 1111 Bayhill Drive San Bruno, CA 94066 800/633-3453


Technical: David Ehrhart, 717/772-6305 Policy: Donald Yearsley, 717/772-6341 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 Acting Director, Division of MCO Monitoring and Compliance Office of Medical Assistance Programs Cherrywood Bldg, DPW Complex #2 Harrisburg, PA 17105 T: 717/772-6300 F: 717/772-2730 E-mail: [email protected]


None

Expanded Drug Coverage Program Contact Thomas M. Snedden, Director PACE Program PA Department of Aging 555 Walnut Street, 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


Pennsylvania-5

Shirley Beer Armstrong County Low Income Rights Organization RD #8, Box 134 Kittanning, PA 16201 Shelley Bishop Pennsylvania Mental Health Consumers Association 4105 Derry Street Harrisburg, PA 17111 Kent D. W. Bream, M.D. Department of Family Practice University of Pennsylvania 2 Gates, HUP, 3400 Spruce Street Philadelphia, PA 19104 Louise Brookins Philadelphia State Welfare Rights Organization 1231 N. Franklin Street Philadelphia, PA 19122 Kevin Casey Pennsylvania Protection and Advocacy 1414 Cameron Street, Suite C Harrisburg, PA 17103 Michael D. Chambers County Commissioners Association of Pennsylvania 17 North Front Street Harrisburg, PA 17101 Barbara Coffin Pennsylvania Association of Area Agencies on Aging Berks County Office of Aging County Services Center 633 Court Street Reading, PA 19601-4303 Dona Dmitrovic Executive Director Pennsylvania Recovery Organization Alliance, Inc. 900 South Arlington Avenue, Suite 119 Harrisburg, PA 17109 Henry R. Fiumelli Executive Director Pennsylvania Forum for Primary Health Care 1035 Mumma Road, Suite 1 Wormleysburg, PA 17043 Vickie Hoak (Vice-Chair) Pennsylvania Homecare Association 20 Erford Road, Suite 115 Lemoyne, PA 17043

Dolores Hodgkiss Managed Care Association of Pennsylvania 240 North Third Street, Suite 501 Harrisburg, PA 17101 Kathy Hubert Pennsylvania County Drug and Alcohol Program Administrators 17 North Front Street Harrisburg, PA 17101 Michelle Jones Healthy Start, Inc. 400 North Lexington Street Pittsburgh, PA 15208 George Kimes Pennsylvania Community Providers Association 2400 Park Drive Harrisburg, PA 17110 Christine Klejbuk PA Assn. Non-Profit Homes for the Aging Dir. of Public Policy 1100 Bent Creek Boulevard Mechanicsburg, PA 17050 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 Donald McCoy (Chair) Pennsylvania Medical Society 777 East Park Drive P.O. Box 8820 Harrisburg, PA 17105-8820 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


Pennsylvania-6

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 P.O. Box 8820 Harrisburg, PA 17105-8820 Mary Ellen Rehrman 10 Bertolet School Road Spring City, PA 19475 Dale Laninga - Ex-Officio Member Department of Aging Intra Governmental Council on Long Term Care 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919 Michael A. Yantis, Jr. - Ex-Officio Member Pennsylvania Department of Health Office of Policy Room 808, Health and Welfare Building Harrisburg, PA 17120

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 Pharmacists Association Patricia A. Epple, CAE Executive Director 508 North Third Street Harrisburg, PA 17101-1199 T: 717/234-6151 F: 717/236-1618 E-mail: [email protected] Internet address: www.papharmacists.com Pennsylvania Osteopathic Medical Association Mario E.J. Lanni Executive Director 1330 Eisenhower Boulevard Harrisburg, PA 17111-2395 T: 717/939-9318 F: 717/939-7255 E-mail: [email protected] Internet address: www.poma.org

Pennsylvania Podiatry Association Michael Q. Davis Executive Director 757 Poplar Church Road Camp Hill, PA 17011 717/763-7665 State Board of Pharmacy Melanie Zimmerman Executive Secretary 124 Pine Street P.O. Box 2649 Harrisburg, PA 17105-2649 T: 717/783-7156 F: 717/787-7769 E-mail: [email protected] Internet address: www.dos.state.pa.us/bpoa/phabd/mainpage.htm The Hospital and Healthsystem Association of Pennsylvania Carolyn F. Scanlan President/CEO 4750 Lindle Road P.O. Box 8600 Harrisburg, PA 17105-8600 T: 717/561-5314 F: 717/561-5334 E-mail: [email protected] Internet address: www.haponline.org


Rhode Island-1

RHODE ISLAND





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expended Recipients Expended Recipients TOTAL $104,912,603 50,379 $120,952,122 50,155 RECEIVING CASH ASSISTANCE TOTAL $63,036,440 28,257 Aged $7,362,321 4,417 Blind/Disabled $55,530,351 22,501 Child $49,522 595 Adult $94,246 744 MEDICALLY NEEDY, TOTAL $8,948,203 3,671 Aged $6,099,170 2,960 Blind/Disabled $2,848,698 709 Child $0 - Adult $335 2 POVERTY RELATED, TOTAL $333,172 911 Aged $94,162 97 Blind/Disabled $152,155 111 Child $61,352 523 Adult $25,503 180 TOTAL OTHER EXPENDITURES/RECIPIENTS* $32,594,788 17,540 *Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. 2002 data provided by the Rhode Island Department of Human Services. Source: CMS, MSIS Report, FY 2001 and Rhode Island Medicaid Statistical Information System, FY 2002. Note: Rhode Island estimates 2003 drug expenditures to be $139 million and the number of Medicaid drug recipients to be 52,000.


Rhode Island-2

C. ADMINISTRATION

Rhode Island Department Human Services.


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: allergy, asthma, and sinus products; analgesics (acetaminophen); cough and cold preparations (guifenisin, diphenhydramine, chlorpheniramine); digestive products (non-H2 antagonists); topical products; (antibiotics only); antacids; and laxatives. Products not covered: allergy, asthma, and sinus products; digestive products (H2 antagonists); feminine products; and smoking deterrent products. Therapeutic Category Coverage: Products covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents, antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents, prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: anoretics; antihistamines; growth hormones; misc. GI drugs; PPIs; Provigil; CNS stimulants; Tracleer; Remodulin; Flolan; Xolair; erectile dysfunction products; and Cox 2 inhibitors; 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 and through the physician payment program for adults. Unit Dose: Unit dose packaging not reimbursable.


Formulary: State has a formulary. Prior authorization is used to manage the formulary. Fair hearing process to appeal prior authorization decision.

Prescribing or Dispensing Limitations Prescription Refill Limit: Refills to a maximum of 5 are allowed. Monthly Quantity Limit: One month’s supply for non-maintenance drugs. One inhaler per fill. 8 tablets per month for erectile dysfunctions medication. Maintenance Medication: The attending physician may prescribe certain maintenance drugs of 100 tablets, capsules or pint of liquid or a 30-day supply of these drugs - whichever is greater. Monthly Dollar Limits: None


PRODUR system implemented in December 1994. State has a DUR Board that meets quarterly.


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 5 percent, the usual and customary charge to the general public, or the allowable cost plus the professional fee for service.

Maximum Allowable Cost: State 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.


Rhode Island-3


Approximated 135,000 Medicaid recipients were enrolled in managed care in 2003. Managed care recipients receive pharmaceutical benefits through managed care plans.


− United Healthcare of New England − Coordinated Health Partners, Inc. − Neighborhood Health Plan of Rhode Island

F. STATE CONTACTS


Paula J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02919 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected] Internet address: www.dhs.state.ri.us

DUR Contact

Paula J. Avarista, R.Ph. 401/462-6390

Rhode Island DUR Board

Raymond Maxim, M.D. Edward Westlake, M.D. Richard Wagner, M.D. Steve Kogurt, Ph.D. Craig Bowen, Pharm.D. John Zevzavadjian R.Ph. Ellen Mauro, R.N, M.P.H.






Technical: Helen Vaughn (EDS), 401/784-3879 Policy: Paula J. Avarista, 401/462-6390


EDS 401/784-3879


Tricia Leddy, Administrator Department of Human Services 600 New London Avenue Cranston, RI 02919 401/462-2127 E-mail: [email protected]



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]


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-4

Rhode Island Pharmacists Association James Hutson Executive Director 1643 Warwick Avenue PMB 113 Warwick, RI 02889 T: 401/737-2600 F: 401/737-0959 E-mail: [email protected] Internet address: www.ripharmacists.org 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 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: 401/274-1647 F: 401/274-1838 E-mail: [email protected] Internet address: www.hari.org


South Carolina-1

SOUTH CAROLINA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $438,498,935 542,764 $456,972,236 576,065 RECEIVING CASH ASSISTANCE, TOTAL $217,671,240 201,137 $219,601,046 214,691 Aged $54,051,659 30,510 $49,524,373 29,073 Blind/Disabled $133,255,085 73,126 $131,756,715 72,534 Child $11,428,870 53,959 $14,462,664 62,082 Adult $18,935,626 43,542 $23,857,294 51,002 MEDICALLY NEEDY, TOTAL $0 - $0 - Aged $0 - $0 - Blind/Disabled $0 - $0 - Child $0 - $0 - Adult $0 - $0 - POVERTY RELATED, TOTAL $135,326,028 239,631 $145,484,844 255,443 Aged $41,923,282 24,199 $42,051,488 24,724 Blind/Disabled $51,608,068 21,735 $53,686,398 23,236 Child $39,949,877 179,897 $47,894,525 194,168 Adult $1,844,801 13,800 $1,852,433 13,315 TOTAL OTHER EXPENDITURES/RECIPIENTS* $85,501,667 101,996 $91,886,346 105,931 *Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by the South Carolina Department of Health and Human Services. Source: CMS, MSIS Report, FY 2001, and South Carolina Medicaid Statistical Information System, FY 2002.


South Carolina-2

C. ADMINISTRATION

South Carolina Department of Health & Human Services.


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). Unit Dose: Unit dose packaging reimbursable.

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®.


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.


South Carolina-3


PRODUR system implemented November 2000. State currently has a DUR Board with a monthly review.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $4.05, effective 7/1/89. Ingredient Reimbursement Basis: EAC = AWP-10%. Prescription Charge Formula: Medicaid reimbursement for pharmacy services will be based on the lowest of: the Estimated Acquisition Cost (EAC); Federal or State maximum allowable cost (MAC); or the provider's submitted usual and customary charge. Maximum Allowable Cost: State imposes Federal Upper Limits as well as State-specific 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 74,000 Medicaid recipients were enrolled in MCOs in FY 2003. Recipients receive pharmaceutical benefits through managed care plans.


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 Pharmaceutical Services and DME S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected] Internet address: www.dhhs.state.sc.us


Caroline Y. Sojourner, R.Ph., Dept. Head Department of Pharmacy Services S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected]

DUR Contact

Caroline Y. Sojourner, R.Ph. 803/898-2876

DUR 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.

New Brand Name Products Contact James M. Assey, R.Ph. 803/898-2876


First DataBank, 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003


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


South Carolina-4


Rod Davis Deputy Director of Information Technology S.C. Department of Health and Human Services P.O. Box 8206 Columbia, SC 29202-8206 803/898-2610 E-mail: [email protected]


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, however, mail order pharmacies may enroll.


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]

South Carolina Department of Health and Human Services Officials

Robert Kerr, Director S. C. Department of Health & Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Melanie Giese, Chief Bureau of Health Services 803/898-2870 Caroline Y. Sojourner, R.Ph., Department Head Department of Pharmacy Services 803/898-2876

Medical Care Advisory Council

Ms. Valerie Aiken Mr. John P. Barber Ms. Susan B. Berkowitz Ms. Lesly A. Bowers Dr. Gloria Bonali Mr. Bruce Carlson Mr. Tommy Cockrell Charles P. Darby, M.D. C. Warren Derrick, M.D. Ana DeFede, Ph.D James M. DuRant, Jr., M.D. C. Morrison Farish, M.D. Mr. Ron Fitzwater Ms. Laura Fowler Ms. Connie Ginsberg Dr. Barbara Haight Jerome E. Kurent, M.D. Mr. Rudy Long Ms. Amy McDonald Mr. J.J. McLawhorn Albert D. Mims, M.D. Dr. Linda S. Moore Mr. John A. Morris J. Michael Ross, R.Ph. Sabra Slaughter, Ph.D. Mr. Lewis Stephens Ms. Cindy White Ms. Deborah Williamson Dr. Constance Yearling Dr. Foster H. Young, Jr. Mr. Hal Zorn


South Carolina Medical Association Todd K. Atwater, Chief Executive Officer 132 West Park Boulevard P.O. Box 11188 Columbia, SC 29210 T: 803/798-6207 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-5

South Carolina Pharmacy Association James R. Bracewell, Executive Vice President 1350 Browning Road Columbia, SC 29210-6903 T: 803/354-9977 F: 803/354-9207 E-mail: [email protected] Internet address: www.scrx.org/scrx State Board of Pharmacy Lee Ann F. Bundrick, Administrator South Carolina Board of Pharmacy Kingstree Building 110 Centerview Drive, Suite 306 Columbia, SC 29210 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


South Carolina-6


South Dakota-1

SOUTH DAKOTA





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $52,608,524 58,203 $62,382,937 RECEIVING CASH ASSISTANCE, TOTAL $27,648,344 20,993 Aged $3,255,890 1,849 Blind/Disabled $21,559,128 8,701 Child $1,147,090 6,450 Adult $1,686,236 3,993 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind/Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $4,526,417 21,497 Aged $39,540 49 Blind/Disabled $66,140 61 Child $4,065,705 19,072 Adult $355,032 2,315 TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,433,763 15,713 *Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


South Dakota-2

C. ADMINISTRATION Department of Social Services, Office of Medical Services.


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: 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.


PRODUR system implemented in 1996. State has a DUR Board with annual review.


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: $10.00 Patient Cost Sharing: Copayment is $2.00. Cognitive Services: Does not pay for cognitive services.


Does not use MCOs to deliver pharmacy services to Medicaid recipients.

F. STATE CONTACTS


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]


South Dakota-3


Mark Petersen, R.Ph. 605/773-3495

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.






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]


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


South Dakota-4

Lynn Greff Apothecary Shop at Medical Arts 719 St. Francis Street Rapid City, SD 57701 Stephen Schroeder, M.D. Hand Co. Clinic P.O. Box 287 Miller, SD 57362 Michelle Miller McKennan Home Health 800 E. 21st Street Sioux Falls, SD 57105-1016 A.A. Lampert, M.D. 13075 Bogus Jim Road Rapid City, SD 57702-9720

Evaluation Committee V. R. Brandenburg, M.D. Dennis Hodge, Pharm.D. Helen Fiechtner, Pharm.D. Jane Mort, Pharm.D. James Clem, Pharm.D. Marc Aldrich (Physician)


South Dakota 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 E-mail: [email protected] Internet address: www.sdsma.org South Dakota Osteopathic Association David A. Lauer, D.O. Secretary-Treasurer P.O. Box 247 Sturgis, SD 57785 T: 605/347-3616 F: 605/347-4713 South Dakota Pharmacists Association Robert Overturf Executive Director 215 W. Sioux Avenue 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 Avenue, 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


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. In an effort to expand coverage to more of Tennessee's uninsured children, the Bureau of TennCare opened enrollment on January 1, 1998 to uninsured Tennesseans under the age of nineteen (19) with access to health insurance whose individual family incomes are below 200% of the poverty level. Effective January 1, 1998, uninsured children under age nineteen (19) who meet the TennCare criteria for uninsured are being allowed to enroll in TennCare indefinitely. The Bureau of TennCare eliminated deductibles and limited co-payments to $5 and $10 for these new eligibility populations and all uninsured children under eighteen (18) years of age who enrolled in TennCare during previous open enrollment periods. Enrollment remains open to persons who are Medicaid-eligible or who are uninsurable. Current enrollment (1/23/04) is approximately 1.3 million of which 1 million are Medicaid eligibles and 300,000 are in the uninsured/uninsurable categories. 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.

ELIGIBILITY FOR TENNCARE COVERAGE The current federal waiver separates TennCare into Two products: TennCare Medicaid and TennCare Standard. Tenncare Medicaid is a continuation of the basic TennCare Medicaid program with a few minor changes in benefits. TennCare Medicaid adds a new eligibility category: woman under 65 who have been screened by The Centers for Disease Control and are in need of treatment for breast or cervical cancer.


Tennessee-2

TennCare Standard is similar to a commercial HMO package. People eligible for TennCare standard are adults below the 100 percent of the federal poverty level, children below 200 percent of the poverty level, and people who are “medically eligible” a new term to describe what the state previously referred to as “uninsurables.” The difference is that “Medical eligibility” will be determined by a State-appointed health insurance underwriter. Under the previous TennCare system, a denial letter from an insurance company defined “uninsurability.” The five-year waiver that TennCare began on July 1, 2002 also includes an annual “open enrollment” period, which would allow people who are uninsured or medically eligible above poverty to enroll in TennCare. The current fiscal year’s budget does not allow for an open enrollment period, at least through the end of the current fiscal year, June 30, 2003. However, if an applicant is both below 100 percent of the poverty level and medically eligible, enrollment will be allowed at any time during the year. Persons wanting to apply for TennCare must visit the local Tennessee Department of Human Services (DHS) office. There is a local DHS office in every Tennessee County. For the applicants' convenience, DHS will make a copy of the application, date stamp it, and process the application.

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 OTCs). Starting in July 1, 2003 all eligible products dispensed through ambulatory pharmacies are invoiced through the CMS rebate program.

Formulary: Preferred Drug List (PDL) was phased in from October 15th through December 15th in 3 phases (see http://tennessee.fhsc.com). Prior Authorization: Prior authorization procedures are administered by Consultec (through 12/31/03) and First Health starting on 1/1/04. Copayment: Deductibles and copayments apply to services other than preventive services (e.g., immunizations) based on a sliding scale according to income. Medicaid recipients and persons or families with income under 100% of the Federal poverty level are not required to pay premiums, deductibles, or copayments in order to participate in the TennCare program.

C. USE OF MANAGED CARE

Medicaid recipients and the uninsured/uninsurable are enrolled in MCOs through the TennCare program. All receive pharmacy benefits through managed care.


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 Avenue, 5th Floor Memphis, TN 38132 PHP TennCare 1420 Centerpoint Boulevard Knoxville, TN 37932 TennCare Select 801 Pine Street Chattanooga, TN 37402-2555 VHP Community Care 215 Centerview Drive, Suite 300 Brentwood, TN 37027


Tennessee-3

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 VHP Community Care

D. STATE CONTACTS


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 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 Jeffrey G. Stockard, D.Ph. 615/532-3107

DUR Contact Jeffrey G. Stockard, D.Ph. 615/532-3107

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 Drive Hermitage, TN 37076-4405

Diane Crutchfield, D.Ph. 1223 Eaglenest Lane Knoxville, TN 37922 Martha Drannon, Pharm.D. Frayser Family Counseling Center Pharmacy 2150 Whitney Avenue Memphis, TN 38127 Don Hazelwood, D.Ph. E.W. James Pharmacy 3100 S. First Street Milan, TN 38358 Connie J. Holladay, M.D. 6432 River Tide Drive Memphis, TN 38120 Mack A. Land, M.D. 5210 Poplar Avenue, Suite 200 Memphis, TN 38119 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 Pharmacy Advisory Board

James Powers, M.D. (Chairman) 7155 Vanderbilt Medical Center East Nashville, TN 37232 Alan Corley, D.Ph. (Vice Chairman) P.O. Box 874 Greenville, TN 37744 Dianne Todd Pace, Ph.D., R.N., FNP 886 Wood Cairn Cove Cordova , TN 38018 Edward Capparelli, M.D. 121 Moore Street Newport, TN 37821 James King, M.D. 1 Prime Care Drive Selmer, TN 38375 Lisa D’Souza, J.D. 301 Charlotte Avenue Nashville, TN 37201


Tennessee-4

Peter Frizzell, M.D. 1 Roundtree Court Johnson City, TN 37604 Lynn Knott, Pharm.D., CGP, FASCP 1744 Stillwater Circle Brentwood, TN 37027 Stanley Dowell, M.D. Eastmoreland Internal Medicine 1325 Eastmoreland Avenue, Suite 245 Memphis, TN 38104 Sheila Spates, Pharm.D. 809 Tree Trunk Road Knoxville, TN 37922 Terry Shea, Pharm.D. 3 Chamblee Court Signal Mountain, TN 37377 William Terrell, M.D. 1444 E. Shelby Drive, Suite 317 Memphis, TN 38116 Tracy Purcell (ex-officio) Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 David Hollis, M.D. (ex-officio) Bureau of TennCare 729 Church Street Nashville, TN 37247-6501

TennCare Bureau

Jeffrey G. Stockard, D.Ph. 615/532-3107

TennCare Medical Care Advisory Committee Iris Snider, M.D. TN Chapter of American Academy of Pediatrics 111 Epperson Avenue Athens, TN 37303 Lloyd A. Walwyn, M.D., J.D. 601 Due West Avenue Madison, TN 37115 Deb Murph, R.N. Cherokee Health Systems 6350 West Andrew Johnson Highway Talbott, TN 37877 Jeannie Beauchamp, D.D.S. 1833 Memorial Drive Clarksville, TN 37043

Don Hazelwood, D.Ph. 3100 S. First Street Milan, TN 38358 Cato Johnson Methodist Healthcare 1211 Union Street, Suite 700 Memphis, TN 38104 Joe Brown Hardin County Nursing Home 2006 Wayne Road Savannah, TN 38372 Sheryl McCormick Region 2 Mental Health Council 7208 Merriwood Drive Knoxville, TN 37919 Don Redden Developmental Services of Dickson County P.O. Box 628 Dickson, TN 37056 Tony Halton National Health Care for the Homeless Council P.O. Box 60427 Nashville, TN 37206 Osbie Howard OmniCare Health Plan, Inc. 1991 Corporate Avenue, 5th Floor Memphis, TN 38132 Nancy Reykdal Blue Cross/Blue Shield of Tennessee 801 Pine Street Chattanooga, TN 37402 Yolanda McClain The Salvation Army 611 Stockell Street Nashville, TN 37207 Effie Candis Pelfrey Tennessee Health Care Campaign 1103 Foothill Court Nashville, TN 37217 Virginia T. Lodge, Commissioner Department of Human Services 400 Deaderick Street, 15th Floor Nashville, TN 37248


Tennessee-5




Audits: Sybil Creekmore, 615/741-0213 Disputes: Jeff Stockard, D.Ph., 615/532-3107


Carmen Gilbert Menser First Health 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7513 F: 804/290-4831 E-mail: [email protected]


Michael Drescher, Public Information Officer Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/741-0213 F: 615/741-0882 E-mail: [email protected]


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

Judy Black Director of Disease Management Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-6705 F: 615/741-0882

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: http://www.state.tn.us/commerce/boards/ pharmacy/index.htm Tennessee Hospital Association Craig A. Becker President 500 Interstate Boulevard South Nashville, TN 37210-4634 T: 615/256-8240 F: 615/242-4803 Internet address: www.tha.com


Tennessee-6

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


Texas-1

TEXAS





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $1,327,222,456 1,917,351 $1,591,064,713 RECEIVING CASH ASSISTANCE, TOTAL $757,087,849 713,254 Aged $225,287,571 155,312 Blind / Disabled $439,674,579 240,642 Child $50,653,592 221,789 Adult $41,472,107 95,511 MEDICALLY NEEDY, TOTAL $13,645,641 30,183 Aged $0 - Blind / Disabled $0 - Child $56,065 264 Adult $13,589,576 29,919 POVERTY RELATED, TOTAL $171,959,460 810,157 Aged $812,066 930 Blind / Disabled $821,022 815 Child $149,515,656 665,651 Adult $20,810,716 142,761 TOTAL OTHER EXPENDITURES/RECIPIENTS* $384,529,506 363,757 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Texas-2

C. ADMINISTRATION

Texas Health and Human Services Commission. Vendor drug program was implemented September 1, 1971.


Benefit Design Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles (pen needles only) and syringe combinations used for insulin. Products not covered: cosmetics; fertility drugs; experimental drugs; total parenteral nutrition; and interdialytic parenteral nutrition; blood glucose test strips; urine ketone test strips. Over-the-Counter Product Coverage: Products covered: feminine products; topical products; allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; smoking deterrent products. Products not covered: Certain OTC drugs are covered on a prescription basis except as otherwise provided in the reimbursement formula and vendor payment to hospitals, nursing homes and institutions. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; antibiotics; analgesics; antipyretics, NSAIDs; anticoagulants; anticonvulsants; anti-depressants; antidiabetic drugs; antihistamine drugs; antilipemic agents; antipsychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; contraceptives; prescribed cold medications; ENT anti-inflammatory agents; estrogens; hypotensive agents; misc. GI drugs; thyroid agents; prescribed smoking deterrents; and sympathominetics (adrenergic). Prior authorization required for: growth hormones; dextroamphetamines (>21 years of age); xenical (hyperlipidemia only). Therapeutic categories not covered: anti-obesity agents; vitamins (except prenatal); children’s vitamins with fluoride; and DESI drugs. Coverage of Injectables: Injectable medicines reimbursable through the Prescription Drug Program when used in home health care, 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: Open formulary; however, products must be listed in the Texas Drug Code Index. Formulary managed through exclusions based on contracting issues, restrictions on use, and prior authorization. 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. Prior Authorization pharmacist may be contacted to appeal a prior authorization decision.


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: . $5.14. ($5.27 was reduced for cost containment purposes in October 2003). The dispensing fee, including all costs of filling a prescription, was established by cost accounting and service evaluation of the expenses involved in dispensing a prescription. Ingredient Reimbursement Basis: EAC = 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 + 5.14) divided by 0.9805 = amount paid

+ $0.15 delivery service. 2. DEAC only for Wyeth-Ayerst and Abbott.


Texas-3

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. 1,317 therapeutic classes and 8,169 NDC numbers are listed on the State-specific MAC list. Override requires “Dispense as Written”, “Medically Necessary”, “Brand Necessary”, or “Brand Medically Necessary.” Incentive Fee: None. Cognitive Services: Does not pay for cognitive services. Patient Cost Sharing: No copayment.


Approximately 530,000 Medicaid recipients were enrolled in MCOs in 2002 (all of whom are AFDC/AFDC- related). Recipients in managed care receive pharmaceutical benefits through the State. (Pharmacy program is “carved out.”)

Managed Care Organizations AMERIGROUP, Inc. 1200 East Copeland Road, Suite 200 Arlington, TX 76011 Community First Health Plan 4801 NW Loop 410, Suite 1000 San Antonio, TX 78229 El Paso First Health Plans 2501 North Mesa El Paso, TX 79902 HMO Blue-Medicaid 901 S. Central Expressway Richardson, TX 75080 Texas Children’s Health Plan 1919 Braeswood Houston, TX 77230 Superior Health Plan 2100 S. IH35, Suite 202 Auston, TX 78704 Community Health Choice 2636 South Loop, Suite 700 Houston, TX 77054

First Care Health Plan 12940 N. Highway 183 Austin, TX 78750 JPS/MetroWest Health Plan 1617 Hemphill Fortworth, TX 76104 Parkland Health First 2777 N. Stemmons Breeway, Suite 1750 Dallas, TX 75207

F. STATE CONTACTS


Barbara Dean, R.Ph. Acting Director, Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/491-1101 F: 512/491-1959 E-mail: [email protected] Internet address: www.hhsc.state.tx.us

Health and Human Services Commission Officials

Albert Hawkins Executive Commissioner Texas Health and Human Service Commission 4900 N. Lamar Boulevard Austin, TX 78751 T: 512/424-6502 F: 512/424-6587 E-mail: [email protected] Jason Cooke Associate Commissioner for Medicaid Texas Health and Human Services Commission 4900 N. Lamar Boulevard Austin, TX 78751 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 T: 512/491-1172 F: 512/491-1962 E-mail: [email protected]


Texas-4

DUR Contact

Barbara Dean, R.Ph. Manager, DUR Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/491-1101 F: 512/491-1959 E-mail: [email protected]

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. 8600 Thackery, Suite 162 Dallas, TX 75225 Mark S. Gittings, D.O., R.Ph. 12340 Almeda Trace Circle, Suite 2302 Austin, TX 78727 Robert L. Hogue, M.D. 101 A South Park Drive Brownwood, TX 76801 Daniel Saylak, D.O., Chairman 841 N. Rosemary Drive 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., CDE 2819 Burning Hill San Antonio, TX 78247 James B. Hills, R.Ph. 9100 South West Freeway Houston, TX 77054 Robert T. Reilly, Pharm.D. Thomason Hospital Department of Pharmacy 4815 Alameda Avenue, P. O. Box 2009 El Paso, TX 79905


Martha McNeill, R.Ph. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected]


Martha McNeill, R.Ph. 512/491-1157

Medicaid Drug Rebates Contact Heather Murphy Manager, Pharmacy Rebates Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78745 T: 512/491-1163 F: 512/491-1960 E-mail: [email protected]


Laura Bagheri Manager, Pharmacy Resolutions Vendor Drug Program Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78745 T: 512/491-1741 F: 512/491-1958 E-mail: [email protected]

Medicaid Managed Care Contact Pamela Coleman Director, Health Plan Operations Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756 512/491-1302 E-mail: [email protected]


None


Texas-5

Executive Officers of State Medical and Pharmaceutical Societies Texas Medical Association Louis J. Goodman, Ph.D., CAE Executive Vice President/CEO 401 W. 15th Street Austin, TX 78701-1680 T: 800/880-1300 F: 512/370-1632 E-mail: [email protected] Internet address: www.texmed.org Texas Pharmacy Association Jim Martin, R.Ph. Executive Director/CEO 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 Street, Suite 3-600 Austin, TX 78701-3942 T: 512/305-8000 F: 512/305-8082 E-mail: [email protected] Internet address: www.tsbp.tx.us Texas Hospital Association Richard Bettis, CAE President & CEO P.O. Box 15587 Austin, TX 78761-5587 T: 512/465-1000 F: 512/465-1090 E-mail: [email protected] Internet address: www.thaonline.org


Texas-6


Utah-1

UTAH





Child Adult

Prescribed Drugs





Physician Services

Dental Services


Expenditures Recipients Expenditures Recipients TOTAL $117,101,302 136,682 $140,275,267 RECEIVING CASH ASSISTANCE TOTAL $48,529,173 33,260 Aged $5,275,146 2,848 Blind/Disabled $37,273,244 12,442 Child $1,949,135 11,105 Adult $4,031,648 6,865 MEDICALLY NEEDY, TOTAL $5,661,159 2,569 Aged $1,083,310 528 Blind/Disabled $3,965,954 965 Child $82,975 441 Adult $528,920 635 POVERTY RELATED, TOTAL $57,527,963 77,811 Aged $15,915,526 6,468 Blind/Disabled $25,732,028 7,940 Child $5,852,559 39,384 Adult $10,027,850 24,019 TOTAL OTHER EXPENDITURES/RECIPIENTS* $5,383,007 23,042



Utah-2

C. ADMINISTRATION

Division of Health Care Financing, State Department of Health.


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. Products covered with restrictions: disposable needles and syringe combinations used for insulin (prefilled restricted to blind clients only) 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 must 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) − 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 digestive 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: antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; antihistamines; antilipemic agents; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-flammatory agents; estrogens; hypotensive agents; misc. GI drugs; and thyroid agents. Products covered with restrictions: anti-depressants; sympathominetics (adrenergic). Prior authorization required for: analgesics, antipyretics, and NSAIDs; anti-psychotics; and growth hormones (partial coverage). Products not covered: anabolic steroids; anoretics; prescribed smoking deterrents; diet medications. 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 at AWP minus 15% plus a fee as part of the EPSDT service, the Children’s Health Insurance Program, and the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization Formulary: Open formulary. Prior Authorization:State has a prior authorization procedure screening for individual drugs with fair hearing appeal process to DUR board.

Prescribing or Dispensing Limitations Prescription Refill Limit: Limited to five. Monthly Quantity Limit: In general, the quantity of medication shall be limited to a supply not to exceed 31 days. Cumulative limits on specific drugs Maximum scripts per month (except children and pregnant women).


Utah-3


PRODUR system implemented in 1994.


Dispensing Fee: $3.90 for urban, $4.40 for rural, effective 1998. $1.00 for OTCs. Ingredient Reimbursement Basis: EAC = Lesser of AWP-15% or AAC. 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 “Dispense as Written”, “Medically Necessary”, or “Brand Medically Necessary.” Incentive Fee: None. Patient Cost Sharing: Copayment = $3.00 Cognitive Services: Does not pay for cognitive services.


Approximately 14,000 Medicaid recipients are enrolled in managed care. Pharmacy benefits are through the State.

Managed Care Organizations American Family Care 2120 South 13th East #303 Salt Lake City, UT 84106

Healthy U 35 W. Broadway Salt Lake City, VT 84101

IHC Access P.O. Box 116670 Salt Lake City, UT 84147 Med Utah Healthwise P.O. Box 30804 Salt Lake City, UT 84130-0804 United Medchoice 7910 South 3500 East Salt Lake City, UT 84121

F. STATE CONTACTS

State Drug Program Administrator RaeDell Ashley, R.Ph. Pharmacy Director Division of Health Care Financing Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected] Internet address: www.utah.gov

New Brand Name Products Contact RaeDell Ashley, R.Ph. 801/538-6495

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 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


Utah-4

Colin B. Van Orman, M.D. PCMC 100 North Medical Drive, Suite 2700 Salt Lake City, UT 84113 Derek Christensen, R.Ph. 9842 Grouse Bend Circle South Jordan, UT 84095 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


RaeDell Ashley, R.Ph. 801/538-6495


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 Connie Higley Information Technology Director Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 801/538-6691 E-mail: [email protected]


Julie Olsen, Director Managed Health Care Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6303 F: 801/538-6009 E-mail: [email protected]


State has a mail order pharmacy program. Utah Medicaid beneficiaries may choose to obtain prescription drugs through mail order.

Department of Health Officials Scott D.Williams 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 Department of Health 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 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: 801/794-9545 E-mail: [email protected] Internet address: www.uoma.net 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-5

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.dopl.utah.gov Utah Hospitals and Health Systems Association Joseph M. Krella, FACHE President 2180 South 1300 East, Suite 440 Salt Lake City, UT 84016 T: 801/486-9915 F: 801/486-0882 E-mail: [email protected] Internet address: www.uha-utah.org


Utah-6


Vermont-1

VERMONT1





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $105,673,417 109,328 $114,157,870

RECEIVING CASH ASSISTANCE TOTAL $39,685,114 25,169 Aged $3,799,046 1,741 Blind/Disabled $30,223,439 10,679 Child $2,061,532 8,225 Adult $3,601,097 4,524 MEDICALLY NEEDY, TOTAL $17,804,948 9,407 Aged $6,488,482 2,836 Blind/Disabled $9,113,456 2,639 Child $537,853 1,641 Adult $1,665,157 2,291 POVERTY RELATED, TOTAL $4,956,436 26,895 Aged $0 - Blind/Disabled $0 - Child $4,726,155 25,385 Adult $230,281 1,510 TOTAL OTHER EXPENDITURES/RECIPIENTS*

$43,226,919 47,857


1 The State of Vermont did not respond to the 2001, 2002, or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Vermont Medicaid program to assess the accuracy and currency of the information included.


Vermont-2

C. ADMINISTRATION

Department of Prevention, Assistance, Transition, and Health Access (PATH)


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: Open formulary with preferred drug list (PDL). General exclusions include cosmetics and experimental drugs. Prior Authorization: Prior authorization required screening for drugs not listed on PDL

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.


PRODUR system implemented in November 1993. State currently has a DUR board with a bimonthly review.


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 as well as State-specific limits on generic drugs. Override requires “Dispense as Written.” Incentive Fee: None. Patient Cost Sharing: Generics: $3.00, Brand: $6.00 to a maximum of $50.00 per beneficiary per quarter. Cognitive Services: Does not pay for cognitive services.


Approximately 82,000 total Medicaid recipients are enrolled in a PCCM in 2002.

F. STATE CONTACTS


Samantha Haley 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]


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] Joshua Slen Medicaid Director Dept. of Prevention, Assistance, Transition, and Health Access 103 South Main Street Waterbury, VT 05676-1201 T: 802/879-5900 F: 802/879-5962 E-mail: [email protected]


Roger Tremblay [email protected]

DUR Contact

Scott Strenio, M.D. Clinical Consultant Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 802/741-7975 E-mail: [email protected]

DUR Board James A. Gray, M.D. (Chair) Jeffrey P. Firlik, R.Ph. Cheryl A. Gibson, M.D. 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.


Christine Dapkiewicz Drug Rebate Coordinator 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440


Christine Dapkiewicz 802/979-4450


Leanne Miles 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440


Liz Reardon [email protected]

Disease Management Initiative/Program Contact

Shona Mossey-Lothrop Pharmacy Consultant 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 Esther Pearlman [email protected]


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 Vermont Pharmacists Association James Marmar Executive Director Box 90 Woodstock, VT 05091 T: 877/483-2646 F: 802/433-4803 E-mail: [email protected] Internet address: www.vtpharmacists.org


Vermont-4

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 Peggy Atkins 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: www.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


Virginia-1

VIRGINIA



Aged Blind/Disable

d


Child Adult

Prescribed Drugs





Physician Services

Dental Services All eligible recipients under age 21


Expenditures Recipients Expenditures Recipients TOTAL $419,133,293 333,880 $453,634,681 319,184

RECEIVING CASH ASSISTANCE TOTAL $252,905,212 102,360 $260,847,901 98,158 Aged $73,894,551 34,599 $81,793,718 33,845 Blind/Disabled $178,608,437 66,480 $178,993,058 64,248 Child $140,364 733 $17,496 90 Adult $261,860 548 $43,629 75

MEDICALLY NEEDY, TOTAL $14,259,566 6,474 $13,520,329 5,705 Aged $5,995,613 3,354 $5,782,480 2,811 Blind/Disabled $8,230,689 2,951 $7,565,189 2,617 Child $27,529 136 $19,393 141 Adult $5,735 33 $153,267 136 POVERTY RELATED, TOTAL $35,351,169 140,124 $54,335,573 137,101 Aged $2,442,573 2,295 $12,378,957 7,008 Blind/Disabled $3,725,012 2,539 $15,064,557 6,389 Child $26,581,071 116,636 $24,559,080 106,380 Adult $2,602,513 18,654 $2,332,979 17,324 TOTAL OTHER EXPENDITURES/RECIPIENTS $116,617,346 84,922 $124,930,878 78,220 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data provided by the Virginia Department of Medical Assistance Services. Source: CMS, MSIS Report, FY 2001 and Virginia Medicaid Statistical Information System, FY 2002.


Virginia-2

C. ADMINISTRATION

Department of Medical Assistance Services. Eligibility determination by the Department of Social Services.


Benefit Design Drug Benefit Product Coverage: Products Covered: prescribed insulin; disosable needles and syringe combinations used for insulin; blood glucose test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; hair growth products; designated DESI drugs; experimental drugs; non-legend drugs; and expired drugs. Over-the-Counter Drug Coverage: A majority of OTC drugs reimbursable when used in nursing homes and certain classes in outpatient populations. These include: allergy, asthma, and sinus products; analgesics; cough and cold preparations; digestive products; feminine products; topical products; and smoking deterrent products. Therapeutic Category Coverage: Therapeutic categories covered: anabolic steroids; analgesics, antipyretics, and NSAIDs; anoretics; antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; estrogens; growth hormones; hypotensive agents; misc. GI drugs; prescribed smoking deterrents, sympathominetics (adrenergic); and thyroid agents. Prior authorization required for: weight loss drugs and non-preferred drugs. Coverage of Injectables: Injectable medicines reimbursable through both the Prescription Drug Program and physician payment when used in home health care, extended care facilities, and 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 with preferred drug list (PDL). Managed through excluding products based on contracting issues, restrictions on use,

prior authorization, therapeutic substitution, preferred products; and physician profiling. Prior Authorization: State currently has a formal prior authorization process to appeal prior authorization decisions (see www.dmas.virginia.gov under pharmacy initiatives for appropriate process). Prior authorization procedure screening for individual drugs for weight loss.

Prescribing or Dispensing Limitations Prescription Refill Limit: Physicians may authorize refills according to legal requirements. Monthly Quantity Limit: 34-day supply.

Drug Utilization Review PRODUR (online) system implemented in July 1994. RetroDUR Program also implemented in 1994. State currently has a DUR Board with quarterly meetings.

Pharmacy Payment and Patient Cost Sharing Dispensing Fee: $3.75, effective 7/1/04. Ingredient Reimbursement Basis: EAC = AWP – 10.25%. Prescription Charge Formula: Based upon the lower of VMAC or EAC plus a fee, or the usual and customary charge minus a copayment of $1.00 for generics and $3.00 for brand-name products, where appropriate. Maximum Allowable Cost: State imposes State-specific limits on generic drugs. Override requires “Dispense as Written.” Incentive Fee: None. Patient Cost Sharing: Copayment is $1.00/Rx for generics and $3.00/Rx on brand-name products. qualifying prescriptions. Exclusions include less than 21 years old, pregnancy related, family planning, and nursing home patients. Cognitive Services: Does not pay for cognitive services at present.

E. USE OF MANAGED CARE Approximately 344,000 beneficiaries enrolled in HMOs in 2002. Recipients enrolled in managed care organizations receive pharmaceutical benefits through managed care plans.


Virginia-3


Virginia Premier Health Plan Anthem HealthKeepers Plus Sentara Family Care Southern Health/CareNet UNICARE Health Plan of Virginia

F. STATE CONTACTS

State Drug Program Administrator Javier Menendez, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/783-2196 F: 804/786-0973 E-mail: [email protected] Internet address: www.dmas.virginia.gov

DUR Contact

Javier Menendez, R.Ph. 804/783-2196

DUR Board

Robert O. Friedel, M.D. Catherine Kelso, M.D. Jason Lynam, M.D. Jennifer Edwards, Pharm.D. Elaine Ferrary, M.S. Jane Settle, N.P. Geneva Briggs, Pharm.D. (Chair) Sandra Dawson, R.Ph. Kelly Goode, Pharm.D. Mark Johnson, Pharm.D. Bill Rock, Pharm.D.






Policy: Javier Menendez, R.Ph. 804/783-2196

Disputes: Charles Townsend Pharmacy Manager First Health Services Corporation Community Pharmacy Coalition 4300 Cox Road Glen Allen, VA 23060 804/965-7400 E-mail: [email protected]


Frank Fury Operations Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 Community Pharmacy Coalition 804/965-7400


None

Medical Managed Care Contact Mary Mitchell Supervisor for Managed Care Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-3594 F: 804/786-5799 E-mail: [email protected]

Department of Medical Assistance Services Officials

Patrick W. Finnerty Director Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-4231 F: 804/225-4512 E-mail: [email protected]

Virginia Medicaid Pharmacy Liaison Committee

Bill Hancock, R.Ph. Long Term Care Pharmacy Coalition Alexander Maculey, R.Ph. Community Pharmacy Michael Ayotte, R.Ph. Virginia Association of Chain Drug Stores


Virginia-4

Rebecca Snead, R.Ph. Virginia Pharmacist Association Jan Burrus Pharmaceutical Research and Manufacturers of America Ann Leigh Kerr Troutman Sanders LLP Richard Grossman Vectre Corporation


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 P. Snead Executive Director 5501 Patterson Avenue, Suite 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 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 T: 804/965-1216 F: 804/965-0475 E-mail: [email protected] Internet address: www.vhha.com


Washington-1

WASHINGTON





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001** 2002** Expenditures Recipients Expenditures Recipients TOTAL $458,332,414 $541,963,790 RECEIVING CASH ASSISTANCE, TOTAL Aged Blind / Disabled Child Adult MEDICALLY NEEDY, TOTAL Aged Blind / Disabled Child Adult POVERTY RELATED, TOTAL Aged Blind / Disabled Child Adult TOTAL OTHER EXPENDITURES/RECIPIENTS* *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2001and 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, CMS-64 Report, FY 2001 and 2002.


Washington-2

C. ADMINISTRATION

Medical Assistance Administration, Department of Social and Health 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; DESI drugs; and experimental drugs. Over-the-Counter Product Coverage: Products covered with restrictions: allergy, asthma and sinus products (selected items); analgesics (ASA and acetaminophen); cough and cold preparations (selected items); digestive products (selected items); feminine products (selected items); and topical products (selected items). Products not covered: smoking deterrent products. (Note: Zyban only covered for pregnant women in smoking cessation program). Therapeutic Category Coverage: Therapeutic categories covered: antibiotics; anticoagulants; anticonvulsants; antidiabetic agents; anti-depressants; antilipemic agents; cardiac drugs; chemotherapy agents; contraceptives; ENT anti-inflammatory agents; estrogens; hypotensive agents; sympathominetics (adrenergic); and thyroid agents. Therapeutic categories requiring prior authorization:* anabolic steroids; analgesics, antipyretics, and NSAIDs; antihistamine drugs; anti-psychotics; anxiolytics, sedatives, and hypnotics; prescribed cold medications; growth hormones; misc. GI drugs; and non-preferred drugs. Therapeutic categories not covered: anoretics; prescribed smoking deterrents and weight loss drugs; products for hair growth; and figidity, impotency, or sexual dysfunction drugs. *Drugs considered for prior authorization are drugs with high risk/benefit ratio, high potential for abuse/misuse, narrow therapeutic indication, and high cost. A complete list of drugs requiring prior authorization may be found on the Medical Assistance Administration’s web site: 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 with preferred drug list (PDL). Managed through prior authorization, preferred products, and physician profiling. 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.


Prescription Refill Limit: Two (2) refills in 30-day period except for antibiotics, anti-asthmatics, Schedule II and III drugs, anti-neoplastic, topicals, and any propoxyphene, which may have 4 refills. Monthly Prescription Limit: Review of client drug profile by a clinical pharmacist when request for 5th brand name prescription in any one-month period. Monthly Quantity Limit: Maximum 34-day supply (90 days on select items).




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.


Washington-3

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.” Incentive Fee: None. Patient Cost Sharing: No copayment. Cognitive Services: State pays for cognitive services under the Emergency Contraceptive Program.


Approximately 450,000 Medicaid recipients were enrolled in MCOs in FY 2002. Recipients receive pharmaceutical benefits through both the State and managed care plans. Anti-retrovirals, mental health drugs, and family planning products are carved out of managed care.


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, Suite 201 Vancouver, WA 98683 360/449-8867 Community Health Plan of Washington 720 Olive Way, Suite 300 Seattle, WA 98101 206/613-8940 Group Health Cooperative 521 Wall Street Seattle, WA 98121 206/448-6110 Kaiser Foundation Health Plan of the Northwest 500 NE Multnomah, Suite 100 Portland, OR 97232-2099 503/813-3985 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


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: 360/586-8827 E-mail: [email protected] Internet address: http://maa.dshs.wa.gov/pharmacy


Siri A. Childs, Pharm.D. 360/725-1564

DUR Contact

Nicole N. Nguyen, Pharm.D. Clinical Pharmacist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1757 F: 360/586-8827 E-mail: [email protected]

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


Washington-4


Siri A. Childs, Pharm.D. 360/725-1564


Tom Zuchlewski Pharmacy Rates Manager Medical Assistance Administrator, DSHS P.O. Box 45510 Olympia, WA 98504-5510 T: 360/725-1837 F: 360/753-9152 E-mail: [email protected]

Medicaid Drug Rebate Contact Connie L. Riddle Medical Assistance Administration P.O. Box 45503 Lacy, WA 98504-5503 360/725-1243 E-mail: [email protected]


Chris Johnson Claims Processing Manager Medical Assistance Administrator, DSHS P.O. Box 45509 Olympia, WA 98504-5509 360/725-1239 E-mail: [email protected]

Medicaid Managed Care Contact MaryAnne Lineblad, Director Division of Program Support Medical Assistance Administration, DSHS P.O. Box 45530 Lacey, WA 98504-5530 360/725-1786 E-mail: [email protected]

Mail Order Pharmacy Program State has mail order pharmacy program for fee-for-service clients.


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


Alice R. Lind Managed Care Coordination Section Medical Assistance Administration, DSHS P.O. Box 45530 Olympia, WA 98504-45530 360/725-1629 E-mail: [email protected]

Social and Health Services Department Officials 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: [email protected] Doug Porter Assistant Secretary Medical Assistance Administration P.O. Box 45100 Olympia, WA 98504-5100 T: 360/725-1863 F: 360/902-7855 E-mail: [email protected]

Department of Social and Health Services Title XIX Advisory Committee

Janet Varon, Co-chair Executive Director, NoHLA 1820 East Pine Street, Suite 322 Seattle, WA 98122 Robert Wardell, Co-chair 3815 N. Pearl, Apartment K-1 Tacoma, WA 98407 Elise Chayet WSHA Harborview Medical Center 325 Ninth Avenue Seattle, WA 98104-2499 Ted Rudd, M.D. WSMA 209 S. 12th Avenue, #A Yakima, WA 98902


Washington-5

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, Suite 900 Seattle, WA 98104-4039 Shawna Connolly Premera Blue Cross P.O. Box 327 Seattle, WA 98111-0327 Steven Gobin 6700 Totem Beach Road Marysville, WA 98271 Blanche Jones Gentiva Health Services 4020 South 56th Street, Suite 101 Tacoma, WA 98409 Barbara Malich Peninsula Community Health Services P.O. Box 960 Bremerton, WA 98337 Eleanor Owen 802 Northwest 70th Seattle, WA 98117 Mark Secord Neighborhood Health Centers 905 Spruce Street, Suite 201 Seattle, WA 98104 Laura Toepfer AOA 31708 2nd Avenue South Federal Way, WA 98003-5260 Raleigh Watts Department of Health P.O. Box 47481 Olympia, WA 98504-7841

Bruce Yoder, D.D.S. WSDA 1890 Pottery Avenue Port Orchard, WA 98366 DSHS Staff Members Debbie Meyer Secretary Medical Assistance Administration P.O. Box 45080 Olympia, WA 98504-5080

Pharmacy Drug Use Review Team Members

Siri A. Childs, Pharm.D. Nicole Nguyen, Pharm.D. Joan Baumgartner, M.D. Olin Cantrell, PA-C Linda Ayers, A.R.N.P. Valerie Vertz Charles Agte Debbie Bellerud Aimee Bennett David Conaway Kevin Davenport Do Huynh Celeste Moore Robin Pfeiffer Sam Trimble Patty Orth


Washington State Medical Association Thomas Curry Executive Director 2033 Sixth Avenue, Suite 1100 Seattle, WA 98121 T: 206/441-9762 F: 206/441-5863 E-mail: [email protected] Internet address: www.wsma.org Washington State Pharmacists Association Rod Shafer CEO 1501 Taylor Avenue, SW Renton, WA 98055-3139 T: 425/228-7171 F: 425/277-3897 E-mail: [email protected] Internet address: www.wsparx.org


Washington-6

Washington Osteopathic Medical Association, Inc. Kathleen S. Itter Executive Director P.O. Box 16486 Seattle, WA 98116-0486 T: 206/937-5358 F: 206/933-6529 E-mail: [email protected] Internet address: www.woma.org State Board of Pharmacy Donald H. Williams Executive Director Department of Health 310 Israel Road P.O. Box 47863 Olympia, WA 98504-7863 T: 360/236-4825 F: 360/586-4359 E-mail: [email protected] Internet address: wws2.wa.gov/doh/hpql/HPS4/Pharmacy/default.htm Washington State Hospital Association Leo F. Greenawalt President/CEO 300 Elliott Avenue W., Suite 300 Seattle, WA 98119-4118 T: 206/281-7211 F: 206/283-6122 E-mail: [email protected] Internet address: www.wsha.org


West Virginia-1

WEST VIRGINIA1





Child Adult

Prescribed Drugs




Nursing Facility Service

Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001* 2002** Expenditures Recipients Expenditures Recipients TOTAL $256,395,319 269,174 $272,457,097 273,908 RECEIVING CASH ASSISTANCE, TOTAL $195,637,527 118,929 $205,598,570 113,800 Aged $50,185,943 22,104 $50,676,511 21,404 Blind/Disabled $130,303,218 61,244 $140,221,050 63,111 Child $857,251 5,485 $13,569 538 Adult $14,291,115 30,096 $14,687,440 28,747 MEDICALLY NEEDY, TOTAL $6,131,673 4,239 $6,544,451 4,605 Aged $503,211 436 $504,387 458 Blind/Disabled $4,672,424 2,545 $4,797,111 2,712 Child $13,214 14 $2,652 12 Adult $942,824 1,244 $1,240,301 1,423 POVERTY RELATED, TOTAL $30,971,475 122,564 $36,538,255 135,209 Aged $643,374 382 $519,840 282 Blind/Disabled $3,506,525 1,578 $3,889,793 1,572 Child $25,536,971 113,637 $30,296,278 125,627 Adult $1,284,605 6,967 $1,832,344 7,728 TOTAL OTHER EXPENDITURES/RECIPIENTS* $23,654,644 23,442 $23,775,822 20,294

*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients and unknown. **2002 data provided by the West Virginia Department of Health and Human Resources, Bureau for Medical Services. Source: CMS, MSIS Report, FY 2001 and West Virginia Medicaid Statistical Information System, FY 2002.

1 The State of West Virginia did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated the profile and the tables in other sections of the Compilation. Users should contact the West Virginia Medicaid program to assess the accuracy and currency of the information included.


West Virginia-2

C. ADMINISTRATION

Bureau for Medical Services, Department of Health & Human Resources.


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.


Formulary/Prior Authorization Formulary: Closed formulary (as of 1/17/03). Restrictions include preferred products and prior authorization through the Rational Drug Therapy Program. General exclusions include: legend agents used for cosmetics purposes or hair growth; DESI drugs; fertility drugs; and products used for anorexia or weight gain. Prior Authorization: State currently has a prior authorization screening procedure for drug classes and home health care.


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.


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.


West Virginia-3

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.


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 Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5967 F: 304/558-1542 E-mail: [email protected] Internet address: www.wvdhhr.org/bma

Department of Health & Human Resources Officials

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] Nancy Atkins, Commissioner Department of Health and Human Resources Bureau for Medical Services 7012 MacCorkle Avenue, SE Charleston, WV 25301 T: 304/558-1700 F: 304/558-1509 E-mail: [email protected] Sandra Joseph, M.D. Medical Director Division of Medical Care Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5967 F: 304/558-1509


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]


West Virginia-4

Pharmaceutical and Therapeutics Committee Kevin W. Yingling, M.D., R.Ph. 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 25301-3709 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., R.Ph. David P. Elliott, Pharm.D. Bernard Lee Smith, R.Ph., M.B.A, M.H.A (Vice Chair) Patrick M. Regan, R.Ph. Karen Reed, R.Ph. (Chair) Mary Nemeth-Pyles, M.S.N., R.N., C.S. Mitch Shaver, M.D. Myra Chiang, M.D. Matthew Watkins, D.O. John R. Vanin, M.D. Lester Labus, M.D. Ernest Miller, D.O. Christopher Terpening, Pharm.D., R.Ph James M. Bennett, M.D. Kerry Sitzinger, R.Ph. George Bryant, PA-C Daniel Dickman, M.D.

New Brand Name Products Contact Peggy A. King, R.Ph. 304/558-5967


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, R.Ph., 304/558-1700 Rebate: Gail Goodnight, R.Ph., 304/558-1700


Becky Garrigan 770/352-8592


Shelley Baston, Director Bureau of Medical Services Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5978 F: 304/558-4398


None

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


West Virginia-5

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 Street 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 400 Allen Drive, Suite 201 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 & General Counsel 232 Capitol Street Charleston, WV 25301 T: 304/558-0558 F: 304/558-0572 E-mail: [email protected] Internet address: www.wvbop.com

West Virginia Hospital Association Steven J. Summer President 100 Association Drive Charleston, WV 25311 T: 304/344-9744 F: 304/344-9745 E-mail: [email protected] Internet address: www.wvha.com


West Virginia-6


Wisconsin-1

WISCONSIN





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $389,373,521 262,238 $442,718,195 RECEIVING CASH ASSISTANCE TOTAL $195,261,895 107,145 Aged $20,208,955 11,879 Blind/Disabled $171,261,361 73,646 Child $1,321,948 11,038 Adult $2,469,631 10,582 MEDICALLY NEEDY, TOTAL $29,447,709 16,508 Aged $12,300,642 6,621 Blind/Disabled $16,741,054 5,048 Child $327,772 3,962 Adult $78,241 877 POVERTY RELATED, TOTAL $7,821,202 24,252 Aged $392,139 593 Blind/Disabled $4,837,078 1,794 Child $2,164,005 17,197 Adult $427,980 4,668 TOTAL OTHER EXPENDITURES/RECIPIENTS* $156,842,715 114,333 *Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Wisconsin-2

C. ADMINISTRATION

State Department of Health and Family Services, Division of Health Care Financing.


Benefit Design

Drug Benefit Product Coverage: Products covered: prescribed insulin; disposable needles and syringe combinations used for insulin; blood glucose test strips; urine ketone test strips; total parenteral nutrition; and interdialytic parenteral nutrition. Products not covered: cosmetics; fertility drugs; experimental drugs; progesterone for PMS; topical minaxidil, legend prenatal vitamins; and impotence treatment drugs. Over-The-Counter Product Coverage: Products covered: analgesics; ophthalmic lubricants. Products covered with restrictions: allergy, asthma, and sinus products (loratadine, diphenhydramine, pseudoephedrine); cough and cold preparations (cough syrups containing expectorant with or without dextromethorphan only); non-H2 antagonists (Prilosec OTC only); feminine products (vaginal antifungals); and topical products (antibiotics, antifungal agents; capsacin, hydrocortisone). Products not covered: digestive products (H2 antagonists); smoking deterrent products. Therapeutic Category Coverage: Products covered: anabolic steroids; antibiotics; anticoagulants; anticonvulsants; anti-depressants; anti-diabetic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives, ENT-anti-inflammatory agents; prescribed smoking deterrents; sympathominetics (adrenergic); and thyroid products. Prior authorization required for: analgesics; antipyretics, and (brand name) NSAIDs; anoretics; brand name non-sedating antihistamines (except loratudine); antilipemic agents; human growth hormone; hypotensive agents; scheduale III and IV stimulants; enteral nutrition products; Cerezyme; Mupirocin; fertility enhaning drugs; anti-obesity drugs; alitretinoin gel; brand name ACE inhibitors; brand name statins; brand name PPIs, stimulants and anti-obesity drugs; and medically necessary drugs with no rebate agreement.

Coverage of Injectables: Injectable medicines reimbursable through the prescription drug program when used in home health care and in extended care facilities, and through both the prescription drug program and physician payment when in physicians’ offices. Vaccines: Vaccines provided plus reimbursement for administrative fee as part of the Vaccines for Children Program. Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization Formulary: Open formulary managed through restrictions on use and prior authorization. Prior Authorization: State currently has formal prior authorization procedure and a Medicaid Pharmacy Prior Authorization Committee. Beneficiaries can request an administrative hearing to appeal prior authorization decisions or coverage for an excluded product.

Prescribing or Dispensing Limitations:

Quantity of Medication: Pharmacists may not dispense more than 34-day supply of a legend drug. Certain exceptions for some maintenance drugs (100 day supply limit).

Refills: Maximum of 11 refills during a 12-month period for non-scheduled medications.

Dollar Limits: None.


Dispensing Fee: $4.88 to a maximum of $40.11, effective 7/1/98. Incremental increases based on pharmaceutical care services being provided. Maximum of two dispensing fees per month, per prescription. Ingredient Reimbursement Basis: EAC = AWP–12.0%. (AWP-13% effective 7/1/04.) Prescription Charge Formula: Reimbursement at the lowest of: AWP-12.0% 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.


Wisconsin-3

Cognitive Services: Provides an expanded dispensing fee for cognitive services. Patient Cost Sharing: All generic legend drugs are subject to a $1.00 copay, brand legend drugs are subject to a $3.00 copay, limited to $12.00 per month maximum per pharmacy. OTCs are subject to a $0.50 copay. Disposable medical supplies are subject to a sliding scale copayment system. Residents of Skilled Nursing Facilities (SNF) or Intermediate Care Facilities (ICF), subsidized adoption recipients, children under age 18 and HMO enrollees are exempt from the copayment.


Approximately 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 54702-3217 Group Health Cooperative of South Central Wisconsin P.O. Box 44971 Madison, WI 53744-4971 Health Tradition HealthPlan 8202 Excelsior Drive LaCrosse, WI 53717 Managed Health Services Insurance Corp. 1205 S. 70th Street, Suite 500 West Allis, WI 53214 MercyCare Insurance Company P.O. Box 2770 Janesville, WI 53547-2770 Network Health Plan c/o Managed Health Services 1205 S. 70th Street, Suite 500 West Allis, WI 53214

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 Touchpoint Health Plane 5 Innovation Court P.O. Box 507 Appleton, WI 54912

F. STATE CONTACTS

Pharmacy Practices Consultant Michael C. Boushon, R.Ph. Pharmacy Practices Consultant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/261/7791 F: 608/267-3380 E-mail: [email protected] Internet address: www.dhfs.wisconsin.gov

Prior Authorization Contact Michael C. Boushon, R.Ph. 608/261-7791

Prior Authorization Advisory Committee Standing Steve Maike, R.Ph. Larry Fleming, M.D. Peg Smelser Tom Frazier, Exec. Dir., CWAG Breadley Fedderly, M.D. James Heersma, M.D. Christine Sorkness, Pharm. D. John Gates, R.Ph. Tom Hirsch, M.D.


Wisconsin-4

Expanded for SSRIs Barry Blackwell, M.D. Diane Greenley Ken Robbins, M.D. John Frey III, M.D. Virginia Bryan Allen Liegal, R.Ph. Molly Cisco Randy Lewis Michelle Thoma, R.Ph.

DUR Contact Michael A. Mergener, R.Ph., Ph.D. Chief Pharmacist APS Healthcare 10 East Doty Street, Suite 210 Madison, WI 53703 T: 608/258-3348 F: 608/258-3359

Wisconsin Drug Utilization Review Committee

Robert M. Breslow, R.Ph. Ward Brown, M.D. Mark E. Buhler, R.Ph. Daniel R. Erickson, M.D. Barry Hess, R.Ph. Nancy E. Ness, M.D. Pamela Ploetz, R.Ph. Lee C. Vermeulen, Jr., R.Ph., M.S. Mary Jo Willis, M.S., N.P.

New Brand Name Prescription Contact

Carol Neeno Pharmacy Assistant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1203 F: 608/267-3380 E-mail: [email protected]


First Databank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 800/633-3453 F: 415/588-6867


Ellen Orsburne Medicaid Systems Analyst Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 608/267-7939 E-mail: [email protected]

Claims Submission Contact Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567

Medicaid Managed Care Contact Angela Dombrowicki, Director Division of Healthcare Financing Bureau of Managed Health Care Programs Department of Health and Family Services One West Wilson P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1935 F: 608/261-7792 E-mail: [email protected]


None

Health and Family Services Department Officials Helene Nelson, Secretary Department of Health and Family Services One West Wilson Street Madison, WI 53701 T: 608/266-9622 F: 608/266-7882 E-mail: [email protected] Mark P. Moody, Administrator Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-2522 F: 608/266-1096 E-mail: [email protected]


Wisconsin-5

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 Heather Jesina Executive Director 5645 Randall Lane Racine, WI 53402 262/752-2280 E-mail: [email protected] Pharmacy Society of Wisconsin Christopher J. Decker Executive Vice President 701 Heartland Trail Madison, WI 53717 T: 608/827-9200 F: 608/827-9292 E-mail: [email protected] Internet address: www.pswi.org Wisconsin Pharmacy Examing Board Tom Ryan, Director 1400 E. Washington Avenue Madison, WI 53703 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 53719-4992 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


Wisconsin-6


Wyoming-1

WYOMING





Child Adult

Prescribed Drugs





Physician Services

Dental Services

B. EXPENDITURES FOR DRUGS 2001 2002** Expenditures Recipients Expenditures Recipients TOTAL $31,881,860 36,704 $39,094,579 RECEIVING CASH ASSISTANCE, TOTAL $12,791,205 12,347 Aged $1,358,763 746 Blind / Disabled $8,964,573 3,913 Child $948,764 4,687 Adult $1,519,105 3,001 MEDICALLY NEEDY, TOTAL $0 - Aged $0 - Blind / Disabled $0 - Child $0 - Adult $0 - POVERTY RELATED, TOTAL $2,817,574 14,975 Aged $13,038 15 Blind / Disabled $20,761 28 Child $2,437,127 12,689 Adult $346,648 2,243 TOTAL OTHER EXPENDITURES/RECIPIENTS* $16,273,081 9,382 *Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown. **2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable. Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.


Wyoming-2

C. ADMINISTRATION

Department of Health, Director’s Office.


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 (must be listed in State’s system and filed with First DataBank): allergy, asthma, and sinus products; analgesics; cough and cold products; digestive products (H2 antagonists); feminine products; topical agents; antidiarrheal products; food thickeners; nutrition products; laxatives; pediatric and prenatal vitamins; and artificial tears. Products not covered: non-H2 antagonists; smoking deterrent products. Therapeutic Category Coverage: Products covered: analgesics, antipyretics, and NSAIDs (prior authorization for COX 2s and oxycontin); antibiotics; anticoagulants; anticonvulsants; anti-depressants; antidiabetic agents; antihistamines; antilipemic agents; anti-psychotics; anxiolytics, sedatives, and hypnotics; cardiac drugs; chemotherapy agents; prescribed cold medications; contraceptives; ENT anti-inflammatory agents; estrogens; growth hormones; hypotensive agents; misc. GI drugs (prior authorization for PPIs); sympathominetics (adrenergic); thyroid agents; antifungals; antiparasitic products; and bronchodiolators. Products not covered; anabolic steroids; prescribed smoking deterrents. 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: Open formulary with preferred drug list (PDL). 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.


Monthly Quantity Limits: Quantity limits on some medications as deemed clinically appropriate.


PRODUR system implemented in October 1995. State currently has a DUR Board with 12 members that meet bimonthly.


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.


Wyoming-3



F. STATE CONTACTS


Antoinette Brown, R.Ph. Medicaid Pharmacist Department of Health-Pharmacy Unit 2424 Pioneer Avenue, Suite 100 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 Email: [email protected] Internet address: www.pharmacy.state.wy.us

Department of Health Officials

Deb Fleming, Ph.D. Director Department of Health 117 Hathaway Building 2300 Capitol Avenue Cheyenne, WY 82002-0710 T: 307/777-7656 F: 307/777-7439 E-mail: [email protected]

DUR Contact

Debra Devereaux, R.Ph. DUR Coordinator University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 T: 307/766-6750 F: 307/766-2953 E-mail: [email protected]

DUR Board Antoinette Brown, R.Ph. (re-officio) 307/777-6016 Debra Devereaux, R.Ph. (DUR Coordinator) 307/766-6750 Becky Drnas, R.Ph. K-Mart Pharmacy 2450 Foothill Boulevard Rock Springs, WY 82901 307/362-7990 Dawn Ford, R.Ph. 2022 Reagan Avenue 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 Johnston, M.D. P.O. Box 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 Street Casper, WY 82609 307/234-3638 Michael Carpenter, PA-C 1121 Washington Boulevard 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. (ex-officio) 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


Wyoming-4

Linda G. Martin, R.Ph. (ex-officio) University of Wyoming School of Pharmacy P.O. Box 3375 Laramie, WY 82071-3375 307/766-6128


Antoinette Brown, R.Ph. 307/777-6016


First DataBank 1111 Bayhill Drive San Bruno, CA 94066 T: 800/633-3453 F: 650/872-4510

Medicaid Drug Rebate Contacts Sheila McInerney TPL Manager ACS P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405


ACS Northridge Center 1, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459



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 Pharmacy Association Mindy Rasmussen Executive Director P.O. Box 366 Cheyenne, WY 82003 T: 307/772-8044 F: 307/772-8004 E-mail: [email protected] Internet address: www.wpha.net 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 P.O. Box 249 Cheyenne, WY 82003 T: 307/632-9344 F: 307/632-9347 E-mail: [email protected] Internet address: www.wyohospitals.com


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Section 6: State Pharmacy Assistance Programs


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State Pharmacy Assistance Programs

As of February 2004, 40 States had various pharmaceutical assistance programs providing coverage or assistance to the low-income elderly and/or persons with disabilities who do not qualify for Medicaid. These programs provide access to State-negotiated discounts or State subsidies, and tax credits for prescription drug expenditures. In addition, we are now including programs that provide coordination of seniors’ services to access manufacturers’ charitable prescription assistance programs. The new Medicare law signed December 8, 2003, will cover or impact many of the same people now served by the State programs listed below. However, State subsidy programs will not be directly affected until 2006. State discount programs already in operation remain effective for now. In 2004, the Federal plan anticipates a series of Department of Health and Human Services (HHS)-endorsed Medicare discount cards that will impact existing state-only discount plans. A limited discount card subsidy (up to $600) also may impact existing benefits. Several State programs have established sunset dates to coincide with the implementation of the Medicare prescription drug benefit program. Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted Alabama SenioRx 2002 Arizona Prescription Discount Program (CoppeRx Card) 2004‡ Arkansas ARx Senior Program 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) 1986

Nemours Pharmacy Assistance 1981 Delaware Delaware Prescription Drug Assistance Program

(DPAP) 1999

Silver SaveRx (formerly Formally, Ron Silver Senior Drug Program/Prescription Affordability Act) 2002 Florida Prescription Discount Program 2000

Georgia Georgia Cares 2002 Hawaii Hawaii Rx Discount Program 2002†

Pharmaceutical Assistance Program (“Circuitbreaker”) 1985 Illinois Rx SeniorCare 2001 Illinois Senior Citizen Prescription Drug Discount Program (Senior Rx Buying Club) 2003†

Indiana Indiana Prescription Drug Program, “HoosierRx” 2000

Iowa Iowa Priority Prescription Savings Program None. Created by federal grant.

Kansas Senior Pharmacy Assistance Program 2000 Louisiana Seniors Pharmacy Assistance Program 2003 Louisiana Louisiana SenioRx Program 2003 Maine Rx+ 2003 Maine Low Cost Drugs for the Elderly Program (DEL) 1975 Maryland Pharmacy Assistance Program 1979 Senior Prescription Drug Program 2000 Maryland Maryland Pharmacy Discount Program 2001


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Prescription Advantage 2000 Massachusetts MassMedLine 2001

Michigan Elder Prescription Insurance Coverage Program 2001 Minnesota Prescription Drug Program 1999 Missouri Senior Rx Program 2001 Montana Prescription Drug Expansion Program 2003† Nevada Senior Rx Program 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

New Mexico Senior Prescription Drug Program 2002

New York Elderly Pharmaceutical Insurance Coverage (EPIC) Program 1987

North Carolina Senior Care 2002 Golden Buckeye Prescription Drug Program 2002 Ohio Ohio’s Best Rx Program 2003†

Oklahoma Pharmacy Connection Council Program 2003 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 benefit program. 2003 Texas State Prescription Drug Program 2001†

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

Vermont

Healthy Vermonters Program 2002 Washington Washington Rx Card 2003† West Virginia Golden Mountaineer Card Program 2000 Wisconsin SeniorCare Prescription Drug Assistance Program 2001 Wyoming Prescription Drug Assistance Program 2002

† Program not yet operational; see below for more details. ‡ Established by executive order.

The Maine Rx Plus Program was finalized during 2003 and replaces the Maine Rx Program, which faced significant legal challenges and was never implemented. Additionally, beneficiaries from the former Healthy Maine Prescription Program were immediately eligible for the Maine Rx Plus program. Beneficiaries with incomes up to 350 percent of the Federal poverty level will be able to buy any drug on the Medicaid preferred drug list (PDL) for the Medicaid price. The State will also begin negotiations with manufacturers for additional program rebates. If successful, the State will not use prior authorization as a management tool. South Dakota also began a new Prescription Drug Discount Card Program in 2003, while three States (Illinois, Ohio and Washington) have plans for new programs that will begin during 2004. Efforts in Tennessee to expand a prescription drug program through TennCare are pending and a new prescription drug program in Montana was cancelled due to enactment of the Federal Medicare prescription drug benefit.


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• South Dakota Senior Citizen Prescription Drug Benefit Program: SB 216 was signed into law March 20, 2003. It establishes a senior citizen prescription drug discount card program and is open to any resident age 65 and older and any person meeting the eligibility criteria for a disability. It is run by the Bureau of Personnel and administered by AdvancePCS. Legislation has been introduced to sunset the program 120 days after the federal Medicare drug discount card program begins in 2004.

• Illinois Senior Rx Buying Club: SB 3 was signed into law June 16, 2003. The new Senior Rx

Buying Club, which went into effect on January 1, 2004, is open to all Illinois residents who are 65 or older and the disabled for an annual administrative fee of $25. By leveraging the buying power of the State’s seniors and disabled with that of nine state entities that purchase $1.8 billion in drugs a year, the State expects pharmaceutical companies will be enticed to participate and offer lower prices and higher rebates. Unlike the Circuit Breaker and SeniorCare programs, the new discount card program is not income-based.

• Ohio’s Best Rx Program: HB 311 was signed into law December 18, 2003. It establishes

Ohio’s Best Rx Program, a prescription drug discount card program for low-income residents under 60 years of age, or residents 60 and older who have no prescription drug insurance coverage. A Pharmacy Benefit Manager (PBM) will negotiate manufacturer discounts that will be fully passed on to all enrollees. The program will use an open formulary and optional mail-order delivery. The implementation date is April 1, 2004.

• Washington Rx Card: SB 6088 was signed into law June 26, 2003. It establishes a discount and

a subsidy program. Eligible residents, defined as the disabled age 19-49 and people age 50 or older with incomes up to 300 percent of the Federal poverty level, will be able to purchase pharmaceuticals at a discounted price, based on voluntary negotiated discounts initiated by the Health Care Authority for State agencies. Participants are charged an enrollment fee. The program is subject to sunset review and termination on June 30, 2010. The law also requires the State to seek a "Pharmacy Plus" waiver under Medicaid to provide subsidies to Medicare-eligible residents up to 200 percent of Federal poverty guidelines.

• The TennCare Rx Program Prescription Benefit (pending): HB 1650 was signed into law June

13, 2003. It creates the TennCare prescription drug program that will expand drug coverage to individuals lacking prescription drug insurance based on criteria established by the TennCare Bureau and the legislature. The program will serve a non-Medicaid population and may utilize tiered copayments, prior authorization and step therapy requirements based on the State PDL. Given TennCare funding difficulties, it is unclear when this program will be implemented.

• Montana Prescription Drug Expansion Program (canceled): SB 473 was signed into law May

1, 2003. It provided for a prescription drug expansion program through Medicaid and a Centers for Medicare and Medicaid Services (CMS) Pharmacy Plus waiver. It offered discounted pharmaceutical prices to qualified individuals with income levels up to 200 percent of the federal poverty level. The program was halted due to the enactment of a Federal Medicare prescription drug benefit on December 8, 2003.

Four States (Alabama, Georgia, Louisiana and Oklahoma) have programs which assist eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. These State programs do not, however, contribute any money for the direct purchase of prescription drugs. Several programs, slated to begin in 2003, were postponed due to lack of funding or support from manufacturers.


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• Golden Bear State Pharmacy Assistance Program: Authorized by passage of SB 696 in October 2001, the Golden Bear State Pharmacy Assistance Program would provide discounts to California seniors over and above those provided by the Discount Prescription Medication Program. The program has been postponed due to lack of manufacturer participation and the pending Federal Medicare prescription drug benefit program scheduled to be implemented between 2004 and 2006.

• Hawaii Rx Program: Authorized by passage of HB 2834 in June 2002, the Hawaii Rx Program

is pending implementation. The legislature will conduct further study and propose additional amendments during 2004 before launching the program.

• Texas Prescription Drug Program: State funding for the program has not been established for

2004-2005. The following pages provide profiles of the States that provided pharmacy assistance in 2003, as well as profiles of the new State programs. Details were provided by contacts on program characteristics, including eligibility criteria, funding and reimbursement information, and drug coverage. Supplemental information was obtained from special surveys of State programs, including the National Conference of State Legislatures site (www.ncsl.org), which is a good source for the most up-to-date information.


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Alabama Alabama SenioRx Program*

Program Type: Coordinate Assistance Between Elderly and Charitable Pharmaceutical Programs

Year Operational: 2002 Number of Recipients (December 2003): 8,495

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+ Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of

FPL Other Eligibility Notes: Individuals may not have any other insurance coverage for

medicines. Individuals must re-enroll in the program on a quarterly basis to verify eligibility.

FUNDING AND REIMBURSEMENT

Funding Source: State general revenue Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The purpose of the program is to utilize available State resources

to help eligible seniors find appropriate charitable pharmaceutical programs from various manufacturers. The State will also coordinate and complete all necessary paperwork for each participant.

DRUG COVERAGE

Formulary: None Drugs Covered: Based on a manufacturer’s charitable program criteria. Drug Coverage Restrictions: Not available Notes: Enrollees must have chronic health care conditions to participate

in the program, i.e., maintenance medications for long-term problems like hypertension. Participants with short-term illnesses are not eligible for the program.

*The Alabama SenioRx Program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.


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PROGRAM CONTACT

Tina Hartley Interim Director Alabama Dept. of Senior Services 770 Washington Avenue RSA Plaza, Suite 470 Montgomery, AL 36130

Phone: 334/242-5743 Fax: 334/242-5594 E-mail: [email protected]


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Arizona Prescription Discount Program (CoppeRx Card)

Program Type: Discount Law Enacted: 2001

Estimated Number of Recipients (December 2003): 15,000*


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): none Eligible Income Level (Single): None Eligible Income Level (Married): None Other Eligibility Notes: Open to all seniors and Medicare-eligible disabled who are

residents of Arizona.


Funding Source: Tobacco Settlement Fund Budget: Not available Cost per Participant: Not Available # of Rx’s Per Participant: Not Available Manufacturer Rebate Type: Not Available Ingredient Cost Calculation: Not Available Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $3.00 for retail and $2.00 for mail order Notes: Average percent savings off the regular prescription price: brand

name drugs (17.7%) and generic drugs (40.1%). Average savings per prescription: $13.39. Total savings to all participants (through 12/31/03) over $1.1 million. RxAmerica (PBM) negotiates discounts with participating manufacturers.

DRUG COVERAGE

Formulary: None Drugs Covered: All FDA-approved drugs. Drug Coverage Restrictions: None

PROGRAM CONTACT

Del Swan Pharmacy Program Administrator Arizona Health Care Cost Containment System 801 E. Jefferson St. Phoenix, AZ 85034

Phone: 602/417-4726

* Replaces RxAmerica (Arizona Drug Discount Program); 15,000 enrollees automatically rolled into the new program. Membership cards sent to more than 1 million eligible residents.


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Arkansas ARx Senior Program

(Prescription Drug Access Improvement Act)

Program Type: Direct Assistance (1115 Waiver) Law Enacted: 2001∗

Projected Number of Recipients: Not available



FPL Other Eligibility Notes: Program provides prescription drug coverage to Qualified

Medicare Beneficiary (QMB) seniors lacking prescription drug coverage.


Funding Source: State General Revenue Fund and Federal matching funds Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Medicaid reimbursement rate Enrollment Fee: $25.00 per year Deductible Amount: $5.00 Copayment Amount: $10.00 for generic drugs and $20.00 for name-brand drugs Dispensing Fee: Not Available

DRUG COVERAGE

Formulary: Same as Medicaid program Drugs Covered: Legend drugs and controlled substances Drug Coverage Restrictions: Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT

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


∗ Program implementation is contingent upon CMS approval of 1115 waiver application. As of January 2004, no communications from CMS had been received. As a result, implementation date is still pending.


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California Discount Prescription Medication Program

Program Type: Discount Year Operational: 2000

Number of Recipients (December 2003): 850,000


Eligibility Age (Elderly): All Medicare eligible

Eligibility Age (Disabled): All Medicare eligible

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.


Funding Source: Medi-Cal pharmacies Budget (FY 02-03): $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: Average wholesale price (AWP) – 10% Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.05 per prescription (-50 cents to help balance the State

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

must allow Medicare recipients to purchase drugs for the same price paid by Medi-Cal. Recipients must pay Medi-Cal price for drug and a 15 cents processing fee.

DRUG COVERAGE

Formulary: No formulary Drugs Covered: Almost all prescription drugs Drug Coverage Restrictions: Over-the-counter drugs and compound drugs not covered

PROGRAM CONTACT

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

Phone: 916/552-9714 1-800-434-0222

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


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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: 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: Implementation of the Golden Bear State Pharmacy Assistance

Program is pending as no pharmaceutical manufacturers are participating in the program. The program has been postponed due to the Federal Medicare prescription drug benefit enacted by Congress in 2003.

DRUG COVERAGE

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

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

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

PROGRAM CONTACT

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

Phone: 916/552-9557

* Golden Bear State Pharmacy Assistance Program is not operational. No manufacturers are participating.


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Connecticut Pharmaceutical Assistance Contract to the Elderly and

Disabled (ConnPACE)

Program Type: Direct Assistance Year Operational: 1986



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): $20,800 Eligible Income Level (Married): $28,100 Other Eligibility Notes: Disabled persons 18-64 must be Social Security Disability

Insurance (SSDI) or Supplemental Security Insurance (SSI) eligible. Effective February 2004, new means test will be used to determine “liquid assets”; $100,000 - individuals; $125,000 – married


Funding Source: State General Revenue Fund Budget (FY 04): $77.9 million Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 12% Enrollment Fee: $30.00 per year Deductible Amount: None Copayment Amount: $16.25 Dispensing Fee: $3.30

DRUG 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.


6-14

Notes:

Generic drugs must be substituted for brand-name drugs, unless otherwise indicated by the prescribing physician (prior authorization required). Prior authorization is required for early refills, drug product costs over $500, physician request for a brand-name product. Under statutory authority, State may implement PDL in the future.

PROGRAM CONTACT

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



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Delaware Nemours Pharmacy Assistance

Program Type: Private Discount Year Operational: 1981

Number of Enrollees (December 2003): 7,822


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 (2003): Not available 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.

DRUG 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



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Delaware Prescription Assistance Program (DPAP)





FPL Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware. Couples are

counted as two individuals. Individuals with income over 200% of FPL can qualify if they have prescription costs exceeding 40% of their income. Those age 65 and over who are eligible for the Nemours Foundation prescription benefit are not eligible for DPAP. DPAP does not replicate coverage for Nemours clients. Disabled persons 18-64 must be Social Security Disability Insurance (SSDI) eligible.


Funding Source: Tobacco Settlement funds Budget: Not available; not subject to budget appropriation Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Negotiated between the State and individual manufacturers Ingredient Cost Calculation: Lower of AWP – 12.9% or Federal Upper Limit or State

maximum allowable cost (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.

EDS administers program on behalf of the State.

DRUG 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

Judy Ackerman – EDS Division of Social Services 248 Chapman Road Suite 100 Newark, DE 19702



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Florida

Silver SaveRx Program Program Type: Direct Assistance (1115 waiver)

Year Operational: 2002 Number of Enrollees (January 2004): 52,074


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+ Eligible Income Level (Single): 88% - 120%

of FPL Eligible Income Level (Married):

88% - 120% of FPL

Other Eligibility Notes: Program covers dual eligibles only. Eligibility is determined on a monthly basis.


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

Budget (FY 03): $100 million Cost per Enrollee (FY 03): $160 per month – maximum benefit # of Rx’s Per Enrollee (FY 03): 108 (estimated) Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: The lesser of AWP – 13.25%, Wholesalers Acquisition Cost

(WAC) +7%, or the usual and customary Enrollment Fee: None Deductible Amount: None Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the

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

Dispensing Fee: $4.23 Notes: Enrollees will have up to $160 deposited monthly in a Silver

Saver account that is maintained by the Medicaid program.

DRUG COVERAGE

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

PROGRAM CONTACT

Michele Hudson Agency for Health Care Admin. 2727 Mahan Drive Tallahassee, FL 32308-7703

Phone: 850/487-4441 E-mail: [email protected]


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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


All income levels

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


Funding Source: None Budget: None Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Not available Ingredient Cost Calculation: AWP – 9% Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.50 Notes: Pharmacies that participate in Medicaid must offer participants a

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

DRUG COVERAGE

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

PROGRAM CONTACT

Michele Hudson 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.


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Georgia Georgia Cares Program*


Year Operational: 2002 Number of Recipients: 24,739


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+ Eligible Income Level (Single): None Eligible Income Level (Married): None Other Eligibility Notes: Individuals may not have any other insurance coverage for

medicines.


Funding Source: State and Federal grant money Budget (FY 04): $580,000 Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The purpose of the program is to utilize available State resources

to help eligible seniors find appropriate charitable pharmaceutical programs from various manufacturers. The program also receives some in-kind grant money from the “Thanks Mom & Dad Fund,” a 501(c)(3) charitable organization that collects private donations for senior assistance programs.

DRUG COVERAGE

Formulary: None Drugs Covered: Based on a manufacturer’s charitable program criteria. Drug Coverage Restrictions: Not available

* The Georgia Cares Program assists eligible State residents in health care insurance counseling and in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.


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PROGRAM CONTACT

Jennie Deese Coordinator Georgia Cares Division of Aging Services 2 Peachtree Street, NW Atlanta, GA 30303

Phone: 404/463-8578 Fax: 404/657-5285 Alternate Contact: J. Eric Ryan Program Consultant Georgia Cares Phone: 404/657-5333 E-mail: [email protected]


6-21

Hawaii

Hawaii Rx* Program Type: Direct Discount

Projected Operational Date: Pending Projected Number of Recipients: Not Available


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


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.

DRUG 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

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

Phone: 808/692-8050

* The legislature will conduct further study and propose additional amendments during 2004 before implementing the program.


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Illinois Pharmaceutical Assistance Program (PAP)

“Circuit Breaker” Program Type: Direct Assistance



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+ Eligible Income Level (Single): 250% of FPL Eligible Income Level

(Married): 250% of FPL

Other Eligibility Notes: A widow or widower who turns 63 or 64 before a deceased enrollee’s death is eligible for PAP. Also, a married couple with a $35,740 annual household income would be eligible if they were filing with one other resident. An individual would be eligible with a $35,740 annual household income if they were filing with two other residents.


Funding Source: State General Revenue Fund and Tobacco Settlement Budget (FY 04): $83 million Cost per Participant (FY 03): $1,255.66 # of Rx’s Per Participant: Not available Manufacturer Rebate Type Negotiated by a Express Scripts (PBM) on behalf of State Ingredient Cost Calculation: AWP – 14% Enrollment Fee: $5.00 if income is below 100% of FPL and $25.00 if income is

at or above 100% of FPL Deductible Amount: None Copayment Amount: For income less than 100% of FPL, there is no copayment until

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

Dispensing Fee: $2.55

DRUG COVERAGE

Formulary: State 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, heart and blood pressure problems, multiple sclerosis, and osteoporosis.


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Drug Coverage Restrictions

Participants are able to receive brand-name drugs even if generic 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 Pharmaceutical Assistance Programs Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021



6-24

Illinois Illinois Rx SeniorCare

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





Other Eligibility Notes: Seniors who are already enrolled in the State’s Circuit Breaker/ Pharmaceutical Assistance Program and fall at or below 200% of FPL are automatically enrolled in this program. Eligible individuals who already have pharmaceutical health insurance benefits may choose to receive a $25 rebate check monthly. By choosing the SeniorCare Rebate, individuals must use their own health insurance to pay for prescription drugs.


Funding 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 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 single with income of no more than $8,979 a

year, or if participant lives with his/her spouse and together the income is no more than $12,119, SeniorCare pays up to $1,750 per person in a year at no cost. After $1,750, participant pays 20% of each prescription.

If the participant is a single individual with an income of $8,980 to $17,960 a year, or if the participants are a married and living together with a total household income of $12,120 to $24,240 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.

Dispensing Fee: Not available


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DRUG 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 Pharmaceutical Assistance Programs Illinois Department of Revenue P.O. Box 19021 Springfield, IL 62794-9021



6-26

Illinois Illinois Rx Buying Club Program Type: Direct Discount

Year Operational: 2004 Number of Eligible Recipients: 1.5 million


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare eligible

Eligible Income Level (Single): None Eligible Income Level (Married): See notes Other Eligibility Notes: Membership is available to individuals only. Circuit Breaker/

Pharmaceutical Assistance participants are automatically enrolled in the buying club.


Funding Source: Enrollment fees Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Sav-Rx (PBM) negotiates discounts with participating

manufacturers. Ingredient Cost Calculation: Not available Enrollment Fee: $25.00 Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The Illinois Rx Buying Club provides discounts on all categories

of prescription drugs. The program also has a mail-order option for enrollees. The $25.00 enrollment fee entitles beneficiary to savings of 20% or more on each prescription for 12 months.

DRUG COVERAGE

Formulary: Preferred Drug List Drugs Covered: All prescriptions ordered by physician that are on the PDL Drug Coverage Restrictions: All FDA-approved drugs are eligible for the program

PROGRAM CONTACT

Deb Corso Illinois Department on Aging 421 East Capitol Avenue, #100 Springfield, IL 62701-1789

Phone: 217/524-7478 Fax: 217/785-4477


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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): 135% of FPL Eligible Income Level


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 each year.


Funding Source: Tobacco Settlement Fund Budget (FY 04): $8 million Cost per Participant (FY 03): $540 # of Rx’s Per Participant (FY 03): 51.6 Manufacturer Rebate Type: None Ingredient Cost Calculation: Medicaid reimbursement rate Enrollment Fee: None Deductible Amount: None Copayment Amount: 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.

DRUG COVERAGE

Formulary: None Drugs Covered: All prescription drugs, as well as insulin


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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]


6-29

Iowa Iowa Priority Prescription Savings Program

Program Type: Negotiated Discount Year Operational: 2002



Eligibility Age (Elderly): All Medicare eligibles

Eligibility Age (Disabled): All Medicare eligibles



All income levels

Other Eligibility Notes: Medicaid recipients are not eligible.


Funding Source: Federal grant and enrollment fees Budget (FY 03): $1.2 million Cost per Enrollee: Not available # of Rx’s Per Enrollee (FY 03): 36 Manufacturer Rebate Type: A pharmacy benefit manager (PBM) negotiates discounts with

participating manufacturers. Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each

participating manufacturer. Enrollment Fee: $20.00 per year Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The Iowa Priority prescription savings program is a nonprofit

organization run by the non-profit Iowa Prescription Drug Corporation. Discounts are available on participating manufacturers’ drugs (Bristol-Myers Squibb, Merck, Novartis, and Schering-Plough). 100% of the discount is passed through directly to the consumer at the point of sale.

DRUG COVERAGE

Formulary: Preferred drug list Drugs Covered: The following therapeutic classes of drugs are covered: Allergy,

Alzheimer’s Disease, Anti-Convulsant Agents, Anti-Fungal Agent, Anti-Psychotic Agent, Antiviral, Arthritis and Analgesia, Asthma, Breast Cancer, Central Nervous System Stimulants, Cholesterol Lowering Agents, Dermatological Products, Diabetes, Enlarged Prostate Treatment, Glaucoma Agents, Hormone Replacement, Hypertension/High Blood Pressure and Cardiovascular, Irritable Bowel Syndrome, Osteoporosis Treatment, Parkinson’s Disease, and Voltaren Ophthalmic® (diclofenac ophthalmic).

Drug Coverage Restrictions: None


6-30

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]


6-31

Kansas Kansas Senior Pharmacy Assistance Program

Program Type: Reimbursement Year Operational: 2001

Number of Enrollees (June 2003): 1,500




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 Low Income Medicare Beneficiary Program. If funded, law permits income eligibility up to 200% of poverty level.


Funding Source: State funds Budget (FY 04): $1.2 million Cost per Enrollee (FY 03): $306 (estimated) # of Rx’s Per Enrollee: Not available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: 30% of pharmaceutical cost Dispensing Fee: None Notes: Maximum annual benefit is $1,200.00 per enrollee annually,

with reimbursement checks to be sent by December 31 of each year.

DRUG COVERAGE

Formulary: None Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare Drug Coverage Restrictions: Program does not cover over-the-counter or lifestyle drugs.


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PROGRAM CONTACT

Janet Boscom Department on Aging 503 S. Kansas Avenue Topeka, KS 66603-3404

Phone: 785/296-4986 General E-mail: [email protected]


6-33

Louisiana Louisiana Seniors Pharmacy Assistance Program

Program Type: Reimbursement Year Operational: Not Yet Operational

Number of Recipients: N/A




Other Eligibility Notes:


Funding Source: Not Available Budget (FY 04): Not Available Cost per Participant: Not available # of Rx’s Per Participant (FY 04): Not Available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes:

DRUG COVERAGE

Formulary: None Drugs Covered: Not available Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Melissa Jenkins Coordinator Governor's Office of Elderly Affairs P.O. Box 80374 Baton Rouge, LA 70898

Phone: 225/342-7100 or 342-3570 Fax: 225/342-7133


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Louisiana Louisiana SenioRx Program*


Year Operational: 2003 Number of Recipients: Under 1,000




Other Eligibility Notes: Individuals may not have any other insurance coverage for medicines.


Funding Source: State general revenue Budget (FY 04): $500,000 Cost per Participant: Not available # of Rx’s Per Participant (FY 04): 84 Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The purpose of the program is to utilize available State resources

to help eligible seniors find appropriate charitable programs from various manufacturers. The State will also coordinate and complete all necessary paperwork for each participant.

DRUG COVERAGE


PROGRAM CONTACT

Melissa Jenkins Coordinator Governor's Office of Elderly Affairs P.O. Box 80374 Baton Rouge, LA 70898

Phone: 225/342-7100 or 342-3570 Fax: 225/342-7133

* The Louisiana Senior Rx Program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.


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Maine Maine Rx Plus*


Estimated Eligibles (FY 04): 275,000


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): 350% FPL Eligible Income Level

(Married): 350% FPL

Other Eligibility Notes: Any person who incurs unreimbursed expenses for prescription drugs equaling 5% or more of family income, or who incurs unreimbursed expenses for all medical care equaling 15% or more of family income, is eligible for the remainder of the eligibility period.


Funding Source: State appropriations and subsidies Budget (FY 04): $800,000 Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: State-only rebates Ingredient Cost Calculation: AWP – 13% Enrollment Fee: None Deductible Amount: None Copayment Amount: Program combines discounts from participating pharmacies with

negotiated rebates from manufacturers Dispensing Fee: $3.35

DRUG COVERAGE

Formulary: Closed formulary Drugs Covered: Only “preferred” drugs included on the MaineCare (Maine

Medicaid) PDL. Drug Coverage Restrictions: Non-preferred drugs (as indicated non-covered on the

MaineCare PDL).

PROGRAM CONTACT

Jude Walsh Department of Human Services 11 State House Station Augusta, ME 04333-0011


* This program replaces the Maine Rx Program, which faced significant legal challenges and was never implemented. Additionally, beneficiaries from the former Healthy Maine Prescription Program were immediately eligible for the Maine Rx Plus program.


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Maine Low Cost Drugs for the Elderly and Disabled Program

(DEL)*

Program Type: Subsidy and Discount Year Operational: 1975





Other Eligibility Notes: This program is made available to Maine residents fitting the age and income eligibility criteria. Individuals with full MaineCare (Maine Medicaid) benefits are not eligible. Medicare recipients are not necessarily excluded.


Funding Source: State appropriations and subsidies Budget (FY 04): $18 million Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: State-only rebates Ingredient Cost Calculation: AWP –15% Enrollment Fee: None Deductible Amount: None Copayment Amount: Basic: 20% +$2.00 of the cost of generic drugs; 20% + $2.00 of

the cost of prescriptions for select medical conditions; 84% of the cost of other covered prescriptions. Supplemental: State pays $2.00 toward the cost of all other drugs from participating manufacturers.

Dispensing Fee: $2.35 Notes: A participant is eligible for a Catastrophic benefit once he or she

has paid total copayments in the DEL benefit of at least $1,000 between August 1 and July 31 of any year(s) in which the participant is eligible.

DRUG COVERAGE

Formulary: Open formulary Drugs Covered: Only those drugs covered with manufacturer participation. Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for

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

* The Low Cost Drugs for the Elderly and Disabled (DEL) Program is also run under the Maine Rx Plus umbrella, distinguished by the eligibility criteria differences.


6-37

PROGRAM CONTACT

Jude Walsh Department of Human Services 11 State House Station Augusta, ME 04333-0011



6-38

Maryland Maryland Pharmacy Assistance Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes Eligible Income Level (Single): 116% of FPL Eligible Income Level


Other Eligibility Notes: No age restrictions on eligibility if they are Medicare-eligible and MD residents. The following groups are ineligible for participation: people detained in a correctional (Federal, State, local) system, Medicaid recipients. Disabled are covered if they are Medicare-eligible.


Funding Source: State General Revenue Fund Budget (FY 03): $73.2 million Cost per Participant (FY 03): $1,697.96 # of Rx’s Per Participant (FY 03): 27.55 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC +9%, Direct

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

Enrollment Fee: None Deductible Amount: None Copayment Amount: $7.50 for brand-name; $2.50 for generics (per prescription) Dispensing Fee: $3.69 for brand-name; $4.69 for generics

DRUG COVERAGE

Formulary: PDL for certain therapeutic classes. Drugs Covered: Follows Medicaid guidelines Drug Coverage Restrictions: Prior authorization for certain medications, including steroids

and some controlled substances. 75% utilization required for prescription refill.

PROGRAM CONTACT

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

Phone: 443/263-7031 E-mail: [email protected] Alternate contact: Frank Tetkosky, 410/767-1460


6-39

Maryland Senior Prescription Drug Program

Program Type: Direct Assistance Year Operational: 2001∗





Other Eligibility Notes: Program open to all MD residents who have no other prescription drug insurance plan. Disabled are covered if they are Medicare-eligible.


Funding Source: CareFirst subsidizes program through a 2% premium tax exemption from the State of Maryland.

Budget (FY 04): $23 million available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: PBM-negotiated with individual drug companies Ingredient Cost Calculation: PBM-negotiated with contracted pharmacies Enrollment Fee: $10 monthly premium Deductible Amount: None Copayment Amount: $10 for generics, $20 for preferred brand-name products, $35

non-preferred brand-name products Dispensing Fee: Varies among contracted pharmacies. Notes: Maximum benefit is $1,000 per enrollee per 12-month period.

AdvancePCS administers the pharmacy benefit and negotiates contracts with individual pharmaceutical manufacturers and pharmacies. Enrollees are expected to save between 13% and 16% on each prescription.

DRUG COVERAGE

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

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

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

∗ The program sunsets June 30, 2005, but may be extended through 12/31/05 to coincide with Federal Medicare drug benefit program changes.


6-40

PROGRAM CONTACT

Richard Popper, Commissioner Maryland Health Insurance Plan 1 Calvert Place Baltimore, MD 21202

Phone: 410/576-2053 Alternate contact: Robin Vahle CareFirst Plan Coordinator, Phone: 410/998-5444, E-mail: [email protected]


6-41

Maryland Maryland Pharmacy Discount Program

Program Type: Discount (1115 Waiver) Operational Date: July 1, 2003





Other Eligibility Notes: Must be a Medicare recipient and a Maryland resident. Disabled are covered if they are Medicare-eligible.


Funding Source: State General Revenue funds and Federal matching funds Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid guidelines Ingredient Cost Calculation: For brand name drugs, lower of AWP-11%, WAC+9%, Direct

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

Enrollment Fee: None Deductible Amount: None Copayment Amount: 65% of the Medicaid price Dispensing Fee: $1.00 per prescription

DRUG COVERAGE

Formulary: PDL for certain therapeutic classes. Drugs Covered: Medicaid guidelines Drug Coverage Restrictions: Medicaid guidelines

PROGRAM CONTACT

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

Phone: 443/767-5394 E-mail: [email protected] Alternate contact: Frank Tetkosky, 410/767-1460


6-42

Massachusetts Prescription Advantage* Program Type: Direct Assistance



Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): See notes Eligible Income Level (Single): Sliding scale Eligible Income Level

(Married): Sliding scale

Other Eligibility Notes: Disabled participants may participate if they are under age 65, work 40 or fewer hours per month, meet CommonHealth disability guidelines and have gross annual household incomes at or below 188% of the Federal Poverty Level. Individuals receiving Medicaid are not eligible to join Prescription Advantage.


Funding Source: State general funding Budget (FY 04): $96.3 million Cost per Participant (FY 03): $90.44 per member per month $ Rx’s Per Participant (FY 03): $1,085.28 Manufacturer Rebate Type: AdvancePCS negotiates price and rebates with drug

manufacturers. Ingredient Cost Calculation: AWP-14% Enrollment Fee: Single: $0-$99 per month per enrollee, depending on income;

Married: $0-$74 per month per enrollee, depending on income Deductible Amount: $0-$500 annually, depending on income. Payments are accepted

quarterly. Copayment Amount: 30-day Rx fill (retail): $9 to $50 based on drug plan level

(tiered) 90-day Rx fill (mail-order): $18 to $100 based on drug plan level (tiered)

Dispensing Fee: $2.40 for retail pharmacy Notes: Premiums, deductibles and copayments are determined through

a sliding scale based on income levels. The annual out-of-pocket limit per enrollee is $2,000 or 10% of income, whichever is less. For married members, the out-of-pocket spending limit is $3,000 combined, or 10% of gross annual household income, whichever is less. The lower premium for married members only applies to those members who are both enrolled in the plan; when not joining as a couple, a married member must pay the individual rate.


6-43

DRUG COVERAGE

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

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

Drug Coverage Restrictions: No OTC Notes: The plan utilizes a formulary that categorizes prescription drugs

into three categories: generic drugs, brand-name drugs, and additional brand-name drugs. Generic drugs have the lowest copayment, while additional brand-name drugs have the highest copayment.

*Program operational. Enrollment temporarily closed due to budgetary restrictions.

PROGRAM CONTACT

Molly McGinnis Massachusetts Executive Office of Elder Affairs One Ashburton Place Boston, MA 02108

Phone: 617/727-7750 Fax: 617/727-9368 Prescription Advantage information line: 800/243-4636


6-44

Massachusetts MassMedLine*

Program Type: Coordinate Assistance Between State Residents and Charitable Pharmaceutical Programs

Year Operational: 2001 Estimated Number of Recipients (2004): 13,000


Eligibility Age (Elderly): none Eligibility Age (Disabled): none Eligible Income Level (Single): none Eligible Income Level (Married): none Other Eligibility Notes: Anyone may call MassMedLine. Charitable programs have their

own eligibility guidelines.


Funding Source: The program is funded partly by the state with the balance of the operational costs subsidized by the Massachusetts College of Pharmacy and Health Sciences with support from Federal, foundation and corporate grants.

Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: The purpose of the program is to utilize available State resources

to help residents find appropriate charitable pharmaceutical programs from various manufacturers.

DRUG COVERAGE


PROGRAM CONTACT

MassMedLine™ Massachusetts College of Pharmacy and Health Sciences

19 Foster Street Worcester, MA, 01608-1705 Phone: 866/633-1617

* MassMedLine assists State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.


6-45

Michigan Elder Prescription Insurance Coverage (EPIC)

Program






Other Eligibility Notes: EPIC enrollment is currently closed due to budget constraints, except for 45-day emergency coverage, which is available up to two times a year. In addition to normal coverage eligibility requirements, to be eligible for emergency coverage:

• A single applicant must make less than 150% of FPL • A married applicant must make equal to or less than 150%

of FPL • A true medical emergency must exist

To be eligible for normal coverage, an applicant:

• Must be a resident of Michigan for three months prior to application

• Cannot be residing in an institution • Cannot have other insurance or program coverage for

prescription drugs • Cannot currently receive Medicaid benefits


Funding Source: State general fund plus rebate revenue Budget: Not available Cost per Enrollee (FY 03): $2,400 (estimated) # of Rx’s Per Enrollee (FY 03): 60 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: Lesser of usual and customary charge, AWP – 15.1% or 13.5%

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

Maximum annual cost-share amount is divided into twelfths so that a monthly amount must be met. If the out-of-pocket amount is not met in that month, the amount is cumulative, and any remainder is added to the following month. Deductibles are re-established yearly.

Copayment Amount: If a brand name drug is prescribed and dispensed when a generically equivalent drug is available, a $15.00 copayment in


6-46

addition to the monthly out-of-pocket share is charged. No copayment may exceed 20% of the cost of the drug


DRUG COVERAGE

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

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

Drug Coverage Restrictions: The EPIC program does not cover the following types of drugs: products used for weight loss or weight gain; fertility or infertility drugs; drugs used to treat erectile dysfunction; drugs or products used for contraception; products used to promote hair growth or for other cosmetic purposes; drugs used to treat the skin aging process; smoking cessation products; cold and cough preparations; fluoride preparations; experimental and investigational drugs; Drug Efficacy Study Implementation program (DESI) drugs; vitamins/minerals, alone or in combination; dietary formulas or nutritional supplements; central nervous system (CNS) stimulants; Acquired Immunodeficiency Syndrome (AIDS) drugs/injectables and orals; injectable drugs; allergy serums; compounds; over-the-counter (OTC) drugs except for prescription insulin and OTC drugs with prescriptions used for approved step therapy programs; miscellaneous products associated with a specific drug administration, except for diabetes needles and syringes; drugs produced by manufacturers not participating in the rebate program; non-Food and Drug Administration (FDA) approved drugs; and drugs for which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

Notes: Most prescription drugs have a 30-day supply; however, covered maintenance drugs may be filled for 100-day supply

PROGRAM CONTACT

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

Phone: 517/373-3364


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Minnesota Prescription Drug Program∗




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64 Eligible Income Level (Single): 120% of FPL Eligible Income Level


Other Eligibility Notes: On July 1, 2002, the program expanded to include coverage for persons on Medicare due to a disability. To be eligible, enrollees must:

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

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

• Not be eligible for Medicaid • Not have prescription drug coverage within four months of

applying • Not be enrolled in MinnesotaCare • Be enrolled in, or applying for, one of the following

Medicare supplement programs, which help enrollees pay their Medicare premiums: Qualified Medicare Beneficiary (QMB), or Service Limited Medicare Beneficiary (SLMB)


Funding Source: State General Revenue Fund plus manufacturer rebates Budget (FY 04): $9 million Cost per Enrollee: Not available # of Rx’s Per Enrollee: Not available Manufacturer Rebate Type: Same as Medicaid Ingredient Cost Calculation: AWP – 11.5% Enrollment Fee: None Deductible Amount: $35.00 per month Copayment Amount: None Dispensing Fee: $3.65

∗ Formerly the Senior Citizen Drug Program.


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DRUG COVERAGE

Formulary: Minnesota Medicaid program formulary Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs

rebate agreement with Department of Human Services. Covers over-the-counter drugs for antacid, insulin products, smoking cessation products, lice medication and vitamins.

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

PROGRAM CONTACT

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



6-49

Missouri Senior Rx Program




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): Tier I: $12,000

Tier II: $17,000 Eligible Income Level (Married):

Tier I: $17,000 Tier II: $23,000

Other Eligibility Notes: Applicant must be a Missouri resident and have lived in the State for 12 months by July 1, 2003. Applicants may not receive Medicaid or veterans pharmacy benefits or have prescription insurance that is equivalent to or greater than the Missouri SenioRx Program. Married couples may have household income up to $25,000 before a $2,000 marital deduction.


Funding Source: Funding comes from the Missouri Senior Rx Fund, which consists of enrollment fees and manufacturer rebates, and funds that are appropriated to it by the general assembly.

Budget (FY 04): $20 million Cost Per Enrollee (FY 03): $850 per year # of Rx’s Per Enrollee (FY 03): 32.4 Manufacturer Rebate Type: 15% for brand drugs; 11% for generic drugs Ingredient Cost Calculation: AWP – 10.43% Enrollment Fee: $25.00 or $35.00, depending on income level Deductible Amount: $250.00 or $500.00, depending on income level Copayment Amount: 40% of prescription cost Dispensing Fee: $4.09 Notes: Maximum annual benefit of $5,000.00

DRUG COVERAGE

Formulary: None Drugs Covered: Follows Medicaid program guidelines. 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.


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Notes: The program requires the use of generic drugs whenever available. If a drug is available in generic form, the program covers the brand name drug only if the doctor determines it is necessary.

If an enrollee has already met the deductible and a brand name drug is needed, the enrollee must pay: 1) the cost difference between the brand name and generic drug and 2) 40% of the generic drug price.

If the enrollee has not met the deductible, the enrollee pays the full cost of the brand-name drug and the cost of the generic drug will be applied to the deductible.

Discount cards cannot be used in conjunction with the program.

PROGRAM CONTACT

Bill Rootes Missouri Senior Rx Program Health and Senior Services Department P.O. Box 570 Jefferson City, MO 65102

Phone: 573/522-3066


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Montana Prescription Drug Expansion Program

Program Type: Discount (CMS Pharmacy Plus Program waiver) Year Operational: Not available*

Number of Recipients: Not available


Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Medicare eligible Eligible Income Level (Single): 200% of FPL Eligible Income Level


Other Eligibility Notes: Montana resident


Funding Source: $1 million State loan and Federal funding Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP Enrollment Fee: $25.00 Deductible Amount: None Copayment Amount: None Dispensing Fee: See notes Notes: Client is responsible for paying the dispensing fee. Dispensing

fee set at the discretion of each participating pharmacist. (This was done to alleviate concerns that the pharmacists’ $4.70 dispensing fee for Medicaid is inadequate.) State pays the discount rate of the prescription drug and the “client” pays the remaining drug cost(s). Discounts average between 6% and 25%.

DRUG COVERAGE

Formulary: None Drugs Covered: Based on participating manufacturers’ pharmaceutical products Drug Coverage Restrictions: None

PROGRAM CONTACT

Duane Preshinger Section Supervisor Medicaid Services Bureau Cogswell Building 1400 Broadway Helena, MT 59620


* The program will not be implemented given the passage of the Federal Medicare prescription drug program.


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Nevada Senior Rx

Program Type: Subsidy Year Operational: 2001



Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): $22,016

$22,434 (7/04) Eligible Income Level (Married):

$28,660 $29,205 (7/04)

Other Eligibility Notes: Must be a Nevada resident for at least one year and not eligible for full Medicaid benefits.


Funding Source: Tobacco Settlement Fund Budget (FY 04): $18 million Cost per Participant (FY 03): $550.00 # of Rx’s Per Participant (FY 03): 42 Manufacturer Rebate Type: Not available Ingredient Cost Calculation: Brand: AWP-14%; Generics: Lower of AWP-14% or CMS’

MAC Enrollment Fee: None Deductible Amount: None Copayment Amount: Retail Pharmacy Co-Pays (30-day fill): $10.00 for generics;

$25.00 for preferred brand-name drugs or medically necessary brand name drugs; and provider’s discounted rate for all other drugs.

Mail Order Co-Pays (90-day fill): $20.00 for generics, $50.00 for preferred brand-name drugs or medically necessary brand name drugs.

Dispensing Fee: $2.25 Notes: Maximum benefit of $5,000.00 per year. An annual per enrollee

deductible of $100.00 is paid by the State to Pharmaceutical Care Network (PCN), the pharmacy benefit manager that manages the program.

DRUG COVERAGE

Formulary: Managed formulary (by PCN) Drugs Covered: Most prescription drugs


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Drug Coverage Restrictions:

Coverage for generic and preferred brand-name drugs is provided under the Senior Rx Prescription Drug Program for the co-pay options outlined above. If the prescription is for a non-preferred brand name drug, coverage is available if the drug is determined to be medically necessary. The co-pay for medically necessary non-preferred drugs is $25.00. If the non-preferred drug is not medically necessary, or is specifically excluded by the policy, it will cost 100% of the pharmacy discount rate.

General exclusions for over-the-counter drugs; blood glucose meters; insulin injecting devices; biologicals; durable medical equipment; nutritional supplements; and cosmetic drugs

PROGRAM CONTACT

Jane Smedes Department of Human Resources 505 E. King Street, Room 201 Carson City, NV 89701-4797



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New Hampshire

Senior Prescription Drug Discount Program* Program Type: Discount Year Operational: 2000



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


All income levels

Other Eligibility Notes: Must be a New Hampshire resident.


Funding Source: Rebates and incentives from pharmaceutical manufacturers negotiated through Express Scripts, which operates the program.

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

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

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

Discounts can be up to 16% for brand-name products and up to 40% for generics.

DRUG COVERAGE

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

PROGRAM CONTACT

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

Phone: 603/271-7857

*The program is offered by Express Scripts and has no State funding.


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New Jersey Pharmaceutical Assistance to the Aged and Disabled

(PAAD)


Projected Number of Recipients (FY 03): 217,484


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64 Eligible Income Level (Single): $20,437 Eligible Income Level

(Married): $25,058

Other Eligibility Notes: Disabled individuals are only eligible if they receive Title II Social Security Disability benefits. Married couples must file individual PAAD applications. If an individual has health insurance or a retiree prescription benefit equal to or better than PAAD, or if s/he receives Medicaid, s/he is not eligible for the PAAD program.


Funding Source: State General Fund and Casino Revenue Fund Budget (FY 04): $291.4 million Cost per Participant (FY 03): Senior: $2,200.00 (projected)

Disabled: $4,200.00 (projected) # of Rx’s Per Participant (FY 03): Senior: 34 (projected)

Disabled: 45 (projected) Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 12.5% Enrollment Fee: None Deductible Amount: None Copayment Amount: $5.00 per prescription Dispensing Fee: $3.73 to $4.07

DRUG COVERAGE

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

testing materials and syringes, and injectables used in treatment of multiple sclerosis


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Drugs must be purchased in New Jersey, and must be covered by a Manufacturer’s Rebate Agreement. Drug Efficacy Study Implementation program (DESI) drugs are not covered. Generic drugs must be dispensed unless physician requires brand-name drug. (Medical justification required in obtaining authorization for brand version of multi-source drugs.)

All first-time prescriptions are limited to a 34-day supply. PAAD allows for refills up to a 34-day supply or 100 unit doses, whichever is greater. Program mandates an enhanced Drug Utilization Review (DUR).

PROGRAM CONTACT

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



6-57

New Jersey Senior Gold Prescription Discount Program


Projected Number of Recipients (FY 03): 61,972


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64 Eligible Income Level (Single): $20,437 -

$30,437 Eligible Income Level (Married):

$25,058 - $35,058

Other Eligibility Notes: Senior citizens and disabled individuals eligible for the Pharmaceutical Assistance for the Aged and Disabled program are not eligible for the Senior Gold Prescription Discount Program. Disabled individuals are only eligible if they receive Title II Social Security Disability benefits.


Funding Source: Tobacco Settlement Fund Budget (FY 04): $28.4 million Cost Per Participant (FY 03): Senior: $574.00 (projected)

Disabled: $764.00 (projected) # of Rx’s Per Participant (FY 03): Senior: 25.4 (projected)

Disabled: 31.2 (projected) Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 12.5% Enrollment Fee: None Deductible Amount: None Copayment Amount: $15.00 plus 50% of the remaining cost of the prescription or the

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

DRUG COVERAGE

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

testing materials and syringes, and injectables used in treatment of multiple sclerosis


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Drugs must be purchased in New Jersey, and must be covered by a Manufacturer’s Rebate Agreement. Drug Efficacy Study Implementation program (DESI) drugs are not covered. Generic drugs must be dispensed unless physician requires dispensing of brand-name drug. (Medical justification required in obtaining authorization for brand version of multi-source drugs.)

All first-time prescriptions are limited to a 34-day supply. Senior Gold allows for refills up to a 34-day supply or 100 unit doses, whichever is greater.

Program mandates an enhanced Drug Utilization Review (DUR).

PROGRAM CONTACT

Jennifer Barron PAAD/Senior Gold Operations P.O. Box 724 Trenton, NJ 08625-0724



6-59

New Mexico Senior Prescription Drug Program

Program Type: Discount Operational Date: 2003



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


All income 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: $10,000 left from State general funds Budget: State Agency on Aging provided $30,000 for initial administration

costs during 2002. No additional State funding is available. Cost per Recipient: Not available # of Rx’s Per Recipient: Not available Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers Ingredient Cost Calculation: Retail: AWP-12% for brand name drugs; AWP-50% for generics

Mail order: AWP-19.5% for brand name drugs; AWP-55% for generics

Enrollment Fee: None Deductible Amount: None Copayment Amount: See notes Dispensing Fee: $3.50 – retail pharmacy; $1.50 – mail order Notes: Cost of prescription is contracted discounted price plus dispensing fee.

For brand name prescriptions average discount is 13%; for generics average discount is 50%. Express Scripts administers the pharmacy benefit. The State receives an additional $2 for each prescription when enrollees use mail order pharmacy.

DRUG COVERAGE

Formulary: None Drugs Covered: Manufacturers’ participating prescription drug products Drug Coverage Restrictions: None

PROGRAM CONTACT

Lauri Hogan New Mexico Retiree Health Care Authority 810 West San Mateo, Suite D Santa Fe, NM 87505



6-60

New York Elderly Pharmaceutical Insurance Coverage (EPIC)

Program Program Type: Direct Assistance



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 million Cost per Participant (FY 03): $2,083 # of Rx’s Per Participant (FY 03): 36 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 –

12% 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

DRUG COVERAGE

Formulary: None Drugs Covered: All legend drugs, insulin and insulin syringes and needles Drug Coverage Restrictions: Drug Efficacy Study and Implementation Program (DESI) drugs

and non-participating manufacturers excluded

PROGRAM CONTACT

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



6-61

North Carolina Senior Care∗






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: Tobacco settlement funds Budget (FY 04): $30 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%. Maximum benefit per year of $1,000

DRUG COVERAGE

Formulary: None Drugs Covered: All prescription drugs 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


∗ Previously referred to as Carolina CaRxes in State legislation.


6-62

Ohio Golden Buckeye Prescription Drug Program

Program Type: Negotiated Discounts Operational Date: 2003

Estimated eligibles (December 2003): 2 million


Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 18-59 Eligible Income Level (Single): All income


All income levels

Other Eligibility Notes: Must be an Ohio resident. The “Special Assistance Program” within the Golden Buckeye Prescription Drug Program establishes further savings for Medicare eligible beneficiaries who have no other prescription drug assistance. Eligibility income levels for the “Special Assistance Program” are: $30,000 - individual; $40,000 – married.


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

Budget: Based on manufacturers’ negotiated rebates Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers. Estimated

savings range from 5% to 40%. Ingredient Cost Calculation: Reimbursement rate based on negotiated contract with each

participating manufacturer. Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: MemberHealth is the PBM administrator for the Golden

Buckeye Prescription Drug Program and the newly announced Ohio’s Best Rx Program.

Nineteen manufacturers are participating in the Golden Buckeye Prescription Drug Program, including Solvay, Procter & Gamble Pharmaceuticals, KOS, Boerhinger, Bausch & Lomb, Andrx Labs, Bayer, Barr, Schering, Merck, Celltech, Abbott Labs, Daiichi, Novo Nordisk, Novartis

Four manufacturers are participating in the Special Assistance Prescription Drug Program within the Golden Buckeye Program: GlaxoSmithKline, Novartis, Bristol Meyers Squibb, and Merck.


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DRUG COVERAGE

Formulary: Preferred Drug List Drugs Covered: Drugs for which the PBM has negotiated rebates with

manufacturers. Drug Coverage Restrictions: None Notes: MemberHealth conducts drug utilization reviews for these

programs.

PROGRAM CONTACT

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

Phone: 800/301-6446 E-mail: [email protected] Alternate contact: Steve Proctor, MemberHealth, 800/422-1976


6-64

Ohio Ohio’s Best Rx Program*

Program Type: Negotiated Discounts Year Operational: 2004 (Not yet operational) Estimated Number of Recipients: 1.3 Million


Eligibility Age (Elderly): 60 + Eligibility Age (Disabled): 18+ Eligible Income Level (Single): 250% of FPL Eligible Income Level


Other Eligibility Notes: Enrollee must not have other outpatient prescription drug coverage


Funding Source: Rebates from participating manufacturers Budget (FY 04): $10 million allocated for start up costs Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Negotiated with each individual manufacturer. Estimated

discounts range between 20% and 40%. Ingredient Cost Calculation: Based on contractual arrangements with participating

manufacturers Enrollment Fee: None Deductible Amount: None Copayment Amount: $3.00 dispensing fee and $1 transaction cost Dispensing Fee: $3.00 Notes: Discounts are calculated from the average rebate paid by drug

manufacturers to State retirement and employees benefit plans. Up to 5% of the money collected through manufacturers’ rebates may be used for the contract with the PBM program administrator, MemberHealth. Program may offer both retail and mail order pharmacy services.

DRUG COVERAGE

Formulary: Open Drugs Covered: Based on pharmaceutical manufacturers participating in the

program. Drug Coverage Restrictions: None Notes: The Ohio’s Best Rx Program Council will advise the

Department of Job and Family Services on the program.

* Program details are still under development. Implementation expected by late summer 2004.


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PROGRAM CONTACT

Ohio Department of Job and Family Services 30 E. Broad St., 32nd Floor Columbus, OH 43215-3414

Phone: 614/446-6282 Fax: 614/466-2815


6-66

Oklahoma Pharmacy Connection Council Program*


Year Operational: 2003 Number of Recipients: Not Available


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Medicare eligible Eligible Income Level (Single): Not available Eligible Income Level

(Married): Not available

Other Eligibility Notes: Eligibility criteria may vary according to manufacturers’ programs.


Funding Source: Not available Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: None Ingredient Cost Calculation: None Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: Not available Notes: To obtain these free or discounted prescriptions, the individual

must complete an application on a form provided by the manufacturer of the drug. One section is for the patient to complete and the other for the prescriber. The doctor submits the application and the prescription to the manufacturer. When approved, the manufacturer sends the free drug to the doctor, who then gives it to the patient.

DRUG COVERAGE


PROGRAM CONTACT

Nancy Davis Pharmacy Bureau, Dept. of Health 1000 Northeast Tenth St Oklahoma City, OK 73117

Phone: 405/271-6576 Fax: 405/271-1308 General E-mail: [email protected]

* The Pharmacy Connection Council program assists eligible State residents in coordinating services from various manufacturers’ charitable prescription assistance programs. The State does not contribute any money for the direct purchase of prescription drugs.


6-67

Oregon Senior Prescription Drug Assistance Program*

Program Type: Discount Operational Date: 2003

Number of Recipients (December 2003): 206




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: None Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Not available Ingredient Cost Calculation: AWP – 14% Enrollment Fee: $50.00 annually Deductible Amount: None Copayment Amount: None Dispensing Fee: $3.50 for retail pharmacy; $3.80 for institutional pharmacies Notes : Currently, the program operates as a discount program based on

voluntary participation from pharmacies.

DRUG COVERAGE

Formulary: None Drugs Covered: All legend drugs. Drug Coverage Restrictions OTC drugs and medical supplies and medical equipment are not

covered.

PROGRAM CONTACT

Sandy Wood, Program Manager Office of Medical Assistance Programs Human Services Building 500 Summer St. NE, E25 Salem, OR 97301-1098

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

*Legislation was enacted in 2003 seeking a CMS waiver for the creation of the Medication Expansion for Disabled Persons and Seniors (MEDS) program. MEDS would have expanded drug coverage for additional seniors’ 65 years of age and older using a sliding scale, cost-share and co-insurance matrix based on income levels. The waiver has not been approved to date. Oregon officials may not implement the program given the Medicare prescription drug benefit enacted by Congress in 2003.


6-68

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): $14,500 Eligible Income Level

(Married): $17,700

Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the date of application.


Funding Source: State Lottery, Tobacco Settlement funds Budget (FY 03-04): $507 million Cost per Participant (FY 02-03): $2,136.00 # of Rx’s Per Participant: Not available Manufacturer Rebate Type: 22% of Average Manufacturer Price Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary Enrollment Fee: None Deductible Amount: None Copayment Amount: $9.00 for brand name drugs; $6.00 for generics Dispensing Fee: $4.00 Notes: Quarterly reporting for Average Manufacturer Price (AMP)

rebate information.

DRUG COVERAGE

Formulary: None Drugs Covered: All Federal legend drugs and insulin, insulin syringes and

needles Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental

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


6-69

PROGRAM CONTACT

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

Phone: 717/787-7313 Fax: 717/772-2730 E-mail: [email protected] Alternate contact: Terry Brown, PACE/PACENET program, Phone: 717/787-7313


6-70

Pennsylvania PACE Needs Enhancement Tier (PACENET)




Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible Eligible Income Level (Single): $14,500 to

$23,500 Eligible Income Level (Married):

$17,700 to $31,500

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 02-03): $1,344.00 # of Rx’s Per Participant: Not available Manufacturer Rebate Type: 22% of Average Manufacturer Price (AMP) Ingredient Cost Calculation: Lesser of AWP – 10% or usual and customary Enrollment Fee: None Deductible Amount: $480.00 per year ($40 per month, but cumulative if not met each

month) Copayment Amount: $15.00 for brand name drugs and $8.00 for generics Dispensing Fee: $4.00 Notes: Quarterly reporting for Average Manufacturer Price (AMP)

rebate information.

DRUG COVERAGE

Formulary: None Drugs Covered: All Federal legend drugs and insulin, insulin syringes and

needles Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental

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

PROGRAM CONTACT

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

Phone: 717/787-7313 Fax: 717/772-2730 E-mail: [email protected] Terry Brown, PACE/PACENET program, Phone: 717/787-7313


6-71

Rhode Island Rhode Island Pharmacy Assistance to the Elderly

(RIPAE) Program Type: Direct Assistance, Discount

Year Operational: 1985 Number of Enrollees (December 2003): 38,600


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65 Eligible Income Level (Single): 420% of

poverty level. See notes


420% of poverty level. See notes

Other Eligibility Notes: Income levels exclude income spent on medical expenses if greater than 3% of total income.


Funding Source: State General Revenue Fund Budget (FY 04): $14.8 million Cost per Enrollee (FY 04): $730.00 (estimated) # of Rx’s Per Enrollee (FY 04): 16.8 Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 13% for brand-name drugs; MAC for generics Enrollment Fee: None Deductible Amount: None Copayment Amount: Participant pays co-pay of 40%, 70%, or 85% of prescription

cost depending on income levels. For members in the lowest income class, the program will pay 100% of the cost of covered medications after the member has paid $1,500.00 in copayments.

Dispensing Fee: $2.75 Notes: Participating pharmaceutical manufacturers must sign a rebate

agreement with the State for covered products.

DRUG COVERAGE

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

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

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



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South Carolina SILVERxCard Senior Prescription Drug Program

Program Type: Direct Assistance (1115 waiver) Year Operational: 2001





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: Not available Cost per Enrollee: Not available # of Rx’s Per Enrollee : Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 10% Enrollment Fee: None Deductible Amount: $500.00 per calendar year Copayment Amount: Members receive discounts up to 10% on prescriptions until the

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

Dispensing Fee: Not available Notes: SILVERxCard covers up to a 34 days’ supply of medication and

generally 4 covered prescriptions or refills during a calendar month. Overrides of the monthly limit are allowed for some conditions, including acute sickle cell disease, behavioral health disorder, cancer, cardiac disease, diabetes, HIV/AIDS, hypertension, and terminal illnesses.

An effort to expand drug coverage through the South Carolina Retirees and Individuals Pooling Together for Savings (SCRIPTS) Program has been postponed due to the Federal Medicare prescription drug coverage proposal enacted by Congress in 2003.

DRUG COVERAGE

Formulary: Same as Medicaid Drugs Covered: Same as Medicaid Drug Coverage Restrictions: Some drugs require prior authorization


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Notes:

Brand name drugs are dispensed when generic drugs are not available. Over-the-counter drugs are paid for when authorized with a prescription. Insulin syringes, insulin, or other injectable products that are either administered at home or self-administered are also covered.

Diabetic supplies such as alcohol wipes and test strips; smoking cessation products; certain lifestyle drugs; and, injectable products administered in a physician’s office or clinic are not covered.

PROGRAM CONTACT

Frank Williams SILVERxCard Office of Insurance Services 1201 Main Street, Suite 350 Columbia, SC 29201

Phone: 803/898-2511 General E-mail: [email protected]


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South Dakota Senior Citizen Prescription Drug Benefit Program

Program Type: Negotiated Discount Year Operational: 2003



Eligibility Age (Elderly): All Medicare eligibles

Eligibility Age (Disabled): All Medicare eligibles



All income levels

Other Eligibility Notes: Must be a resident of South Dakota. Medicaid recipients are not eligible.


Funding Source: Not available Budget: Not available Cost per Enrollee: Not available # of Rx’s Per Enrollee: Not available Manufacturer Rebate Type: AdvancePCS (PBM) negotiates discounted prescription costs

rather than trying to set mandatory price reductions. Prescription discounts average between 15% and 20%.

Ingredient Cost Calculation: AWP-10.5% Enrollment Fee: None Deductible Amount: None Copayment Amount: None Dispensing Fee: $3.50 Notes: Since July 1, 2003, AdvancePCS has processed 117,000

prescriptions with direct savings to the enrollee of $913,000. The average discount per prescription is 17.7%.

DRUG COVERAGE

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

PROGRAM CONTACT

Larry Kucker Bureau of Personnel 500 East Capitol Avenue Pierre, SD 57501

Phone: 605/773-3148 Fax: 605/773-4344


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Texas State Prescription Drug Program

Program Type: State-Subsidy Law Enacted: 2001∗

Estimated Eligibles: None




Other Eligibility Notes: Upper income limits may increase if funding becomes available. However, the categories most likely to qualify for the program at proposed FY 04-05 funding levels are Qualified Medicare Beneficiaries (QMBs) and Specified Low-Income Medicare Beneficiaries (SLMBs).


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

Budget: None Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Not available Ingredient Cost Calculation: Not available Enrollment Fee: Not available Deductible Amount: Not available Copayment Amount: Not available Dispensing Fee: Not available Notes: According to statute, the Health and Human Services

Commission may require a cost-sharing payment.

DRUG COVERAGE

Formulary: Not available Drugs Covered: Not available Drug Coverage Restrictions: Not available Notes: The Health and Human Services Commission may require that,

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

∗This program has not been implemented due to the fact that no funding has been budgeted for it.


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PROGRAM CONTACT

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

Phone: 512/424-6514


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Vermont VSCRIPT

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

Number of Recipients (FY03): 3,081


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


150% - 175% of FPL


Funding Source: Federal and State funds Budget (FY 04): $4.3 million Cost per Participant (FY 03): $1,408.00 # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: $17.00 per month Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.25

DRUG COVERAGE

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

PROGRAM CONTACT

Joshua Slen Director Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676


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


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Vermont VSCRIPT Expanded


Number of Recipients (FY 03): 3,364


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


175% - 225% of FPL


Funding Source: State General Fund Budget (FY 04): $1.2 million Cost per Participant (FY 03): $338.00 # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: $35.00 per month Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.25

DRUG COVERAGE

Formulary: Preferred Drug List Drugs Covered: Medicaid covered maintenance drugs under separate

manufacturer’s rebate agreement Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT




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Vermont Vermont Health Access Plan (VHAP) Pharmacy

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

Number of Recipients (FY 03): 8,570




Other Eligibility Notes: Medicaid recipients are not eligible. Individuals may not have any other prescription drug insurance.


Funding Source: Federal and State funds Budget (FY 03): $13.3 million Cost per Participant (FY03): $1,554.00 # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Medicaid Ingredient Cost Calculation: AWP – 11.9% Enrollment Fee: $13.00 per month Deductible Amount: None Copayment Amount: None Dispensing Fee: $4.25

DRUG COVERAGE

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

insulin syringes. Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT




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Vermont

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

Year Operational: July 1, 2002 Eligible Recipients (FY 04): 11,373




Other Eligibility Notes: Vermont residentsof 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. This program also covers drugs for acute conditions for VScript or VScript Expanded beneficiaries (up to 225% of FPL) who previously received a benefit only for maintenance drugs. VScript and VScript Expanded beneficiaries will be automatically enrolled in Healthy Vermonters and have the advantage of Healthy Vermonters benefits for prescriptions not covered under the VScripts programs.


Funding Source: State revenue fund Budget (FY 04): $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: Not available Deductible Amount: None Copayment Amount: Not available Dispensing fee: $4.25 Note: Beneficiary purchases drugs at the Medicaid payment rate.

DRUG COVERAGE

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

PROGRAM CONTACT

Joshua Slen, Director Office of Vermont Health Access 103 South Main Street Waterbury, VT 05676



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Washington Rx Card Program

Program Type: Negotiated Rebates Year Operational: 2004*

Number of Recipients: not available


Eligibility Age (Elderly): 50+ Eligibility Age (Disabled): 19-49 Eligible Income Level (Single): 300% of FPL Eligible Income Level


Other Eligibility Notes: Individuals may not have any other prescription drug insurance coverage or prescription drug benefits.


Funding Source: Enrollment fees Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Not available Ingredient Cost Calculation: AWP-13% Enrollment Fee: $10.00 Deductible Amount: Not available Copayment Amount: Not available Dispensing Fee: $3.00 Notes: Express Scripts (PBM) will administer the program for the State. The Washington Health

Care Authority is working with Express Scripts to determine discount levels, program costs and processing applications. The program is scheduled to be operational by April 1, 2004.

DRUG COVERAGE

Formulary: PBM formulary Drugs Covered: Not Available Drug Coverage Restrictions: Not Available Notes: State officials wanted to use a State-sponsored PDL; however,

the PBM would not agree to these terms, as the program’s overall market share is not large enough.

PROGRAM CONTACT

Erika Barker, Project Coordinator Prescription Drug Program Health Care Authority Post Office Box 91132 Seattle, WA 98111-9232

Phone: 206/521-2027 Alternate Contact: Duane Thurman, Health Care Authority, 206/521-2036

* The Washington Rx Card has not yet been implemented. It is being revised to coordinate with recent changes in federal law that will provide transitional prescription drug discount cards to Medicare-eligible individuals beginning in June 2004. . This is one component of broader efforts by the State to combine use of a Preferred Drug List (PDL), an evidence-based prescription drug program, the Washington State Pharmacy and Therapeutics Committee, and, participating practitioners. The ultimate goal of these various programs is to maximum purchasing through a pooled pharmaceutical-buying program.


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West Virginia Gold Mountaineer Card Program


Number of Recipients (December 2003): 17,000/month*


Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): 60+ Eligible Income Level (Single): All income


All income levels

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


Funding Source: Lottery funds and State General Fund Budget: Not available Cost per Participant: Not available # of Rx’s Per Participant (2002): 33 Manufacturer Rebate Type: Rebates negotiated by PBM (AdvancePCS) 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.

DRUG COVERAGE

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

PROGRAM CONTACT

Jan Bowen Bureau of Senior Services Holly Grove, Building No. 10 Charleston, WV 25305-0160

Phone: 304/558-3317 Fax: 304/558-0004

*There are a total of 360,000 eligible seniors for the Gold Mountaineer Card Program. Monthly card usage varies.


6-83

Wisconsin SeniorCare


Estimated Enrollment (May 2003): 86,700


Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+ Eligible Income Level (Single): See note Eligible Income Level

(Married): See note

Other Eligibility Notes: Person must not be a recipient of medical assistance and must be a resident of the State. The State implemented four participation levels for the program and each has a corresponding out-of-pocket expense and/or co-pay amount.

SeniorCare level FPL Level 1 up to 160% Level 2a between 160% and 200% Level 2b between 200% and 240% Level 3 greater than 240%


Funding Source: State general revenue and some Federal funding. Budget (FY 03-05): $23 million Cost per Participant: Not available # of Rx’s Per Participant: Not available Manufacturer Rebate Type: Manufacturers must sign separate SeniorCare rebate agreement

with the State. Ingredient Cost Calculation: AWP-12% or MAC. The National Drug Code (NDC) innovator

price will be paid only when “Brand Medically Necessary” is handwritten on the prescription.

Enrollment Fee: $30.00 Deductible Amount: Level 1: No deductible

Level 2a: $500 deductible per person and pay SeniorCare rate for drugs

Level 2b: $850 deductible per person and pay SeniorCare rate for drugs

Level 3: Pay retail price for drugs equal to the difference between your income and $21,553 per individual or $29,089 per couple. This is called "spenddown." During “spenddown”, no discount for drugs. After “spenddown”, meet an $850 deductible per person but pay SeniorCare rate for covered drugs.


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Copayment Amount:

Level 1: $15 co-pay for covered brand name drugs, $5

co-pay for covered generics Level 2a: After $500 deductible, $15 co-pay for covered

brand name drugs, $5 co-pay for covered generics

Level 2b: After $850 deductible, $15 co-pay for covered brand name drugs, $5 co-pay for covered generics

Level 3: After $850 deductible is met, $15 co-pay for covered brand name drugs, $5 co-pay for covered generics


DRUG COVERAGE

Formulary: None Drugs Covered: Manufacturers’ products that have a signed SeniorCare rebate

agreement Drug Coverage Restrictions: Reimbursement for most drugs is limited to a 34-day supply.

Some maintenance drugs may be provided in a 100-day supply.

PROGRAM CONTACT

Michael Boushon Pharmacy Program Division of Health Care Financing 1 West Wilson Street P.O. Box 309 Madison, WI 53701-3380

Phone: 608/261-7791 Fax: 608/267-3380 Alternate contact: Pamela Appleby Budget and Policy Analyst, Division of Health Care Financing, Phone: 608/266-7685; Fax: 608/266-1096; Email: [email protected]


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Wyoming Prescription Drug Assistance Program


Number of Recipients (November 2003): 1,081 (monthly average)


Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages Eligible Income Level (Single): 100% of FPL Eligible Income Level


Other Eligible Groups: Medicaid enrollees are not eligible.


Funding Source: General Revenue Fund Budget (FY 03-04): $2.1 million Cost per Participant (FY 03): $1,591.20 # of Rx’s Per Participant (FY 03): 25.2 Manufacturer Rebate Type: Varies by participating manufacturer Ingredient Cost Calculation: AWP – 11% Enrollment Fee: None Deductible Amount: None Copayment Amount: $10.00 for generics and $25.00 for brand-name drugs Dispensing Fee: $5.00 Notes: Maximum 3 prescriptions per month and oxygen services if

needed

DRUG 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

Susan Malm Community and Family Health Division Hathaway Bldg, Rm 157 2300 Capitol Ave. Cheyenne, WY 82002

Phone: 307/777-5548 Fax: 307/777-6964


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A-1

Appendix A: State and Federal Medicaid Contacts


A-2

STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2003

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 Dell Swan Pharmacy Program Administrator AHCCCS 801 East Jefferson Street MD 400 Phoenix, AZ 85034 612/417-4000 E-mail: [email protected]

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

CALIFORNIA J. Kevin Gorospe, Pharm.D. California Department of Health Services Chief, Medi-Cal Pharmacy Policy Unit Medi-Cal Policy Division 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95814 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] Internet address: http://www.dhs.ca.gov

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

CONNECTICUT Evelyn A. Dudley Pharmacy Unit Manager Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] Internet address: www.dss.state.ct.us

DELAWARE Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected] Internet address: www.dmap.state.de.us


A-3

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 Jerry F. Wells Pharmacy Program Manager 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.B.A., M.H.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 S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Boulevard, Room 506B P.O. Box 700190 Honolulu, HI 96707 T: 808/692-8116 F: 808/692-8131 Internet address: www.med-quest.us

IDAHO Shawna L. Kittridge, R.Ph., M.H.S. Pharmacy Services Supervisor Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1956 F: 208/364-1864 E-mail: [email protected] Internet address: www.idahohealth.org

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] Internet address: www.indianamedicaid.com

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]


A-4

KANSAS Mary H. Obley, Pharmacist Pharmacy Program Manager 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.eds.org

KENTUCKY Dan Yeager, R.Ph. Interim Pharmacy Director Department for Medicaid Services CHR Building, 6 W-A 275 East Main Street Frankfort, KY 40621 T: 502/564-7940 F: 502/564-0509 E-mail: dan.yeager.ky.gov

LOUISIANA Mary J. Terrebonne, Pharm. D. Pharmacy Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected] Internet address: www.lamedicaid.com

MAINE Jude Walsh, Director Health Care Management Division Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1815 F: 207/287-6533 E-mail: [email protected] Internet address: www.maine.gov/bms

MARYLAND Mr. Joseph L. Fine Director Maryland Pharmacy Program DHMH, Office of Operations and Eligibility 201 West Preston Street Baltimore, MD 21201 T: 410/767-1455 F: 410/333-5398 E-mail: [email protected] Internet address: www.dhmh.state.md.us

MASSACHUSETTS Paul L. Jeffrey, Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210/5865 E-mail: [email protected] Internet address: www.state.ma.us/dma MICHIGAN Giovannino A. Perri, M.D. Chief Medical Consultant MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected] Internet address: www.michigan.gov/mdhc

MINNESOTA Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] Internet address: www.dhs.mn.us


A-5

MISSISSIPPI Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: www.dom.state.ms.us

MISSOURI George L. Oestreich Pharmacy Program Director Department of Social Services Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-6961 F: 573/522-8514 E-mail: [email protected] Internet address: www.dss.mo.gov/dms

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] Internet address: www.dhcfp.state.nv.us

NEW HAMPSHIRE Margaret A. Clifford Pharmacy Administrator Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4210 F: 603/271-8701 E-mail: [email protected] Internet address: www.dhhs.state.nh.us

NEW JERSEY Edward J. Vaccaro, R.Ph. Assistant Director Office of Utilization Management Division of Medical Assistance and Health Services 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 Neal Solomon, M.P.H., R.Ph. Drug Program Administrator Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected]


A-6

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, R.Ph., M.P.H. Pharmacy Program Manager Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive 2501 Mail Service Center Raleigh, NC 27699-2501 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. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-1544 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 43215-3414 T: 614/466-6420 F: 614/466-2908 E-mail: [email protected]

OKLAHOMA Nancy Nesser, D.Ph., J.D. 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.dhs.state.or.us/healthplan

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 02919 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected] Internet address: www.dhs.state.ri.us


A-7

SOUTH CAROLINA James M. Assey, R.Ph., Division Director Division of Pharmaceutical Services and DME S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/898-4517 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 Jeffrey G. Stockard, D.Ph. Associate Pharmacy Director Bureau of TennCare 729 Church Street Nashville, TN 37247-6501 T: 615/532-3107 F: 615/253-5481 E-mail: [email protected] Internet address: www.state.tn.us/health/tenncare

TEXAS Barbara Dean Acting Director, Vendor Drug Program Texas Health and Human Services Commission 1100 W. 49th Street Austin, TX 78756-3174 T: 512/491-1101 F: 512/491-1959 E-mail: [email protected] Internet address: www.hhsc.state.tx.us

UTAH RaeDell Ashley, R.Ph. Pharmacy Director Division of Health Care Financing Utah Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected] Internet address: www.utah.gov

VERMONT Samantha Haley, Operations Manager Office of Vermont Health Access 103 South Main Street Waterbury, VT 05671-1201 T: 802/241-8765 F: 802/241-2974 E-mail: [email protected]

VIRGINIA Javier Menendez, R.Ph. Pharmacy Consultant 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.virginia.gov

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: 360/586-8827 E-mail: [email protected]/pharmacy Internet address: http://maa.dshs.wa.gov/pharmacy


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WEST VIRGINIA Peggy A. King, R.Ph. Director, Office of Pharmacy Services WV Department of Health and Human Resources 350 Capitol St., Room 251 Charleston, WV 25301-3709 T: 304/558-5967 F: 304/558-1542 E-mail: [email protected] Internet address: www.wvhhhr.org/bms

WISCONSIN Michael C. Boushon, R.Ph. Pharmacy Practices Consultant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/261-7791 F: 608/267-3380 E-mail: [email protected] Internet address: www.dhfs.wisconsin.gov

WYOMING Antoinette Brown, R.Ph. Medicaid Pharmacist Department of Health-Pharmacy Unit 2424 Pioneer Ave, Suite 100 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 Email: [email protected] Internet address: www.pharmacy.state.wy.us


A-9

NEW BRAND NAME PRODUCT CONTACT INFORMATION, 2003 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] 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 Contact health plans directly. ARKANSAS Suzette Bridges, P.D., Administrator Pharmacy Program Dept. of Human Services Division of Medical Services P.O. Box 1437, Slot S 415 Little Rock, AR 72203-1437 T: 501/683-4120 F: 501/683-4124 E-mail: [email protected]

CALIFORNIA J. Kevin Gorospe, Pharm.D. Chief, Medi-Cal Pharmacy Policy Unit California Department of Health Services Medi-Cal Policy Division 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected] COLORADO Catherine Traugott Pharmacist Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2463 F: 303/866-2578 E-mail: [email protected] CONNECTICUT Evelyn A. Dudley Pharmacy Unit Manager Department of Social Services, Medical Operations 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5654 F: 860/424-5206 E-mail: [email protected] DELAWARE Cynthia R. Denemark, R.Ph. Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]


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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 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] GEORGIA 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] HAWAII Lynn S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Boulevard, Suite 506B Kapolei, HI 96707 T: 808/692-8116 F: 808/692-8131

IDAHO Shawna L. Kittridge, R.Ph., M.H.S. Pharmacy Services Supervisor Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1956 F: 208/364-1864 E-mail: [email protected] ILLINOIS Marvin L. Hazelwood, Manager Pharmacy and Ancillary Services Programs Illinois Department of Public Aid Division of Medical Assistance 1001 N. Walnut Street Springfield, IL 62702 T: 217/524-5565 F: 217/524-7194 E-mail: [email protected] INDIANA 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] Note: All manufacturer inquiries and/or submissions must be in electronic format and sent to [email protected]. Paper copies will not be accepted and should not be mailed to any of the involved parties, including OMPP, ACS, or the Therapeutic Committee. Visit: http://indianapbm.com/downloads/T-committe%20PDL%20submission%20Form1-5-04.pdf for necessary forms.


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IOWA Susan L. Parker, Pharm.D. Pharmacy Consultant Division of Medical Services Bureau of Long Term Care Hoover State Office Building Des Moines, IA 50319 T: 515/281-3002 F: 515/281-8512 E-mail: [email protected]. KANSAS Mary H. Obley, Pharmacist Pharmacy Program Manager Health Care Policy Division Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harrison, Room 651-South Topeka, KS 66612-1570 T: 785-296-8406 F: 785/296-4813 E-mail: [email protected] KENTUCKY 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] LOUISIANA Mary J. Terrebonne, P.D. Pharmacy Director Department of Health & Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected]

MAINE Jude Walsh, Director Health Care Management Division Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1815 F: 207/287-6533 E-mail: [email protected] MARYLAND Frank Tetkoski Manager Services and Preauthorization DHMH Division of Pharmacy Services 201 W. Preston Street, Room 409 Baltimore, MD 21201 T: 410/767-1460 F: 410/333-5398 E-mail: [email protected] MASSASCHUSETTS Christopher T. Burke Policy Analyst Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5592 F: 617/210-5597 E-mail: [email protected] MICHIGAN Donna Hammel Office of Medical Affairs MDCH/Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]


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MINNESOTA Cody C. Wiberg, Pharm.D., R.Ph. Pharmacy Program Manager Minnesota Department of Human Services 444 Lafayette Road North St. Paul, MN 55155-3853 T: 651/296-8515 F: 651/282-6744 E-mail: [email protected] MISSISSIPPI Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar Street, Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] MISSOURI Rhonda A. Driver Clinical Pharmacist Department of Social Services Division of Medical Services P.O. Box 6500 Jefferson City, MO 65102- 6500 T: 573/751-6961 F: 573/522-8514 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]

NEBRASKA Dyke Anderson, R.Ph Pharmacy Consultant Department of Health and Human Services Finance and Support-Medicaid Division 301 Centennial Mall South 5th Floor-NSOB P.O. Box 95026 Lincoln, NE 68509-5026 T: 402/471-9379 F: 402/471-9092 E-mail: [email protected] NEVADA Dionne Coston, R.N. Medical Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected] NEW HAMPSHIRE Lisè Farrand, R.Ph. Pharmaceutical Services Specialist Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected] NEW JERSEY Edward J. Vaccaro, R.Ph. Assistant Director Office of Utilization Management Department of Human Services Division of Medical Assistance and Health Services P.O. Box 712, Bldg. 11-A Trenton, NJ 08625-0712 T: 609/588-2726 F: 609/588-3889 Email: [email protected]


A-13

NEW MEXICO Neal Solomon, M.P.H., R.Ph. Pharmacist Human Services Department Medical Assistance Division P.O. Box 2348 Santa Fe, NM 87504-2348 T: 505/827-3174 F: 505/827-3185 E-mail: [email protected] NEW YORK 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 Avenue, Suite 606 Albany, NY 12210 T: 518/474-9219 F: 518/473-5508 E-mail: [email protected] NORTH CAROLINA Sharman C. Leinwand, R.Ph., M.P.H. Pharmacy Program Manager Division of Medical Assistance Department of Health and Human Services 1985 Umstead Drive, 2501 Mail Service Center Raleigh, NC 27699-2501 T: 919/857-4034 F: 919/715-1255 E-mail: [email protected] NORTH DAKOTA Brendan K. Joyce, Pharm.D., R.Ph. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-1544 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 Rodney Ramsey Pharmacy Claims Specialist Oklahoma Health Care Authority 4545 North Lincoln, Suite 124 Oklahoma City, OK 73105 T: 405/522-7492 F: 405/530-3238 E-mail: [email protected] OREGON Kathy L. Ketchum, R.Ph., M.P.A.-H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected] PENNSYLVANIA Joseph E. Concino, R.Ph., Chief 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]


A-14

RHODE ISLAND Paula J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02919 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected] SOUTH CAROLINA James M. Assey, R.Ph., Division Director Division of Pharmaceutical Services and DME S.C. Department of Health & Human Services P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2876 F: 803/255-8353 E-mail: [email protected] 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 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]

TEXAS Martha McNeil, R.Ph. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected] UTAH RaeDell Ashley, R.Ph. Pharmacy Director Division of Health Care Financing Department of Health 288 North 1460 West P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6495 F: 801/538-6099 E-mail: [email protected] VERMONT Samantha Haley 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] VIRGINIA Javier Menendez, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-2196 F: 804/786-0973 E-mail: [email protected]


A-15

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: 360/586-8827 E-mail: [email protected] WEST VIRGINIA Peggy A. King, R.Ph. Director, Office of Pharmacy Services Department of Health and Human Resources 350 Capitol Street, Room 251 Charleston, WV 25301-3709 T: 304/558-5967 F: 304/558-1542 E-mail: [email protected] WISCONSIN Carol Neeno Pharmacy Assistant Division of Health Care Financing Department of Health and Family Services One West Wilson Street P.O. Box 309 Madison, WI 53701-0309 T: 608/266-1203 F: 608/267-3380 E-mail: [email protected] WYOMING Antoinette Brown, R.Ph. Medicaid Pharmacist Department of Health Pharmacy Unit 2424 Pioneer Avenue, Suite 100 Cheyenne, WY 82002 T: 307/777-6016 F: 307/777-8623 E-mail: [email protected]


A-16

DUR CONTACT INFORMATION, 2003

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 1437, Slot 415 Little Rock, AR 72203-1437 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 Contracted DUR

State Contact Vic Walker, R.Ph. B.C.P.P. Senior Consulting Pharmacist California Department of Health Services Medi-Cal Policy Division 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

Contractor Jude Simon-Leack DUR Pharmacist EDS Medi-Cal 3215 Prospect Park Dr. Rancho Cordova, CA 95670 T: 916/636-1000 F: 916/636-1002 E-mail: [email protected]


A-17

COLORADO Contracted DUR

State Contact Catherine Traugott Pharmacist Deptartment of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 T: 303/866-2468 F: 303/866-2573 E-mail: catherine. [email protected]

Contractor Steve Espy, R.Ph. Director of Drug Utilization Health Information Designs, Inc. 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531

CONNECTICUT Contracted DUR

State Contact James Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services Medical Operations Unit 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-4961 F: 860/424-5206 E-mail: [email protected]

Contractor Vita Judkins Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866/759-4113 F: 866/759-4110 E-mail: [email protected]

DELAWARE Contracted DUR

State Contact Cynthia R. Denemark Director of Pharmacy Services DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224 E-mail: [email protected]

Contractor Joli Martini Pharmacist Consultant DSS/EDS 248 Chapman Road, Suit 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224

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]


A-18

FLORIDA Contracted DUR

State Contact Linda G. Barnes Senior Pharmacist 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 Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Boulevard, Room 506-B Kapolei, HI 90707 T: 808/692-8065 F: 808/692-8131

IDAHO Contracted DUR

State Contact Tamara Eide, Pharm.D., BCPS, FASHP Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1821 F: 208/364-1864 E-mail: [email protected]

Contractor Vaughn Culbertson, Pharm.D. DUR Project Coordinator Idaho State U. - College of Pharmacy Campus Box 8356 Pocatello, ID 83209-8356 T: 208/282-2586 F: 208/282-4482 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 E-mail: [email protected]


A-19

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: 317/232-4307 F: 317/232-7382 E-mail: [email protected]

Contractor ACS 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 866/759-4100

IOWA Contracted DUR

State Contact Julie Kuhle, R.Ph. 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 Vicki L. Schmidt Pharmacist Health Care Policy Division Kansas Department of Social and Rehabilitation Services Docking State Office Building 915 SW Harris, Room 651-South Topeka, KS 66612-1570 T: 785/274-4287 F: 785/296-4813 E-mail: [email protected]


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]


A-20

LOUISIANA Contracted DUR

State Contact Mary J. Terrebonne, Pharm.D. Pharmacy Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-9768 F: 225/342-1980 E-mail: [email protected]

Contractor Shelly Delaville Pharmacist Unisys 8591 United Plaza Blvd., Ste.300 Baton Rouge, LA 70809 T: 225/237-3227 F: 225/237-3334 E-mail: [email protected]

MAINE Contracted DUR

State Contact Jude Walsh, Director Health Care Management Division 442 Civic Center Drive 11SHS, DHS – Bureau of Medical Services Augusta, ME 04333 T: 207/287-1815 F: 207/287-6533 E-mail: [email protected]


MARYLAND Contracted DUR

State Contact Judy Geisler Pharmacist Consultant DHMH-Office of Operations and Eligibility Division of Pharmacy Services 201 W. Preston St. Baltimore, MD 21201 T: 410/787-1455 F: 410/333-5398 E-mail: [email protected]

Contractor Contact Judy Geisler Pharmacist Consultant

MASSACHUSETTS Contracted DUR

State Contact Paul Jeffrey Director of Pharmacy Office of Medicaid 600 Washington Street, 5th Floor Boston, MA 02111 T: 617/210-5319 F: 617/210-5865 E-mail: [email protected]

Contractor Paul L. Jeffrey Director of Pharmacy

MICHIGAN Contracted DUR

State Contact Debera Eggleston, M.D. MDCH/Medical Services Administration 400 S. Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]

Contractor First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696


A-21

MINNESOTA In-House DUR

State Contact Mary Beth Reinke, Pharm.D., R.Ph. DUR Coordinator Minnesota Dept. of Human Services 444 Lafayette Rd. North St. Paul, MN 55155-3853 T: 651/215-1239 F: 651/282-6744 E-mail: [email protected]

MISSISSIPPI Contracted DUR

State Contact Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Ste. 801 Jackson, MS 39201 T: 601/359-6296 F: 601/359-9555 E-mail: [email protected]

Contractor Sam Warman, R.Ph. Project Manager Heritage Information Design P.O. Box 320506 Flowood, MS 39232 T: 601/709-0000 F: 800/459-2135 E-mail: [email protected]

MISSOURI In-House DUR

State Contact Jayne Zemmer DUR Coordinator Div. of Medical Services P.O. Box 6500 Jefferson City, MO 65102-6500 T: 573/751-1612 F: 573/526-4650 E-mail: [email protected]

MONTANA Contracted DUR

State Contact Mark Eichler, R.Ph., FASCP 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, Suite A Lincoln, NE 68516 T: 402/420-1500 F: 402/420-1406 E-mail: [email protected]

Contractor Same as State Contact


A-22

NEVADA Contracted DUR

State Contact Dionne Coston, R.N. Medical Services Specialist Division of Health Care Financing and Policy Pharmacy Program 1100 E. Williams Street Carson City, NV 89701 T: 775/684-3775 F: 775/684-3762 E-mail: [email protected]

Contractor Steve Espy, R.Ph. Director of Drug Utilization Health Info. Design, Inc. 1550 Pumphrey Avenue Auburn, AL 36832 T: 205/402-9530 F: 205/402-9531

NEW HAMPSHIRE Contracted DUR

State Contact Lisè Ferrand, R.Ph. Pharmaceutical Services Specialist Office of Health Planning & Medicaid 129 Pleasant Street, Annex 1 Concord, NH 03301 T: 603/271-4419 F: 603/271-8701 E-mail: [email protected]

Contractor Robert Coppola Clinical Manager First Health Services Corp. 17 Chenell Drive Concord, NH 03301 T: 603/224/2083 F: 603/224/6690 E-mail: [email protected]

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. Pharmacist Human Services Department Medical Assistance Division 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


A-23

NEW YORK In-House DUR

State Contact Lydia Kosinski, R.Ph. 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, R.Ph., M.P.H. Pharmacy Program Manager Division of Medical Assistance Department of Human Resources 1985 Umstead Drive 2501 Mail Services Center Raleigh, NC 27699-2501 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. Administrator, Pharmacy Services North Dakota Department of Human Services 600 E. Boulevard Avenue, Dept. 325 Bismarck, ND 58505-0250 T: 701/328-4023 F: 701/328-1544 E-mail: [email protected]

OHIO In-House and Contracted DUR

State Contact Jan Lawson DUR Administrator 255 East Main Street Columbus, OH 43215 T: 614/466-9698 F: 614/466-2866

Contractor First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 800/884-7696

OKLAHOMA Contracted DUR

State Contact Nancy Nesser, D.Ph., J.D. 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, D.Ph. Manager, Operations/DUR University of Oklahoma College of Pharmacy P.O. Box 26801 Oklahoma City, OK 73109 T: 405/271-6614 F: 405/271-2615 E-mail: [email protected]


A-24

OREGON Contracted DUR

State Contact Kathy L. Ketchum, R.Ph., M.P.A.: H.A. Medicaid Program Coordinator Oregon State University College of Pharmacy 840 SW Gaines Road, MC 212 Portland, OR 97239-3098 T: 503/494-1589 F: 503/494-8797 E-mail: [email protected]

Contractor Jim Rowland Account Manager First Health Services Corporation 925 Commercial Street SE, Suite 350 Salem, OR 97301-2460 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

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 J. Avarista, R.Ph. Chief of Pharmacy Departrment of Human Services 600 New London Avenue Cranston, RI 02919 T: 401/462-6390 F: 401/462-6336 E-mail: [email protected]

Contractor Joseph Paradis Clinical Pharmacist Health Information Designs, Inc. 228 West Church Street Salisbury, MD 21801 866/260-2555 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]


A-25

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 Barbara Dean Acting Director, Vendor Drug Program Texas Health and Human Services Commision 1100 West 49th Street Austin, TX 78756-3174 T: 512/491-1101 F: 512/491-1959 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 Scott Strenio, M.D. Clinical Consultant Office of VT Health Access 103 S. Main St. Waterbury, VT 05671 T: 802/741-7975 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


A-26

VIRGINIA In-House DUR

State Contact Javier Menendez, 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]

Contractor Donna Johnson Pharmacy Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 804/965-7400 E-mail: [email protected]

WASHINGTON In-House DUR

State Contact Nicole N. Nguyen, Pharm.D. Clinical Pharmacist Medical Assistance Administration, DSHS 805 Plum Street, SE P.O. Box 45506 Olympia, WA 98504-5506 T: 360/725-1757 F: 360/586-8827 E-mail: [email protected]

WEST VIRGINIA Contracted DUR

State Contact Vicki M. Cunningham, R.Ph. DUR Coordinator Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3709 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


A-27

CLAIMS SUBMISSION CONTACTS, 2003

ALABAMA Cyndi Crockett Supervisor 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]


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

CALIFORNIA EDS P.O. Box 13029 Sacramento, CA 95813-4029 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 Sheila Dorval Health Program Supervisor Department of Social Services Medical Operations Unit 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-5149 F: 860/424-5206 E-mail: [email protected]

DELAWARE Jose Tieso System Manager EDS 248 Chapman Rd, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224

DISTRICT OF COLUMBIA Anita Martin Manager-Plan Administration First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7425 F: 804/273-6961 E-mail: [email protected]


A-28

FLORIDA Kevin Whittington Clinical Program Coordinator ACS 9040 Roswell Road Roswell, GA 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 Heather Bodiford Account Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 T: 866/322-5960 F: 866/759-4100 Attn: Hawaii Medicaid

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 Ulka Pandya ACS State Healthcare 365 Northridge Rd., Suite 400 Atlanta, GA 30350 T: 866-322-5960 x4032 F: 866/759-4100 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 785/274-4200

KENTUCKY Unisys Provider Services P.O. Box 2106 Frankfort, KY 40602 T: 502/226-1140 F: 502/226-1860

LOUISIANA Doug Hasty Project Manager Unisys 8591 United Plaza Blvd., Ste. 300 Baton Rouge, LA 70809 T: 225/237-3391 F: 225/237-3334 E-mail: [email protected]


A-29

MAINE Marcia Pykare Manager of Data Processing Goold Health Systems P.O. Box 1090 Augusta, ME 04332-1090 T: 207/622-7153 F: 207/623-5125 E-mail: [email protected] MARYLAND James Demery Manager, Pharmacy Services First Health Services Corporation Division of Claims Processing 201 W. Preston St. Baltimore, MD 21201 T: 401/767-1460 F: 410/333-5398 E-mail: [email protected]

MASSACHUSETTS ACS State Health Care 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 800/358-2381

MICHIGAN First Health Services Corp. 4300 Cox Rd. Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696

MINNESOTA Dwaine Voas MMIS Unit Supervisor Minnesota Dept. of Human Services 800 Minnehaha Avenue St. Paul, MN 51555

MISSISSIPPI Bob Parenteu PBM Account Manager ACS State Healthcare 385-B Highland Colony Parkway Ridgeland, MS 39157 T: 601/296-2934 F: 601/296-3119 E-mail: [email protected] MISSOURI Diane Twehous Claims Process Administrator Verzion Data Services 905 Weathered Rock Rd. Jefferson City, MO 65109 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 Steve Smith Account Representative ACS State Healthcare 365 Northridge Road Northridge Center One, Suite 400 Atlanta, GA 30350 T: 770/901-5002 F: 770/730-5198 E-mail: [email protected]

NEVADA First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 800/884-3238


A-30

NEW HAMPSHIRE Sherrill Bryant Plan Administrator First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]

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 T: 770/352-8592 F: 770/730-5198

NEW YORK eMedNY Computer Sciences Corporation One CSC Way Rensselaer, NY 12144 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.

Administrator, Pharmacy Services North Dakota Department of Human Services 600 East Boulevard Avenue Department 325 Bismarck, ND 58505-0250 T: 701/328-1544 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 EDS 2401 N.W. 23rd Street, Suite 11 Oklahoma City, OK 73107 405/416-6794

OREGON Jim Rowland Pharmacist Account Manager First Health Services Corporation 925 Commercial Street SE, Suite 350 Salem, OR 97301-2460 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.)


A-31

RHODE ISLAND

EDS 1471 Elmwood Avenue Cranston, RI 02910 401/784-3879

SOUTH CAROLINA Rod Davis Deputy Director of Information Technology 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 Rita Marcoux Account Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 804/965-7400

TEXAS Laura Bagheri Manager, Pharmacy Resolutions Vendor Drug Program Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78745 T: 512/491-1741 F: 512/491-1958 E-mail: [email protected]

UTAH Connie Higley Information Technology Director Division of Health Care Financing Department of Health P.O. Box 143102 Salt Lake City, UT 84114-3102 T: 801/538-6136 F: 801-538-6099 E-mail: [email protected]

VERMONT EDS 312 Hurricane Lane, Ste 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA Frank Fury Operations Manager First Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 Community Pharmacy Coalition 804/965-7400

WASHINGTON Chris Johnson Claims Processing Manager Medical Assistance Administrator, DSHS P.O. Box 45509 Olympia, WA 98504-5509 360/725-1239 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


A-32

Mark Gajewski Account Director EDS 6406 Bridge Road Madison, WI 53784-0014 T: 608/221-4746 F: 608/221-4567

WYOMING ACS Northridge Center One, Suite 400 365 Northridge Road Atlanta, GA 30350 T: 866/322-5960 F: 888/335-8459


A-33

PRESCRIPTION PRICE UPDATING CONTACTS, 2003

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]


ARKANSAS First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

CALIFORNIA EDS Federal Corporation P.O. Box 13029 Sacramento, CA 95813-4029 916/636-1000

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

CONNECTICUT James Zakszewski, R.Ph. Pharmacy Consultant Department of Social Services Medical Operations Unit 25 Sigourney Street Hartford, CT 06106-5033 T: 860/424-4961 F: 860/424-5206 E-mail: [email protected]

DELAWARE Don Cohn DSS/EDS 248 Chapman Road, Suite 100 Newark, DE 19702 T: 302/453-8453 F: 302/454-0224

DISTRICT OF COLUMBIA Glenn Sharp Clinical Account Manager First Help Service Corporation 4300 Cox Road Glen Allen, VA 23060 T: 804/965-7447 F: 804/273-6961 E-mail: [email protected]

FLORIDA First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4578


A-34

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 Katie Ayad Technical Records II Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1970 F: 208/364-1864 E-mail: [email protected]

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 T: 650/588-5454 F: 650/588-4003

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 Pharmacy Program Manager 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]

KENTUCKY Unisys Provider Services P.O. Box 2106 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]


A-35

MAINE Jude Walsh, Director Health Care Management Division Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1815 F: 207/287-6533 E-mail: [email protected] Internet address: www.maine.gov/bms

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 Health Services Corporation 4300 Cox Road Glen Allen, VA 23060 T: 877/864-9014 F: 888/603-7696

MINNESOTA First DataBank 1111 Bay Hill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/588-4003

MISSISSIPPI Judith P. Clark, R.Ph. Pharmacy Director Division of Medicaid Robert E. Lee Building 239 North Lamar St., Suite 801 Jackson, MS 39201 T: 601/359-5253 F: 601/359-9555 E-mail: [email protected] Internet address: www.dom.state.ms.us

MISSOURI First DataBank 1111 Bayhill Drive, Suite 350 San Bruno, CA 94066 T: 650/588-5454 F: 650/827-4510

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


A-36

NEW HAMPSHIRE Sherrill Bryant Plan Administrator First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]

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. Pharmacist Human Services Department Medical 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. Manager, Pharmacy Operations Pharmacy Policy and Operations Office of Medicaid Management NYS Dept. of Health 99 Washington Ave., Suite 606 Albany, NY 12210 T: 518/474-9219 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. Administrator, Pharmacy Services North Dakota Department of Human Services 600 East Boulevard Ave. Dept. 325 Bismark, ND 58505-0250 T: 701/328-1544 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 E-mail: www.firstdatabank.com

OREGON Jim Rowland Account Manager First Health Sevices Corporation 925 Commercial Street SE, Suite 350 Salem, OR 97301-2460 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]


A-37

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 02919 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 Office of Medical 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. Product and Prescriber Manager Texas Health and Human Services Commission 11209 Metric Boulevard, Building H Austin, TX 78758 T: 512/491-1157 F: 512/491-1961 E-mail: [email protected]

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 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA Javier Menendez, 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] Internet address: www.dmas.virginia.gov


A-38

WASHINGTON Tom Zuchlewski Pharmacy Rates Manager Medical Assistance Administration, DSHS P.O. Box 45510 Olympia, WA 98504-5510 T: 360/725-1837 F: 360/753-9152 E-mail: [email protected]

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 T: 800/633-3453 F: 650/872-4510


A-39

MEDICAID DRUG REBATE CONTACTS, 2003

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


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

CALIFORNIA Craig Miller Chief, Medi-Cal Rebate and Vision Section Medi-Cal Policy Division 1501 Capitol Avenue P.O. Box 997413, MS 4604 Sacramento, CA 95899-7413 T: 916/552-9500 F: 916/552-9563 E-mail: [email protected]

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

CONNECTICUT Mark Heuschkel Lead Planning Analyst - Pharmacy Department of Social Services Medical Operations Unit 25 Sigourney Street Hartford, CT 06106 T: 860/424-5347 F: 860/424-5206 E-mail: [email protected]

DELAWARE Frank Long Contracts Manager DSS Herman Holloway Campus Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9624 F: 302/255-4425


A-40

DISTRICT OF COLUMBIA Donna Bovell, R.Ph. 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 Rebate Coordinator Agency for Health Care Administration 2727 Mahan Dr., MS 38 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 S. Donovan, R.Ph. Pharmacy Consultant Department of Human Services Med-Quest Division 601 Kanokila Boulevard, Suite 506B Kapolei, HI 96707 T: 808/692-8116 F: 808/692-8131 Internet address: www.med-quest.us

IDAHO Mary Wheatly Pharmacy Services Specialist Department of Health and Welfare Division of Medicaid 3232 Elder Boise, ID 83705 T: 208/364-1832 F: 208/364-1864 E-mail: [email protected]

ILLINOIS Bradley Wallner Manager Illinois Department of Public Aid 2200 Churchill Road Springfield, IL 62704 217/785-6114 E-mail: [email protected]

INDIANA Martha Kessenich Rebate Accounting Manager Indiana State Healthcare 365 Northridge Rd., Suite 400 Atlanta, GA 30350 T: 770/730-3292 F: 866/759-4100 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


A-41

KANSAS Mary H. Obley Pharmacist Pharmacy Program Manager 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 Timothy T. Williams Health Services Financing Program Director Department of Health and Hospitals 1201 Capitol Access Road, 6th Floor P.O. Box 91030 Baton Rouge, LA 70821 T: 225/342-5194 F: 225/342-1980 E-mail: [email protected]

MAINE Rossi Rowe Insurance Recovery/ Drug Rebate Manager Department of Human Services Bureau of Medical Services 11 SHS, 442 Civic Center Drive Augusta, ME 04333 T: 207/287-1838 F: 207/287-1788 E-mail: [email protected]

MARYLAND Alex Taylor First Health Services Corporation Montgomery Park Business Center 1800 Washington Boulevard, Suite 420 Baltimore, MD 21230 T: 443/263-7048 F: 443/263-7062

MASSACHUSETTS Martha Kessenich Rebate Accounting Manager ACS State Healthcare 365 Northridge Road, Suite 400 Atlanta, GA 30350 800/358-2381

MICHIGAN Dawn Parsons Pharmacy Consultant MDCH/ Medical Services Administration 400 South Pine Street P.O. Box 30479 Lansing, MI 48909-7979 T: 517/335-5181 F: 517/241-8135 E-mail: [email protected]

MINNESOTA Jarvis P. Jackson, R.Ph. Drug Rebate Coordinator Dept. of Human Services 444 Lafayette Rd. North St. Paul, MN 55155-3853 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]


A-42

MISSOURI Lynn Hebenheimer Medicaid Unit Supervisor Division of Medical Services Drug Rebate Unit P.O. Box 6500 Jefferson City, MO 65102 T: 573/526-5664 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 John Cox Rebate Pharmacist First Health Services Corp. 4300 Cox Road Glen Allen, VA 23060 T: 800/884-2822 F: 804/965-7647 E-mail: [email protected]

NEW JERSEY Edward J. Vaccaro, R.Ph. Assistant Director Office of Utilization Management Division 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]

NEW MEXICO Delfinia Sandoval Human Services Department ASD 729 St. Michaels Drive Santa Fe, NM 87504-2348 T: 505/476-8920 F: 505/827-1147 E-mail: [email protected]

NEW YORK 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]


A-43

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. Administrator, Pharmacy Services Department of Human Services 600 East Boulevard Ave. Department 325 Bismarck, ND 58505-0250 T: 701/328-1544 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 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 Jim Rowland Account Manager First Health Sevices Corporation 925 Commercial Street SE, Suite 350 Salem, OR 97301-2460 T: 503/391-1980 F: 503/391-1979 E-mail: [email protected]

PENNSYLVANIA Louis J. Cappello Pharmacy Consultant 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 J. Avarista, R.Ph. Chief of Pharmacy Department of Human Services 600 New London Avenue Cranston, RI 02919 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]


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SOUTH DAKOTA Helen Rokusek Rebate Coordinator SD Dept. of Social Services 700 Governors Drive Pierre, SD 57501 605/773-3653

TENNESSEE Sybil Creekmore Accounting Manager 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 Texas Health and Human Services Commission 1100 West 49th Street Austin, TX 78745 T: 512/491-1163 F: 512/491-1960 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 312 Hurricane Lane, Suite 101 Williston, VT 05495 T: 802/879-4450 F: 802/878-3440

VIRGINIA Javier Menendez, R.Ph. Pharmacy Manager Department of Medical Assistance Services 600 East Broad Street, Suite 1300 Richmond, VA 23219 T: 804/786-2196 F: 804/786-0973 E-mail: [email protected]

WASHINGTON Connie Riddle Medical Assistance Administration, DSHS P.O. Box 45503 Lacey, WA 98504-5503 360/725-1243 E-mail: [email protected]

WEST VIRGINIA Gail Goodnight, R.Ph. Rebate Coordinator Bureau for Medical Services Office of Pharmacy Services 350 Capitol Street, Room 251 Charleston, WV 25301-3709 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 608/267-7939 E-mail: [email protected]

WYOMING Sheila McInerney TPL Manager ACS P.O. Box 667 Cheyenne, WY 82003 T: 307/772-8400 F: 307/772-8405


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STATE OFFICIALS -- 2004 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: 334/242-5600 F: 334/242-0556 E-mail: [email protected] Internet address : www.medicaid.state.al.us 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 350 Main Street, Room 229 Juneau, AK 99811-0601 T: 907/465-3030 F: 907/465-3068 E-mail: [email protected] Internet address: www.hss.state.ak.us Medicaid Director Mr. Dwayne Peeples, 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


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ARKANSAS Governor Honorable Mike Huckabee State Capitol Building Room 250 Little Rock, AR 72201 T: 501/682-2345 F: 501/682-3597 E-mail: [email protected] Internet address: www.state.ar.us/governor/staff.html Single State Agency Director Mr. Kurt Knickrehm, Director Department of Human Services P.O. Box 1437, Slot 201 Little Rock, AR 72203-1437 T: 501/682-8650 F: 501/682-6836 E-mail: [email protected] Internet address: www.accessarkansas.org/dhs Medicaid Director Mr. Roy Jeffus, Director Division of Medical Services, Dept. of Human Services P.O. Box 1437, Slot 1100 Little Rock, AR 72203-1437 T: 50l/682-1671 F: 501/682-1197 E-mail: [email protected] Internet address: www.medicaid.state.ar.us

CALIFORNIA Governor Honorable Arnold Schwarzenegger State Capitol, First Floor Sacramento, CA 958l4 T: 916/445-2841 F: 916/445-4633 E-mail: [email protected] Internet address: www.governor.ca.gov/state/govsite/ gov_hompage.jsp Single State Agency Director Mr. Richard Bayquen, Chief Deputy Mr. Tom McCaffrey, Chief Deputy Department of Health Services 1501 Capitol Avenue Sacramento, CA 95899 T: 916/440-7400 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 1501 Capitol Avenue P.O. Box 997413, MS 4000 Sacramento, CA 95899-7413 T: 916/440-7800 F: 916/440-7805 E-mail: [email protected] Internet address: www.medi-cal.ca.gov

COLORADO Governor Honorable Bill Owens State Capitol Room 136 Denver, CO 80203-1792 T: 303/866-2471 F: 303/866-2003 E-mail: [email protected] Internet address: www.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: 303/866-5700 F: 303/866-4047 E-mail: [email protected] Internet address: www.cdhs.state.co.us Medicaid Director Ms. Karen K. Reinertson Executive Director Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203-1818 T: 303/866-2993 F: 303/866-4411 E-mail: [email protected] Internet address: www.chcpf.state.co.us


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CONNECTICUT Governor Honorable John G. Rowland State Capitol, Room 210 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: 302/744-4101 F: 302/739-2775 E-mail: [email protected] Internet address: www.state.de.us/governor Single State Agency Director Mr. Vincent P. Meconi, Secretary Department of Health and Social Services 1901 North DuPont Highway New Castle, DE l9720 T: 302/255-9040 F: 302/255-4429 E-mail: [email protected] Internet address: www.state.de.us/dhss Medicaid Director Mr. Philip Soulé Medicaid Division/Deputy Director Department of Health and Social Services Lewis Building 1901 North DuPont Highway New Castle, DE 19720 T: 302/255-9501 F: 302/255-4425 E-mail: [email protected] Internet address: www.state.de.us/dhss

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 Mr. Robert Maruca Senior Deputy Director Medical Assistance Administration Department of Health 825 North Capitol Street, NE Fifth Floor Washington, DC 20002 T: 202/442-5988 F: 202/442-4790 E-mail: [email protected] Internet address: www.dchealth.dc.gov


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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 Vacant 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: 850/488-2520 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


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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 T: 808/586-4997 F: 808/586/4890 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.state.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: 2l7/782-1200 F: 217/524-7979 E-mail: [email protected] Internet address: www.state.il.us/dpa


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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 Mr. Eugene Gessow Medicaid Director Division of Medical Services Department of Human Services Hoover State Office Building Fifth Floor Des Moines, IA 503l9-0114 T: 5l5/281-6249 F: 515/281-8512 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.ksgovernor.org 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


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KENTUCKY Governor Honorable Ernie Fletcher State Capitol Building 700 Capitol Avenue Frankfort, KY 4060l T: 502/564-2611 F: 502/564-2517 E-mail: [email protected] Internet address: www.governor.ky.gov Single State Agency Director Mr. James W. Holsinger, Jr., M.D. Secretary Cabinet for Health and Family Services 275 East Main Street, 5W-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.gov./dms

LOUISIANA Governor Honorable Kathleen Blanco State Capitol P.O. Box 94004 Baton Rouge, LA 70804 T: 225/342-7015 F: 225/342-7099 E-mail: www.gov.state.la.us/gov_email.html Internet address: www.gov.state.la.us Single State Agency Director Mr. Frederick P. Cerise, Secretary Department of Health and Hospitals P.O. Box 629, Bin #2 Baton Rouge, LA 70821-0629 T: 225/342-9500 F: 225/342-9508 E-mail: [email protected] Internet address: www.dhh.state.la.us Medicaid Director Mr. Ben Bearden, Director Bureau of Health Services Financing Department of Health and Hospitals P.O. Box 91030 Baton Rouge, LA 70821-9030 T: 225/342-3891 F: 225/342-9508 E-mail: [email protected] Internet address: www.dhh.state.la.us/MEDICAID/ index.htm

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.main.gov/governor/baldacci/ index.shtml 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.main.gov/dhs/index.htm Medicaid Director Ms. Chris Zukas Lessard, 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]


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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 Ms. Beth Waldman, Director Office of Medicaid One Ashburton Place, Room 1109 Boston, MA 02108 T: 617/573-1770 F: 617/573-1894 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


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MINNESOTA Governor Honorable Tim Pawlenty 130 State Capitol St. Paul, MN 55155-1099 T: 651/296-3391 F: 651/296-2089 E-mail: [email protected] Internet address: www.governor.state.mn.us 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 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 Haley Barbour 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 Mr. Donald Taylor 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 Mr. Warren A. Jones, M.D. Executive Director Division of Medicaid Suite 801, Robert E. Lee Building 239 North Lamar Street Jackson, MS 39201-1399 T: 601/359-6050 F: 601/359-6048 E-mail: [email protected] Internet address: www.mdhs.state.ms.us

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.htm Internet address: www.gov.state.mo.us Single State Agency Director Mr. Steve Roling, Director Department of Social Services 221 West High Street P.O. Box 1527 Jefferson City, MO 65102 T: 573/751-4815 F: 573/751-3203 E-mail: [email protected] Internet address: www.dss.state.mo.us Medicaid Director Ms. Christine Rackers, Director 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] Internet address: www.dss.state.mo.us/dms


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MONTANA Governor Honorable Judy Martz State Capitol Helena, MT 59620-0801 T: 406/444-3111 F: 406/444-4151 E-mail: www.state.mt.us/gov2/css/staff/ contact.asp 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 Mr. John Chappuis Medicaid Director Division of Health Policy and Services Department of Public Health and Human Services 1400 Broadway Helena, MT 59601 T: 406/444-4141 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. Robert J. 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: 402/471-9223 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: 702/684-5670 F: 775/684-5683 E-mail: www.gov.state.nv.us/mail.gov.htm Internet address: www.gov.state.nv.us Single State Agency Director 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: 775/687-3893 E-mail: [email protected] Internet address: www.dhcfp.state.nv.us


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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. John Stephen, Commissioner Department of Health and Human Services 129 Pleasant Street Concord, NH 03301-3857 T: 603/271-4331 F: 603/271-4912 E-mail: [email protected] Internet address: www.dhhs.state.nh.us/DHHS/ DHHS_SITE/default.htm Medicaid Director Ms. Lori Rea, 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 E-mail: www.dhhs.state.nh.us/DHHS/ DHHS_SITE/special/feedback.htm Internet address: www.dhhs.state.nh.us/DHHS/ MEDICAIDPROGRAM/ 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 P.O. Box 700 Trenton, NJ 08625 T: 609/292-3717 F: 609/292-3824 E-mail: [email protected] Internet address: www.state.nj.us/humanservices Medicaid Director Ms. Ann Clemency Kohler, Director Division of Medical Assistance and Health Services Department of Human Services P.O. Box 712 Trenton, NJ 08625-0712 T: 609/588-2600 F: 609/588-3583 E-mail: [email protected] Internet address: www.state.nj.us/humanservices/ dmahs/index.html

NEW MEXICO Governor Honorable Bill Richardson Office of the Governor State Capitol Suite 400 Santa Fe, NM 87501 T: 505/476-2200 F: 505/476-2226 E-mail: [email protected] Internet address: www.governor.state.nm.us Single State Agency Director 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: 505/827-3100 F: 505/827-3185 E-mail: [email protected] Internet address: www.state.nm.us/hsd/mad/index


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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] Internet address : www.health.state.ny.us/nysdoh/ medicaid/medicaid.htm

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 T: 919/733-5811 F: 919/733-2120 F: 919/715-3175 E-mail: www.governor.state.nc.us/email.asp?to=1 Internet address: www.governor.state.nc.us 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, Interim 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


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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

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 T: 614/466-6282 F: 614/466-2815 E-mail: [email protected] Internet address: www.jfs.ohio.gov Medicaid Director Ms. Barbara Coulter Edwards, Deputy Director Ohio Health Plans Ohio Department of Job and Family Services 30 East Broad Street, 31st Floor Columbus, OH 43215-3414 T: 614/466-0140 F: 614/752-3986 E-mail: [email protected] Internet address : www.state.oh.us/odjfs/ohp

OKLAHOMA Governor Honorable Brad Henry 212 State Capitol 2300 N. Lincold Boulevard Oklahoma City, OK 73105 T: 405/521-2342 F: 405/521-3353 E-mail: [email protected] Internet address: www.governor.state.ok.us Single State Agency Director Mike Fogarty, J.D. Director Oklahoma Health Care Authority 4545 North Lincoln Boulevard Suite 124 Oklahoma City, OK 73105 T: 405/522-7300 F: 405/522-7187 E-mail: [email protected] Internet address: www.ohca.state.ok.us Medicaid Director 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


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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: www.governor.state.or.us/ Contact.htm 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, E15 Salem, OR 97301 T: 503/945-5944 F: 503/378-2897 E-mail: [email protected] Internet address: www.dhs.state.or.us Medicaid Director Ms. Lynn Read, Director Office of Medical Assistance Programs Department of Human Services 500 Summer Street, NE, E37 Salem, OR 97301 T: 503/945-5772 F: 503/373-7689 E-mail: [email protected] Internet address: www.dhs.state.or.us/healthplan

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 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 Medicaid Director Mr. David S. Feinberg Deputy Secretary Office of Medical Assistance Programs Department of Public Welfare Health and Welfare Building, Room 515 P.O. Box 2675 Harrisburg, PA 17105-2675 T: 717/787-1870 F: 717/787-4639 E-mail: [email protected] Internet address: www.dpw.state.pa.us/omap

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 Office of Economic Assistance to The Medically Indigent Department of Health G.P.O. Box 70184 San Juan, PR 00936 T: 787/765-1230, ext. 200 F: 787/250-0990 E-mail: [email protected]


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RHODE ISLAND Governor Honorable Don Carcieri 222 State House Providence, RI 02903-1196 T: 401/222-2080 F: 401/222-8096 E-mail: [email protected] Internet address: www.governor.state.ri.us Single State Agency Director Ms. Jane Hayward, Director Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-2121 F: 401/462-3677 E-mail: [email protected] Internet address: www.dhs.state.ri.us Medicaid Director Mr. John C. Young, C.P.M. Associate Director Division of Medical Services Department of Human Services 600 New London Avenue Cranston, RI 02920 T: 401/462-3575 F: 401/462-6338 E-mail: [email protected] Internet address: www.dhs.state.ri.us

SOUTH CAROLINA Governor Honorable Mark Sanford P.O. Box 12267 Columbia, SC 29211 T: 803/734-2100 F: 803/734-5167 E-mail: [email protected] Internet address: www.state.sc.us/governor Single State Agency Director Mr. Robert Kerr, Director Department of Health and Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Internet address: www.dhhs.state.sc.us Medicaid Director Mr. Robert Kerr, Director Department of Health and Human Services 1801 Main Street P.O. Box 8206 Columbia, SC 29202-8206 T: 803/898-2504 F: 803/898-4515 E-mail: [email protected] Internet address: www.dhhs.state.sc.us

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/governor 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/medical


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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 Ms. Gina Lodge, Commissioner Department of Human Services 400 Deaderick Street, 15th Floor Nashville, TN 37248-0001 T: 615/313-4700 F: 615/741-4165 E-mail: humanservices.webmaster@ state.tn.us Internet address: www.state.tn.us/humanserv Medicaid Director Mr. Manny Martins Deputy Commissioner Department of Finance and Administration Bureau of TennCare 729 Church Street Nashville, TN 37247 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 Internet address: www.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 78751 T: 5l2/424-6502 F: 512/424-6587 E-mail: [email protected] Internet address: www.hhsc.state.tx.us Medicaid Director Mr. Jason Cooke Associate Commissioner for Medicaid Health and Human Services Commission 4900 N. Lamar Boulevard, 4th Floor P.O. Box 13247 Austin, TX 78751 T: 512/424-6517 F: 512/424-6587 E-mail: [email protected] Internet address: www.hhsc.tx.us/medicaid

UTAH Governor Honorable Olene S. Walker 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. Scott D. Williams, 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 84114-3101 T: 801/538-6406 F: 801/538-6099 E-mail: [email protected] Internet address: www.hlunix. Ex.state.ut.us/medicaid


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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. Charlie Smith, Secretary Agency of Human Services 103 South Main Street Waterbury, VT 05671-0201 T: 802/241-2220 F: 802/241-2979 E-mail: [email protected] Internet address: www.ahs.state.vt.us Medicaid Director Mr. Joshua Slen, Medicaid Director Department of Prevention, Transition, and Health Access 103 South Main Street Waterbury, VT 05676-1201 T: 802/879-5900 F: 802/879-5962 E-mail: [email protected] Internet address: www.dsw.state.vt.us

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 Office of The Secretary of Health and Human Resources 202 N. Ninth Street, Suite 622 P.O. Box 1475 Richmond, VA 23219 T: 804/786-7765 F: 804/371-6984 E-mail: [email protected] Internet address : www.hhr.state.va.us Medicaid Director Mr. Patrick Finnerty, Director Department of Medical Assistance Services 600 East Broad Street Suite 1300 Richmond, VA 23219 T: 804/786-4231 F: 804/371-4981 E-mail: [email protected] Internet address: www.dmas.state.va.us

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 Ms. Darlene A Carty Commissioner of Health Virgin Islands Department of Health 48 Sugar Estate St. Thomas, VI 00802 T: 340/774-0117 F: 340/777-4001 E-mail: [email protected] Medicaid Director Ms. Priscilla Berry-Quetel, Executive Director Bureau of Health Insurance and Medical Assistance Department of Health 3730 Altona, Suite 302 Frostco Center Charlotte Amalie St. Thomas, VI 00802 T: 340/774-4624 F: 340/774-4918 E-mail: [email protected]


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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 Internet address: www.governor.wa.gov 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: [email protected] Internet address: www.wa.gov/dshs Medicaid Director Mr. Doug Porter, Assistant Secretary Medical Assistance Administration P.O. Box 45100 Olympia, WA 98504-5100 T: 360/902-1863 F: 360/902-7855 E-mail: [email protected] Internet address: www.fortress.wa.gov/dshs/maa

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 350 Capitol Street, Room 251 Charleston, WV 25301 T: 304/558-1700 F: 304/558-1451 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 P.O. Box 309 Madison, WI 53701-0309 T: 608/266-2522 F: 608/266-1096 E-mail: [email protected] Internet address: www.dhfs.state.wi.us


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WYOMING Governor Honorable Dave Freudenthal State Capitol, Room 124 Cheyenne, WY 82002-0010 T: 307/777-7434 F: 307/632-3909 E-mail: [email protected] Internet address: www.state.wy.us Single State Agency Director Ms. Deb Fleming, Ph.D., Director Department of Health 117 Hathaway Building Cheyenne, WY 82002 T: 307/777-7656 F: 307/777-7439 E-mail: [email protected] Internet address: www.wdhfs.state.wy.us Medicaid Director Ms. Iris Oleske, State Medicaid Agent Department of Health 147 Hathaway Building Cheyenne, WY 82002 T: 307/777-7531 F: 307/777-6964 E-mail: [email protected] Internet address: wdhfs.state.wy.us


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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) REGIONAL OFFICES

ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID Region I Boston Regional Office

Bruce Greenstein 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 The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 215/861-4261

Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia

Region IV Atlanta Regional Office

Hugh Webster (Acting) Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 404/562-7432

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

Diane Livesay Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 303/844-7057

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-43 Seattle, WA 98121-2500 206/615-2330

Alaska, Idaho, Oregon, Washington

Source: CMS, Central Office, Centers for Medicaid and State Operations, as of February 11, 2004.


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CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) NATIONAL ACCOUNT REPRESENTATIVES

STATE CENTRAL OFFICE REGIONAL OFFICE

Alabama Virginia Wanamaker Deputy Director Division of Laboratory Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-7304 E-mail: [email protected]

Jay Gavens Financial Analyst Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7430 E-mail: [email protected]

Alaska Richard Strauss Director Division of Financial Management Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-2019 E-mail: [email protected]

Elizabeth Trias Health Insurance Specialist Medicaid Branch, Region X 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2400 E-mail: [email protected]

American Samoa Linda Murphy Health Insurance Specialist Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0435 E-mail: [email protected]

Mary Rydell Pacific Area Representative P.O. Box 50081 300 Ala Moana Blvd., 6-225 Honolulu, HI 96850 T: 808/541-2732 E-mail: [email protected]

Arizona Rhonda Rhodes Director Division of Benefits, Coverage and Payment Family and Children's Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1848 E-mail: [email protected]

Ronald Reepen Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3601 E-mail: [email protected]


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Arkansas Marty Svolos Director Division of Eligibility, Enrollment and Outreach Family and Children's Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4582 E-mail: [email protected]

J. P. Peters Health Insurance Specialist 1301 Young Street, Room 833 Dallas, TX 75202 T: 214/767-2628 E-mail: [email protected]

California Bill Lasowski Financial Advisor Office of the Center Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-2003 E-mail: [email protected]

Pat Daley Health Insurance Specialist 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3592 E-mail: [email protected]

Colorado 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 Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7117 E-mail: [email protected]

Connecticut Edward Hutton Technical Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6616 E-mail: [email protected]

Elena Nicolella Health Insurance Specialist JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1243 E-mail: [email protected]


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Delaware Mike Goldman Technical Director Division of Continuing Care Providers Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6813 E-mail: [email protected]

Paul Hughes Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4171 E-mail: [email protected]

District of Columbia

Rick Fenton Deputy Director Family and Children's Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5920 E-mail: [email protected]

Marguerite Clark Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4199 E-mail: [email protected]

Florida Jim Frizzera Co-Lead, National Institutional Reimbursement Team Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-9535 E-mail: [email protected]

Roberta Kelley Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7338 E-mail: [email protected]

Georgia

Jerry Zelinger Medical Advisor Division of Benefits, Coverage and Payment Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5929 E-mail: [email protected]

Hugh Webster Chief Medicaid Financial Management Branch Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7432 E-mail: [email protected]


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Guam Paul Miner Technical Director Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5937 E-mail: [email protected]

Eddie Martin Accountant 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3567 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, Room 408 San Francisco, CA 94105-3901 T: 415/744-3599 E-mail: [email protected]

Idaho Georgia Johnson Technical Director Division of Continuing Care Providers Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6859 E-mail: [email protected]

David Meacham Health Insurance Specialist 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2356 E-mail: [email protected]

Illinois Mary Beth Hance Director Policy Coordination and Planning Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4299 E-mail: [email protected]

Vera Drivalas 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/886-0792 E-mail: [email protected]


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Indiana Regina Fletcher Special Assistant 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: 410/786-3293 E-mail: [email protected]

Leslie Campbell Indiana State Representative 233 N. Michigan Avenue Suite 600 Chicago, IL 6061 T: 312/353-1557 E-mail: [email protected]

Iowa Mary Jean Duckett Director Division of Benefits, Coverage and Payment Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3294 E-mail: [email protected]

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]

Kansas Frank Sokolik Director Division of Acute Care Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-7089 E-mail: [email protected]

Tim Watson Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3309 E-mail: [email protected]

Kentucky Jack Williams Director Division of National Systems Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6743 E-mail: [email protected]

Renard Murray Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7417 E-mail: [email protected]


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Louisiana Jean Sheil Director Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-1285 E-mail: [email protected]

Robert Cowan Financial Operations Specialist 1301 Young Street, Room 714 Dallas, TX 75202 T: 214/767-6485 E-mail: [email protected]

Maine Roger Buchanan Director Division of Informational Analysis and Technical Assistance Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0780 E-mail: [email protected]

Irvin Rich JFK Federal Building Government Center, 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, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4196 E-mail: [email protected]

Massachusetts Tom Hamilton Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6763 E-mail: [email protected]

Alan P. Bryan Health Insurance Specialist JFK Federal Building Government Center, Room 2275 Boston, MA 02203-0003 T: 617/565-1246 E-mail: [email protected]


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Michigan Lillian Gibbons Senior Advisor Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-8705 E-mail: [email protected]

Ruth Hughes 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-1670 E-mail: [email protected]

Minnesota Terry Pratt Director Division of Integrated Health Systems Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-9499 E-mail: [email protected]

Doris Ross 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-9843 E-mail: [email protected]

Mississippi Diona Kristian Technical Director Family and Children’s Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3283 E-mail: [email protected]

Selwyn White Atlanta Federal Center 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7427 E-mail: [email protected]

Missouri

Peggy Clark Technical Director Division of Integrated Health Systems Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5321 E-mail: [email protected]

Jackie Glaze Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3318 E-mail: [email protected]


A-72

Montana Steven Lutzky, Ph.D. Director Division of Advocacy for Systems Improvement 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: 410/786-3257 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 Tracey Mummert Special Assistant Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3398 E-mail: [email protected]

Diana Townsend Health Insurance Specialist Richard Bolling Federal Building 601 East 12th Street, Room 227 Kansas City, MO 64106-2808 T: 816/426-3406 Ext. 3316 E-mail: [email protected]

Nevada Judy Yost Director Division of Laboratory Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3407 E-mail: [email protected]

Lee Netzer Health Insurance Specialist 75th Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3595 E-mail: [email protected]

New Hampshire Jan Tarantino Deputy Director Division of Continuing Care Providers Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0905 E-mail: [email protected]

Harold Finn JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1225 E-mail: [email protected]


A-73

New Jersey Fred Gladden Technical Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3033 E-mail: [email protected]

Julie Alberino 26 Federal Plaza Room 3800 New York, NY 10278-0063 T: 212/264-3904 E-mail: [email protected]

New Mexico 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 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7406 E-mail: [email protected]


A-74

North Dakota James Merrill Life Safety Code Specialist Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6998 E-mail: [email protected]

Bernadette Quevedo-Mendoza State Program Coordinator Office of the Regional Administrator, CMS Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7121 E-mail: [email protected]

Northern Mariana Islands

Edward Mortimore Technical Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3509 E-mail: [email protected]

H. Stephen Deering Deputy Regional Administrator, CMS 75 Hawthorne Street, Room 408 San Francisco, CA 94105-3901 T: 415/744-3501 E-mail: [email protected]

Ohio Deirdre Duzor Co-Lead, Pharmacy Team Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4626 E-mail: [email protected]

Gwendolyn Sampson 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-9861 E-mail: [email protected]

Oklahoma Melissa Hulbert Director Division of Continuing Care Providers Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6568 E-mail: [email protected]

Ford Blunt Health Insurance Specialist 1301 Young Street, Room 827 Dallas, TX 75202 T: 214/767-6381 E-mail: [email protected]


A-75

Oregon Alissa DeBoy Special Assistant Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6041 E-mail: [email protected]

Barbara Subert Health Insurance Specialist Medicaid Branch, Region X 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2390 E-mail: [email protected]

Pennsylvania Cheryl Austein-Casnoff Director Division of State Children’s Health Insurance Family and Children's Health Program Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4196 E-mail: [email protected]

Michael Cruse Health Insurance Specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4216 E-mail: [email protected]

Puerto Rico Cindy Melanson Health Program Evaluator Division of Acute Care Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-0310 E-mail: [email protected]

Frank Fournier La Torre de Plaza Las Americas Suite 1116 525 F. SD. Roosevelt Ave. San Juan, PR 000919-8024 T: 787/771-3687 E-mail: [email protected]

Rhode Island Rick Friedman Director Division of State Systems Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-4451 E-mail: [email protected]

Richard Pecorella JFK Federal Building Government Center, Room 2325 Boston, MA 02203-0003 T: 617/565-1244 E-mail: [email protected]


A-76

South Carolina Helaine Jeffers Deputy Director Division of Acute Care Services Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-5648 E-mail: [email protected]

Jessie Spillers 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7418 E-mail: [email protected]

South Dakota David Eddinger Technical Director Division of Laboratory Systems Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3429 E-mail: [email protected]

Cynthia Myers State Program Coordinator Office of the Regional Administrator Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7116 E-mail: [email protected]

Tennessee Mike Fiore 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 61 Forsyth Street, SW, Suite 4T20 Atlanta, GA 30303-8909 T: 404/562-7159 E-mail: [email protected]

Texas

Dave McNally Financial Management Specialist Finance, Systems and Budget Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3292 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]


A-77

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 State Program Coordinator Office of the Regional Administrator Colorado State Bank Building 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-7111 E-mail: [email protected]

Vermont Clarke Cagey Special Assistant Office of the Director Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3135 E-mail: [email protected]

Chong B. Tieng Health Insurance Specialist JFK Federal Building Government Center, Room 2275 Boston, MA 02203-0003 T: 617/565-9157 E-mail: [email protected]

Virginia Ginni Hain Director Division of Eligibility, Enrollment and Outreach Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6036 E-mail: [email protected]

Jake Hubik Health Insurance specialist The Public Ledger Building, Suite 216 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4181 E-mail: [email protected]

Virgin Islands Cindy Graunke Director Division of Nursing Homes Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6782 E-mail: [email protected]

Ricardo Holligan 26 Federal Plaza Room 3811 New York, NY 10278-0063 T: 212/264-3978 E-mail: [email protected]


A-78

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, Region X 2201 6th Avenue MS/RX-43 Seattle, WA 98121 T: 206/615-2515 E-mail: [email protected]

West Virginia Joan Simmons Deputy Director Division of Nursing Homes Survey and Certification Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-3409 E-mail: [email protected]

Donna Fischer Health Insurance Specialist The Public Ledger Building, Suite 230 150 S. Independence Mall West Philadelphia, PA 19106 T: 215/861-4221 E-mail: [email protected]

Wisconsin

Glenn Stanton Deputy Director Disabled and Elderly Health Programs Group Center for Medicaid and State Operations Mail Stop S2-26-12 7500 Security Boulevard Baltimore, MD 21244-1850 T: 410/786-6768 E-mail: [email protected]

Pam Carson 233 N. Michigan Avenue Suite 600 Chicago, IL 60601 T: 312/353-0108 E-mail: [email protected]

Wyoming

Sidney Trieger Technical Director Division of Integrated Health Systems 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: 410/786-6613 E-mail: [email protected]

Robert Tonsberg Epidemiologist, Sr. Health Services Office Manager Office of the Regional Administrator Colorado State Bank Bldg. 1600 Broadway, Suite 700 Denver, CO 80202-4367 T: 303/844-1981 E-mail: [email protected]

Source: CMS Website at www.cms.hhs.gov/states/natreps.pdf. Information as of January 21, 2004.


A-79

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) CENTER FOR MEDICAID AND STATE OPERATIONS (CMSO)

CENTRAL OFFICE STAFF 7500 Security Boulevard

Baltimore, MD 21244-1850 410/786-3000

Director Dennis Smith 410/786-3870

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

John Hoover 410/786-2020

Children’s Health Insurance

Cheryl Austein Casnoff 410/786-6614

Coordination of Benefits

Gina Clemens (Disabled & Elderly) 410/786-9644

Marty Svolos (Families & Children) 410/786-4582

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 Vince Powell 410/786-3314


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

Larry Reed 410/786-3325 Deirdre Duzor 410/786-4626

Managed Care Enrollment Report

Carolyn Lawson 410/786-0704

Medicaid Statistical Information System (MSIS)

Ron North 410/786-5651

Pharmacy Issues

(Coverage, Payment & Rebate Program) Larry Reed

410/786-3325 Deirdre Duzor 410/786-4626

Source: CMS Central Office, CMSO, February 11, 2004.


A-80


B-1

Appendix B: Medicaid Program Statistics - CMS MSIS Tables


B-2


B-3

Medicaid Program Statistics -- MSIS Report

The CMS MSIS Report is an annual report designed to collect State-reported statistical summary data on eligibles, recipients, services, and expenditures during a Federal fiscal year (i.e., October l through September 30). The data reported for a given year represent recipients of service and the amount of payments for claims adjudicated during the year. The data reflect bills adjudicated during the year rather than the services used during the year.

Historically, States summarized and reported the data processed through their Medicaid claims processing and payment operations unless they opted to participate in the Medicaid Statistical Information System (MSIS) project. Prior to Federal fiscal year 1999, MSIS was a voluntary program and those States participating in the MSIS project provide data tapes from their claims processing systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with the Balanced Budget Act of 1997, all claims processed on or after January 1, 1999, must be submitted electronically in the MSIS format.

The MSIS Report is the primary CMS source on recipients’ use of services and the associated payments for these services. However, the new reporting requirements have resulted in a lag in the timely release of MSIS summary tables. The most recent MSIS service utilization information available from CMS is for FY 2001. However, MSIS data for FY 2001 are missing for Washington and Hawaii. The latest available MSIS data has been substituted in its place. In addition, Puerto Rico and the U.S. territories have been excluded from the tables and the National totals.

In an effort to provide more recent recipient information as well as to maintain continuity with previous version of the Compilation, we have compiled ten tables from the MSIS data system for inclusion in this Appendix. The first two tables provide national level summary information on total expenditures and total number of recipients by type of service for FY 2000 and FY 2001. The remaining tables present State-by-State and national level data, including some trend information, on total Medicaid recipients, total Medicaid payments, number of prescription drug recipients, and Medicaid prescription drug payments. Additionally, there are three partial tables at the end of the Appendix that correspond to FY 2001 tables presented in Section 2.


B-4


B-5

Total U.S. Medical Assistance Recipients By Type of Service

Service FY 2000** Percent of Total* FY 2001** Percent of Total* Percent Change 2000-2001Capitated Payment Services 21,261,218 49.7% 22,342,525 49.9% 4.8%Pharmaceuticals 20,516,882 48.0% 21,729,110 48.5% 5.6%Physicians 19,103,558 44.7% 19,930,824 44.5% 4.2%Hospital Outpatient 13,226,305 30.9% 13,565,921 30.3% 2.5%Lab/X-ray 11,395,712 26.6% 12,278,048 27.4% 7.2%Other Care 9,036,596 21.1% 9,633,385 21.5% 6.2%Clinic 7,666,977 17.9% 8,369,692 18.7% 8.4%Dental 5,891,733 13.8% 6,910,064 15.4% 14.7%PCCM Services 5,560,441 13.0% 6,166,012 13.8% 9.8%Hospital Inpatient 4,933,277 11.5% 4,820,360 10.8% -2.3%Other Practitioners 4,735,427 11.1% 5,040,417 11.3% 6.1%Personal Support Services 4,549,488 10.6% 4,919,252 11.0% 7.5%Nursing Facility 1,702,885 4.0% 1,638,484 3.7% -3.9%Home Health Care 994,801 2.3% 989,339 2.2% -0.6%ICF-Mentally Retarded 118,171 0.3% 115,531 0.3% -2.3%Mental Health Facility 99,342 0.2% 89,142 0.2% -11.4%

Total Unduplicated Recipients* 42,763,233 44,793,217 4.5% *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. **Hawaii did not report for FY 2000 and FY 2001**. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.


B-6

Total U.S. Medical Assistance Payments By Type of Service

Service FY 2000**Percent of

Total* FY 2001**Percent of

Total* Percent Change 2000-2001Nursing Facility $34,432,018,376 20.5% $37,065,353,039 20.0% 7.1%Capitated Payment Services $24,412,582,129 14.5% $27,756,782,607 14.9% 12.0%Hospital Inpatient $24,265,794,997 14.4% $25,557,564,614 13.8% 5.1%Pharmaceuticals $20,013,770,558 11.9% $23,712,173,253 12.8% 15.6%Other Care $14,808,103,169 8.8% $16,483,018,278 8.9% 10.2%Personal Support Services $11,567,367,970 6.9% $13,009,737,222 7.0% 11.1%ICF-Mentally Retarded $9,374,506,773 5.6% $9,645,307,943 5.2% 2.8%Hospital Outpatient $7,053,041,842 4.2% $7,506,157,691 4.0% 6.0%Physicians $6,805,694,595 4.0% $7,421,942,400 4.0% 8.3%Clinic $6,174,164,021 3.7% $5,580,484,682 3.0% -10.6%Home Health Care $3,118,966,203 1.9% $3,505,452,939 1.9% 11.0%Mental Health Facility $1,768,270,710 1.1% $1,946,334,080 1.0% 9.1%Dental $1,404,498,611 0.8% $1,862,434,571 1.0% 24.6%Lab/X-Ray $1,288,213,313 0.8% $1,607,744,292 0.9% 19.9%Unknown $997,460,227 0.6% $1,427,842,139 0.8% 30.1%Other Practitioners $658,455,027 0.4% $752,657,038 0.4% 12.5%PCCM Services $164,562,061 0.1% $182,020,535 0.1% 9.6%

Total Payments $168,307,398,582 $185,786,851,245 9.4% *Percentages may not add to 100% due to rounding. Puerto Rico and the U.S. Territories are not included in these national totals. **Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000 and FY 2001.


B-7

2001 Baseline Data*

State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of TotalNational Total $185,786,851,245 $23,712,173,253 44,793,217 21,750,110 12.8%Alabama $2,950,095,956 $392,482,787 703,486 464,695 13.3%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 $535,162,729 $44,849,664 203,763 35,687 8.4%Idaho $713,433,025 $105,473,425 157,121 112,357 14.8%Illinois $8,150,021,068 $934,241,252 1,655,958 1,068,535 11.5%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 $2,881,578,117 $554,670,701 804,987 628,571 19.2%Maine $1,457,465,782 $203,693,259 249,050 192,833 14.0%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 $374,197,254 $43,288,363 60,217 39,758 11.6%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 $1,878,673,356 $222,018,784 564,820 220,711 11.8%Pennsylvania $7,634,325,250 $690,558,773 1,557,802 461,114 9.0%Rhode Island $1,095,852,989 $104,912,603 188,188 50,379 9.6%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 0.0%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 $2,432,050,117 $387,877,281 895,279 339,440 15.9%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% *Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY1999, FY2000, and FY 2001.


B-8

Medicaid Payments and Recipients, 2001*

State Total Payments Total Recipients Payments Per Recipient National Total $185,786,851,245 45,329,755 $4,099 Alabama $2,950,095,956 703,486 $4,194 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 $535,162,729 203,763 $2,626 Idaho $713,433,025 157,121 $4,541 Illinois $8,150,021,068 1,655,958 $4,922 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 $2,881,578,117 804,987 $3,580 Maine $1,457,465,782 249,050 $5,852 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 $374,197,254 60,217 $6,214 Ohio $7,772,738,205 1,413,925 $5,497 Oklahoma $2,004,799,211 570,671 $3,513 Oregon $1,878,673,356 564,820 $3,326 Pennsylvania $7,634,325,250 1,557,802 $4,901 Rhode Island $1,095,852,989 188,188 $5,823 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 $4,099 Vermont $541,283,084 149,262 $4,194 Virginia $2,715,962,318 618,395 $5,285 Washington $2,432,050,117 895,279 $3,213 West Virginia $1,565,008,585 349,229 $3,170 Wisconsin $3,029,722,940 633,463 $2,306 Wyoming $241,187,030 51,068 $4,966

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000,and FY 2001.


B-9

Drug Payments and Recipients, 2001*

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.

State Total Drug Payments Total Drug Recipients Drug Payments per Recipient National Total $23,712,173,253 21,750,110 $1,090 Alabama $392,482,787 464,695 $845 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 $44,849,664 35,687 $1,257 Idaho $105,473,425 112,357 $939 Illinois $934,241,252 1,068,535 $874 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 $554,670,701 628,571 $882 Maine $203,693,259 192,833 $1,056 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 $43,288,363 39,758 $1,089 Ohio $1,087,552,923 904,380 $1,203 Oklahoma $215,717,760 249,678 $864 Oregon $222,018,784 220,711 $1,006 Pennsylvania $690,558,773 461,114 $1,498 Rhode Island $104,912,603 50,379 $2,082 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 $387,877,281 339,440 $1,143 West Virginia $256,395,319 269,174 $953 Wisconsin $389,373,521 262,238 $1,485 Wyoming $31,881,860 36,704 $869


B-10

Drug Payment Trends, Percent Change 2000-2001*

State 2000 2001 Percent Change National Total $20,013,770,558 $23,712,173,253 15.6% Alabama $331,574,388 $392,482,787 15.5% Alaska $51,196,685 $64,923,574 21.1% Arizona $1,952,231 $4,254,191 54.1% Arkansas $209,933,612 $248,392,084 15.5% California $2,316,135,493 $2,808,298,437 17.5% Colorado $152,478,786 $177,115,553 13.9% Connecticut $264,641,409 $304,470,534 13.1% Delaware $66,263,771 $81,623,058 18.8% District of Columbia $55,092,178 $62,292,004 11.6% Florida $1,366,193,807 $1,487,935,645 8.2% Georgia $580,612,920 $655,515,772 11.4% Hawaii $44,849,664 $44,849,664 0.0% Idaho $83,525,730 $105,473,425 20.8% Illinois $847,001,431 $934,241,252 9.3% Indiana $464,982,829 $562,120,344 17.3% Iowa $193,832,443 $230,430,967 15.9% Kansas $167,216,488 $189,290,260 11.7% Kentucky $465,178,958 $598,093,343 22.2% Louisiana $476,400,908 $554,670,701 14.1% Maine $175,938,952 $203,693,259 13.6% Maryland $374,121,433 $417,080,496 10.3% Massachusetts $682,519,910 $795,309,302 14.2% Michigan $374,334,359 $604,759,491 38.1% Minnesota $221,682,000 $265,240,353 16.4% Mississippi $370,355,016 $494,805,247 25.2% Missouri $600,484,118 $680,574,899 11.8% Montana $58,634,278 $69,552,397 15.7% Nebraska $135,355,734 $161,577,499 16.2% Nevada $51,682,326 $62,849,319 17.8% New Hampshire $80,562,181 $90,927,579 11.4% New Jersey $584,533,211 $649,274,352 10.0% New Mexico $57,502,713 $70,147,344 18.0% New York $2,366,900,006 $2,779,026,904 14.8% North Carolina $794,550,074 $971,066,103 18.2% North Dakota $38,076,519 $43,288,363 12.0% Ohio $882,579,749 $1,087,552,923 18.8% Oklahoma $178,254,361 $215,717,760 17.4% Oregon $163,263,562 $222,018,784 26.5% Pennsylvania $533,527,373 $690,558,773 22.7% Rhode Island $89,482,143 $104,912,603 14.7% South Carolina $334,740,332 $438,498,935 23.7% South Dakota $44,650,518 $52,608,524 15.1% Tennessee $0 $0 0% Texas $1,125,238,856 $1,327,222,456 15.2% Utah $100,794,076 $117,101,302 13.9% Vermont $91,724,918 $105,673,417 13.2% Virginia $382,471,744 $419,133,293 8.7% Washington $387,877,281 $387,877,281 0.0% West Virginia $216,077,217 $256,395,319 15.7% Wisconsin $349,558,072 $389,373,521 10.2% Wyoming $27,233,795 $31,881,860 14.6%

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and 2001.


B-11

Rankings Based on Drug Payments*

State 2001 Payments 2001 Ranking % of 2000 Total Medicaid

Drug Payments 2000 Payments 2000

Ranking California $2,808,298,437 1 11.84% $2,316,135,493 2 New York $2,779,026,904 2 11.72% $2,366,900,006 1 Florida $1,487,935,645 3 6.27% $1,366,193,807 3 Texas $1,327,222,456 4 5.60% $1,125,238,856 4 Ohio $1,087,552,923 5 4.59% $882,579,749 5 North Carolina $971,066,103 6 4.10% $794,550,074 7 Illinois $934,241,252 7 3.94% $847,001,431 6 Massachusetts $795,309,302 8 3.35% $682,519,910 8 Pennsylvania $690,558,773 9 2.91% $533,527,373 12 Missouri $680,574,899 10 2.87% $600,484,118 9 Georgia $655,515,772 11 2.76% $580,612,920 11 New Jersey $649,274,352 12 2.74% $584,533,211 10 Michigan $604,759,491 13 2.55% $374,334,359 18 Kentucky $598,093,343 14 2.52% $465,178,958 14 Indiana $562,120,344 15 2.37% $464,982,829 15 Louisiana $554,670,701 16 2.34% $476,400,908 13 Mississippi $494,805,247 17 2.09% $370,355,016 20 South Carolina $438,498,935 18 1.85% $334,740,332 22 Virginia $419,133,293 19 1.77% $382,471,744 17 Maryland $417,080,496 20 1.76% $374,121,433 19 Alabama $392,482,787 21 1.66% $331,574,388 23 Wisconsin $389,373,521 22 1.64% $349,558,072 21 Washington $387,877,281 23 1.64% $387,877,281 16 Connecticut $304,470,534 24 1.28% $264,641,409 24 Minnesota $265,240,353 25 1.12% $221,682,000 25 West Virginia $256,395,319 26 1.08% $216,077,217 26 Arkansas $248,392,084 27 1.05% $209,933,612 27 Iowa $230,430,967 28 0.97% $193,832,443 28 Oregon $222,018,784 29 0.94% $163,263,562 32 Oklahoma $215,717,760 30 0.91% $178,254,361 29 Maine $203,693,259 31 0.86% $175,938,952 30 Kansas $189,290,260 32 0.80% $167,216,488 31 Colorado $177,115,553 33 0.75% $152,478,786 33 Nebraska $161,577,499 34 0.68% $135,355,734 34 Utah $117,101,302 35 0.49% $100,794,076 35 Vermont $105,673,417 36 0.45% $91,724,918 36 Idaho $105,473,425 37 0.44% $83,525,730 38 Rhode Island $104,912,603 38 0.44% $89,482,143 37 New Hampshire $90,927,579 39 0.38% $80,562,181 39 Delaware $81,623,058 40 0.34% $66,263,771 40 New Mexico $70,147,344 41 0.30% $57,502,713 42 Montana $69,552,397 42 0.29% $58,634,278 41 Alaska $64,923,574 43 0.27% $51,196,685 45 Nevada $62,849,319 44 0.27% $51,682,326 44 District of Columbia $62,292,004 45 0.26% $55,092,178 43 South Dakota $52,608,524 46 0.22% $44,650,518 47 Hawaii $44,849,664 47 0.19% $44,849,664 46 North Dakota $43,288,363 48 0.18% $38,076,519 48 Wyoming $31,881,860 49 0.13% $27,233,795 49 Arizona $4,254,191 50 0.02% $1,952,231 50 Tennessee $0 51 0.00% $0 51

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2000 and FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.


B-12

Drugs as a Percentage of Total Payments, 2001*

State Drug Payments Total Payments Percent of Total Payments National Total $23,712,173,253 $2,950,095,956 12.8% Alabama $392,482,787 $557,398,672 13.3% Alaska $64,923,574 $2,453,184,175 11.6% Arizona $4,254,191 $1,684,717,766 0.2% Arkansas $248,392,084 $19,824,989,448 14.7% California $2,808,298,437 $1,952,708,545 14.2% Colorado $177,115,553 $2,962,088,094 9.1% Connecticut $304,470,534 $601,182,212 10.3% Delaware $81,623,058 $830,258,078 13.6% District of Columbia $62,292,004 $8,398,159,525 7.5% Florida $1,487,935,645 $3,815,267,274 17.7% Georgia $655,515,772 $535,162,729 17.2% Hawaii $44,849,664 $713,433,025 8.4% Idaho $105,473,425 $8,150,021,068 14.8% Illinois $934,241,252 $3,355,995,714 11.5% Indiana $562,120,344 $1,660,864,098 16.7% Iowa $230,430,967 $1,370,248,183 13.9% Kansas $189,290,260 $3,235,072,953 13.8% Kentucky $598,093,343 $2,881,578,117 18.5% Louisiana $554,670,701 $1,457,465,782 19.2% Maine $203,693,259 $3,855,002,531 14.0% Maryland $417,080,496 $5,765,107,723 10.8% Massachusetts $795,309,302 $5,316,248,739 13.8% Michigan $604,759,491 $3,766,604,923 11.4% Minnesota $265,240,353 $2,180,662,071 7.0% Mississippi $494,805,247 $3,626,212,602 22.7% Missouri $680,574,899 $482,543,436 18.8% Montana $69,552,397 $1,089,787,848 14.4% Nebraska $161,577,499 $565,299,853 14.8% Nevada $62,849,319 $691,195,787 11.1% New Hampshire $90,927,579 $5,011,794,888 13.2% New Jersey $649,274,352 $1,476,537,827 13.0% New Mexico $70,147,344 $27,497,918,486 4.8% New York $2,779,026,904 $5,499,093,501 10.1% North Carolina $971,066,103 $374,197,254 17.7% North Dakota $43,288,363 $7,772,738,205 11.6% Ohio $1,087,552,923 $2,004,799,211 14.0% Oklahoma $215,717,760 $1,878,673,356 10.8% Oregon $222,018,784 $7,634,325,250 11.8% Pennsylvania $690,558,773 $1,095,852,989 9.0% Rhode Island $104,912,603 $3,096,853,528 9.6% South Carolina $438,498,935 $426,633,598 14.2% South Dakota $52,608,524 $4,059,332,053 12.3% Tennessee $0 $9,644,600,358 0.0% Texas $1,327,222,456 $1,059,729,740 13.8% Utah $117,101,302 $541,283,084 11.1% Vermont $105,673,417 $2,715,962,318 19.5% Virginia $419,133,293 $2,432,050,117 15.4% Washington $387,877,281 $1,565,008,585 15.9% West Virginia $256,395,319 $3,029,722,940 16.4% Wisconsin $389,373,521 $241,187,030 12.9% Wyoming $31,881,860 $2,950,095,956 13.2%

*Hawaii did not report for FY 2000 and FY 2001. Their FY 1999 data are included in the FY 2001 totals. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001


B-13

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% 12.8% Alabama 13.9% 14.4% 12.4% 16.6% 13.9% 13.3% 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% 11.5% 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% 19.2% Maine 11.6% 13.2% 16.3% 12.1% 13.5% 14.0% 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% 11.6% 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% 11.8% Pennsylvania 11.5% 11.8% 8.6% 9.9% 8.4% 9.0% Rhode Island 6.7% 7.1% 6.7% 8.5% 8.4% 9.6% 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%

*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 and FY 2001. 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. Washington State did not report data for FY 2001. Source: CMS, HCFA-2082 Reports, FY 1996-FY 1998 and MSIS Reports, FY 1999-2001.


B-14

Total Drug Recipients *

State 1996 1997 1998 1999 2000 2001National Total 22,575,656 20,943,872 19,324,605 19,854,953 20,516,082 21,750,110Alabama 412,511 412,739 395,290 405,338 438,529 464,695Alaska 40,839 42,174 43,734 52,086 60,273 65,278Arizona 63,103 80,450 56,796 5,545 7,034 9,761Arkansas 255,211 254,079 262,907 280,573 290,749 321,920California 3,565,667 3,158,386 2,644,430 2,264,942 2,487,875 2,486,910Colorado 173,707 156,631 147,033 151,581 160,264 143,169Connecticut 209,557 120,522 108,331 108,753 113,089 116,755Delaware 61,380 68,672 69,027 73,093 78,167 85,351District of Columbia 66,349 64,494 57,733 37,862 38,129 35,324Florida 1,079,467 1,024,555 1,014,372 1,079,997 1,072,082 1,159,155Georgia 891,335 846,963 805,923 841,024 847,730 856,797Hawaii 29,657 - 32,222 35,687 - -Idaho 84,553 79,961 86,775 81,943 92,776 112,357Illinois 1,028,753 1,008,740 959,472 965,747 1,013,254 1,068,535Indiana 401,042 352,814 323,811 361,784 420,041 464,879Iowa 230,749 221,061 215,173 213,161 212,178 221,691Kansas 179,653 170,167 155,875 153,117 158,334 158,515Kentucky 497,251 494,293 429,102 372,254 427,514 475,365Louisiana 593,415 563,864 552,481 549,296 581,356 628,571Maine 138,360 139,524 137,816 142,043 148,049 192,833Maryland 268,440 256,423 176,403 345,740 409,511 413,755Massachusetts 527,114 559,215 613,186 664,528 666,627 664,891Michigan 763,232 688,882 589,818 436,652 435,654 551,593Minnesota 294,589 227,027 203,220 184,947 180,104 188,566Mississippi 404,263 391,328 368,609 375,585 415,925 478,404Missouri 469,821 395,478 353,902 411,959 447,062 472,624Montana 66,465 62,092 58,641 59,204 58,899 63,338Nebraska 138,322 151,973 145,408 155,169 165,891 178,365Nevada 60,274 55,876 50,903 48,535 51,169 55,580New Hampshire 75,701 71,692 70,339 71,037 73,313 73,489New Jersey 518,833 347,105 309,849 302,687 298,450 307,798New Mexico 197,565 184,502 96,637 55,020 67,238 75,669New York 1,737,372 1,667,927 1,803,428 2,193,515 2,173,791 2,283,293North Carolina 764,482 779,229 764,886 797,903 827,039 907,413North Dakota 40,062 39,654 37,675 38,191 38,957 39,758Ohio 902,211 786,322 702,143 796,720 777,632 904,380Oklahoma 245,075 207,441 - 224,742 221,984 249,678Oregon 154,801 149,461 148,258 171,997 191,101 220,711Pennsylvania 857,818 763,255 580,749 520,251 416,498 461,114Rhode Island 52,239 46,817 44,852 49,285 49,809 50,379South Carolina 365,409 359,910 401,611 446,938 474,465 542,764South Dakota 49,056 47,845 46,588 50,783 53,666 58,203Tennessee^ 18 3 1 0 0 0 Texas 2,058,903 1,986,178 1,894,447 1,853,536 1,852,801 1,917,351Utah 114,321 105,676 126,953 128,297 133,164 136,682Vermont 78,376 83,057 58,037 88,322 103,228 109,328Virginia 417,580 396,719 383,880 373,491 347,251 333,880Washington 305,791 292,733 274,463 301,753 339,440 -West Virginia 299,967 280,550 267,398 274,842 261,544 269,174Wisconsin 309,582 265,987 221,508 224,213 267,417 262,238Wyoming 35,415 33,426 32,510 33,285 33,342 36,704 Note: Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs. *Hawaii did not report on time for FY 1997. Hawaii also did not report for FY 2000 and FY 2001. They are excluded from the national total for that year. Washington State did not report data for FY 2001. 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.


B-15

Total Medicaid Eligibles by Basis of Eligibility, 2001*

State Total Eligibles Aged

Blind/Disabled Children Adults

Foster CareChildren

BOEUnknown

National Total 46,910,257 4,400,601 7,657,411 22,438,138 11,546,609 866,692 806Alabama 780,434 89,484 182,696 377,130 125,448 5,676 0Alaska 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 202,912 18,824 21,616 85,074 73,338 4,060 -Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0Illinois 1,798,723 112,455 282,956 952,915 368,149 82,248 0Indiana 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 277,843 56,942 74,955 91,418 51,163 3,365 0Maryland 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 65,425 10,242 9,672 29,750 14,026 1,735 0Ohio 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 594,679 43,195 64,579 234,692 237,679 14,525 9Pennsylvania 1,647,440 206,976 364,161 754,343 275,074 46,886 0Rhode Island 194,113 19,137 36,402 84,191 48,834 5,548 1South 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 92,498 14,334 45Washington 916,838 69,054 121,662 520,323 191,871 13,927 1West 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

Note: Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year. *Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 data are used in this table. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: CMS, MSIS Report, FY 1999, FY 2000, and FY 2001.


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Total Medicaid Eligibles Per 1000 Population, 2001*

State Total State Population Total Eligibles* Eligibles per 1000 PopulationsNational Total 285,093,813 46,910,257 164.5Alabama 4,466,440 780,434 174.7Alaska 632,674 115,996 183.3Arizona 5,297,684 808,386 152.6Arkansas 2,692,041 550,668 204.6California 34,533,054 8,495,030 246.0Colorado 4,428,786 410,611 92.7Connecticut 3,432,550 446,326 130.0Delaware 795,576 133,079 167.3District of Columbia 572,716 152,597 266.4Florida 16,355,193 2,462,171 150.5Georgia 8,394,795 1,328,379 158.2Hawaii 1,225,038 202,912 165.6Idaho 1,321,309 172,348 130.4Illinois 12,517,168 1,798,723 143.7Indiana 6,126,470 825,556 134.8Iowa 2,932,225 331,025 112.9Kansas 2,700,453 291,837 108.1Kentucky 4,067,336 762,871 187.6Louisiana 4,466,001 886,518 198.5Maine 1,284,691 277,843 216.3Maryland 5,383,377 704,628 130.9Massachusetts 6,399,869 1,125,607 175.9Michigan 10,005,218 1,430,246 143.0Minnesota 4,985,202 609,856 122.3Mississippi 2,857,716 681,161 238.4Missouri 5,636,220 1,032,047 183.1Montana 905,954 101,966 112.6Nebraska 1,719,000 249,079 144.9Nevada 2,094,633 167,247 79.8New Hampshire 1,258,974 108,562 86.2New Jersey 8,504,114 923,697 108.6New Mexico 1,829,110 423,543 231.6New York 19,074,843 3,548,630 186.0North Carolina 8,195,249 1,397,486 170.5North Dakota 636,285 65,425 102.8Ohio 11,385,833 1,660,463 145.8Oklahoma 3,467,181 631,996 182.3Oregon 3,472,629 594,679 171.2Pennsylvania 12,298,363 1,647,440 134.0Rhode Island 1,058,992 194,113 183.3South Carolina 4,059,818 871,675 214.7South Dakota 758,156 106,154 140.0Tennessee 5,745,808 1,601,406 278.7Texas 21,340,598 2,729,660 127.9Utah 2,279,590 214,597 94.1Vermont 612,923 154,991 252.9Virginia 7,192,697 700,715 97.4Washington 5,992,760 916,838 153.0West Virginia 1,801,641 351,489 195.1Wisconsin 5,405,140 673,538 124.6Wyoming 493,720 58,013 117.5

*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals. Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 and FY 2001.


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Medicaid Total Net Expenditures and Eligibles, 2001*

State


TotalEligibles

AveragePer Eligible

National Total $215,809,899,631 46,910,257 $4,000Alabama $2,875,372,953 780,434 $3,684Alaska $576,586,201 115,996 $4,971Arizona $2,665,261,328 808,386 $3,297Arkansas $1,852,176,546 550,668 $3,364California $23,870,521,004 8,495,030 $2,810Colorado $2,142,029,851 410,611 $5,217Connecticut $3,213,848,086 446,326 $7,201Delaware $591,974,246 133,079 $4,448District of Columbia $979,941,105 152,597 $6,422Florida $8,557,796,303 2,462,171 $3,476Georgia $5,037,084,881 1,328,379 $3,792Hawaii $634,781,970 202,912 $3,128Idaho $693,205,598 172,348 $4,022Illinois $7,764,611,352 1,798,723 $4,317Indiana $4,008,812,857 825,556 $4,856Iowa $1,666,923,701 331,025 $5,036Kansas $1,686,410,544 291,837 $5,779Kentucky $3,304,053,663 762,871 $4,331Louisiana $4,201,982,590 886,518 $4,740Maine $1,315,523,163 277,843 $4,735Maryland $3,256,576,882 704,628 $4,622Massachusetts $6,619,524,971 1,125,607 $5,881Michigan $7,218,697,113 1,430,246 $5,047Minnesota $3,835,870,579 609,856 $6,290Mississippi $2,438,979,981 681,161 $3,581Missouri $4,744,963,426 1,032,047 $4,598Montana $482,357,404 101,966 $4,731Nebraska $1,187,237,577 249,079 $4,767Nevada $674,337,888 167,247 $4,032New Hampshire $873,248,831 108,562 $8,044New Jersey $7,123,653,988 923,697 $7,712New Mexico $1,467,417,736 423,543 $3,465New York $31,367,464,639 3,548,630 $8,839North Carolina $6,150,681,587 1,397,486 $4,401North Dakota $406,418,593 65,425 $6,212Ohio $8,433,412,161 1,660,463 $5,079Oklahoma $2,021,033,069 631,996 $3,198Oregon $2,658,358,391 594,679 $4,470Pennsylvania $10,908,343,146 1,647,440 $6,621Rhode Island $1,187,880,819 194,113 $6,120South Carolina $3,019,387,228 871,675 $3,464South Dakota $464,455,469 106,154 $4,375Tennessee $5,501,312,153 1,601,406 $3,435Texas $11,583,679,558 2,729,660 $4,244Utah $833,720,115 214,597 $3,885Vermont $601,467,093 154,991 $3,881Virginia $3,036,846,387 700,715 $4,334Washington $4,305,724,247 916,838 $4,696West Virginia $1,548,398,817 351,489 $4,405Wisconsin $3,976,142,914 673,538 $5,903Wyoming $243,408,927 58,013 $4,196 *Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table. Washington State did not report data for FY 2001. Their FY 2000 data are included in the FY 2001 totals.

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


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Appendix C: Medicaid Rebate Law


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TITLE 42 - THE PUBLIC HEALTH AND WELFARE CHAPTER 7 - SOCIAL SECURITY SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS Sec. 1396r-8. Payment for covered outpatient drugs1 (a) Requirement for rebate agreement (1) In general In order for payment to be available under section 1396b(a) of this title or under part B of title XVIII for covered outpatient drugs of a manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph (5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after November 4, 1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991, shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be retroactively calculated as if the agreement between the manufacturer and the State had been entered into on January 1, 1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an agreement, subsequently entered into, shall become effective as of the date on which the agreement is entered into or, at State option, on any date thereafter on or before the first day of the calendar quarter that begins more than 60 days after the date of the agreement is entered into. (2) Effective date Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991. (3) Authorizing payment for drugs not covered under rebate agreements Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single source drug or innovator multiple source drug if (A)(i) the State has made a determination that the availability of the drug is essential to the health of beneficiaries under the State Plan for medical assistance; (ii) such drug has been given a rating of 1-A by the Food and Drug Administration; and (iii)(I) the physician has obtained approval for use of the drug in advance of its dispensing in accordance with a prior authorization program described in subsection (d) of this section, or (II) the Secretary has reviewed and approved the State’s determination under subparagraph (A); or (B) the Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances. (4) Effect on existing agreements In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990, such agreement, for the initial agreement period specified therein, shall be considered to be a rebate agreement in compliance with this section with respect to that State, if the State agrees to report to the Secretary any rebates paid pursuant to the agreement and such agreement provides for a minimum aggregate rebate of 10 percent of the State’s total expenditures under the State Plan for coverage of the manufacturer’s drugs under this subchapter. If, after the initial agreement period, the State establishes to the satisfaction of the Secretary that an agreement in effect on November 5, 1990, provides for rebates that are at least as large as the rebates otherwise required under this section, and the State agrees to report any rebates under the agreement to the Secretary, the agreement shall be considered to be a rebate agreement in compliance with the section for the renewal periods of such agreement. (5) Limitation on prices of drugs purchased by covered entities

(A) Agreement with Secretary

1 This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States Code.


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A manufacturer meets the requirements of this paragraph if the manufacturer has entered into an agreement with the Secretary that meets the requirements of section 256b of this title with respect to covered outpatient drugs purchased by a covered entity on or after the first day of the first month that begins after November 4, 1992.

(B) “Covered entity” defined In this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of this title. (C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within 12 months of November 4, 1992, the following requirements shall apply: (i) Entities Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title when it is seeking reimbursement from the State Plan for medical assistance described in section 1396d(a)(12) of this title with respect to a unit of any covered outpatient drug which is subject to an agreement under section 256b(a) of this title. (ii) State agency Each such single State agency shall provide a means by which a covered entity shall indicate on any drug reimbursement claims form (or format, where electronic claims management is used) that a unit of the drug that is the subject of the form is subject to an agreement under section 256b of this title, and not submit to any manufacturer a claim for a rebate payment under subsection (b) of this section with respect to such a drug. (D) Effect of subsequent amendments In determining whether an agreement under subparagraph (A) meets the requirements of section 256b of this title, the Secretary shall not take into account any amendments to such section that are enacted after November 4, 1992. (E) Determination of compliance A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of section 256b of this title (as in effect immediately after November 4, 1992) and would have entered into an agreement under such section (as such section was in effect at such time), but for a legislative change in such section after November 4, 1992.

(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certain other Federal agencies

(A) In general A manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisions of section 8126 of title 38, including the requirement of entering into a master agreement with the Secretary of Veterans Affairs under such section. (B) Effect of subsequent amendments In determining whether a master agreement described in subparagraph (A) meets the requirements of section 8126 of title 38, the Secretary shall not take into account any amendments to such section that are enacted after November 4, 1992. (C) Determination of compliance A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the provisions of section 8126 of title 38, (as in effect immediately


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after November 4, 1992) and would have entered into an agreement under such section (as such section was in effect at such time), but for a legislative change in such section after November 4, 1992.

(b) Terms of rebate agreement (1) Periodic rebates

(A) In general A rebate agreement under this subsection shall require the manufacturer to provide, to each State Plan approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (c) of this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for which payment was made under the State Plan for such period. Such rebate shall be paid by the manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2) for the period involved. (B) Offset against medical assistance Amounts received by a State under this section (or under an agreement authorized by the Secretary under subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) in any quarter shall be considered to be a reduction in the amount expended under the State Plan in the quarter for medical assistance for purposes of section 1396b(a)(1) of this title.

(2) State provision of information

(A) State responsibility Each State agency under this subchapter shall report to each manufacturer not later than 60 days after the end of each rebate period and in a form consistent with a standard reporting format established by the Secretary, information on the total number of units of each dosage form and strength and package size of each covered outpatient drug dispensed after December 31, 1990, for which payment was made under the plan during the period, and shall promptly transmit a copy of such report to the Secretary. (B) Audits A manufacturer may audit the information provided (or required to be provided) under subparagraph (A). Adjustments to rebates shall be made to the extent that information indicates that utilization was greater or less than the amount previously specified.

(3) Manufacturer provision of price information

(A) In general. -- Each manufacturer with an agreement in effect under this section shall report to the Secretary – (i) not later than 30 days after the last day of each rebate period under the agreement (beginning on or after January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and, (for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the agreement; (ii) not later than 30 days after the date of entering into an agreement under this section on the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 for each of the manufacturer’s covered outpatient drugs; and (iii) for calendar quarters beginning on or after January 1, 2004, in conjunction with reporting required under clause (i) and by National Drug Code (including package size)— (I) the manufacturer’s average sales price (as defined in section 1847A(c)) and the

total number of units specified under section 1847A(b)(2)(A);


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(II) if required to make payment under section 1847A, the manufacturer’s wholesale acquisition cost, as defined in subsection (c)(6) of such section; and

(III) information on those sales that were made at a nominal price or otherwise described in section 1847A(c)(2)(B);

for a drug or biological described in subparagraph (C), (D), (E), or (G) of section 1842 (o)(1) or section 1881(b)(13)(A)(ii). Information reported under this subparagraph is subject to audit by the Inspector General of the Department of Health and Human Services. (B) Verification surveys of average manufacturer price The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient drugs, when necessary, to verify manufacturer prices and manufacturer’s average sales prices (including wholesale acquisition cost) if required to make payment reported under subparagraph (A). The Secretary may impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler, manufacturer, or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drug refuses a request for information about charges or prices by the Secretary in connection with a survey under this subparagraph or knowingly provides false information. The provisions of section 1320a-7a of this title (other than subsections (a) (with respect to amounts of penalties or additional assessments) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title. (C) Penalties

(i) Failure to provide timely information In the case of a manufacturer with an agreement under this section that fails to provide information required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by $10,000 for each day in which such information has not been provided and such amount shall be paid to the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the agreement shall be suspended for services furnished after the end of such 90-day period and until the date such information is reported (but in no case shall such suspension be for a period of less than 30 days).

(ii) False information Any manufacturer with an agreement under this section that knowingly provides false information is subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions of section 1320a-7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1320a-7a(a) of this title.

(D) Confidentiality of information Notwithstanding any other provision of law, information disclosed by manufacturers or wholesalers under this paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection (a)(6)(A)(ii) of this section (other than the wholesale acquisition cost for purposes of carrying out section 1847A) is confidential and shall not be disclosed by the Secretary or the Secretary of Veterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of a specific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler, except-

(i) as the Secretary determines to be necessary to carry out this section, to carry out section 1847A (including the determination and implementation of the payment amount), or to carry out section 1847B,


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(ii) to permit the Comptroller General to review the information provided, and (iii) to permit the Director of the Congressional Budget Office to review the information provided.

The previous sentence shall also apply to information disclosed under section 1860D-2(d)(2) or 1860D-4(c)(2)(E) and drug pricing data reported under the first sentence of section 1860D-31(i)(1).

(4) Length of agreement

(A) In general A rebate agreement shall be effective for an initial period of not less than 1 year and shall be automatically renewed for a period of not less than one year unless terminated under subparagraph (B). (B) Termination

(i) By the Secretary The Secretary may provide for termination of a rebate agreement for violation of the requirements of the agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a hearing concerning such a termination, but such hearing shall not delay the effective date of the termination. (ii) By a manufacturer A manufacturer may terminate a rebate agreement under this section for any reason. Any such termination shall not be effective until the calendar quarter beginning at least 60 days after the date the manufacturer provides notice to the Secretary. (iii) Effectiveness of termination Any termination under this subparagraph shall not affect rebates due under the agreement before the effective date of its termination. (iv) Notice to States In the case of a termination under this subparagraph, the Secretary shall provide notice of such termination to the States within not less than 30 days before the effective date of such termination. (v) Application to terminations of other agreements The provisions of this subparagraph shall apply to the terminations of agreements described in section 256b(a)(1) of this title and master agreements described in section 8126(a) of title 38.

(C) Delay before reentry

(c) In the case of any rebate agreement with a manufacturer under this section which is terminated, another such agreement with the manufacturer (or a successor manufacturer) may not be entered into until a period of 1 calendar quarter has elapsed since the date of the termination, unless the Secretary finds good cause for an earlier reinstatement of such an agreement.

Determination of amount of rebate (1) Basic rebate for single source drugs and innovator multiple source drugs

(A) In general Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a single source drug or an innovator multiple source drug shall be equal to the product of -


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(i) the total number of units of each dosage form and strength paid for under the State Plan in the rebate period (as reported by the State); and (ii) subject to subparagraph (B)(ii), the greater of -

(I) the difference between the average manufacturer price and the best price (as defined in subparagraph (C)) for the dosage form and strength of the drug, or (II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer price, for the rebate period.

(B) Range of rebates required

(i) Minimum rebate percentage For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate periods beginning -

(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent; (II) after September 30, 1992, and before January 1, 1994, is 15.7 percent; (III) after December 31, 1993, and before January 1, 1995, is 15.4 percent; (IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and (V) after December 31, 1995, is 15.1 percent.

(ii) Temporary limitation on maximum rebate amount In no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning -

(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or (II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the average manufacturer price.

(C) “Best price” defined For purposes of this section -

(i) In general The term “best price” means, with respect to a single source drug or innovator multiple source drug of a manufacturer, the lowest price available from the manufacturer during the rebate period to any wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity within the United States, excluding -

(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department of Veterans Affairs, a State home receiving funds under section 1741 of title 38, the Department of Defense, the Public Health Service, or a covered entity described in subsection (a)(5)(B) of this section (including inpatient prices charged to hospitals described in section 340B(a)(4)(L) of the Public Health Service Act); (II) any prices charged under the Federal Supply Schedule of the General Services Administration; (III) any prices used under a State pharmaceutical assistance program; and (IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of the Federal Government; (V) the prices negotiated from drug manufacturers for covered discount card drugs under an endorsed discount card program under section 1860D-31; and (VI) any prices charged which are negotiated by a prescription drug plan under part D of title XVIII, by an MA-PD plan under part C of such title with respect to covered part D drugs or by a qualified retiree prescription drug plan (as defined in section 1860D-22(a)(2)) with respect to such drugs on behalf of individuals entitled to benefits under part A or enrolled under part B of such title.

(ii) Special rules The term “best price” -

(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement, volume discounts, and rebates (other than rebates under this section); (II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form or product or package; and


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(III) shall not take into account prices that are merely nominal in amount. (iii) Application of auditing and recordkeeping requirements With respect to a covered entity described in section 340B(a)(4)(L) of the Public Health Service Act, any drug purchased for inpatient use shall be subject to the auditing and recordkeeping requirements described in section 340B(a)(5)(C) of the Public Health Service Act.

(2) Additional rebate for single source and innovator multiple source drugs

(A) In general The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount equal to the product of -

(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State Plan for the rebate period; and (ii) the amount (if any) by which -

(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds (II) the average manufacturer price for such dosage form and strength for the calendar quarter beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an entity, including a division or subsidiary of the manufacturer, after the first day of such quarter), increased by the percentage by which the consumer price index for all urban consumers (United States city average) for the month before the month in which the rebate period begins exceeds such index for September 1990.

. (B) Treatment of subsequently approved drugs In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1, 1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter after the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and “the month prior to the first month of the first full calendar quarter after the day on which the drug was first marketed” for “September 1990.”

(3) Rebate for other drugs

(A) In general The amount of the rebate paid to a State for a rebate period with respect to each dosage form and strength of covered outpatient drugs (other than single source drugs and innovator multiple source drugs) shall be equal to the product of -

(i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the dosage form and strength for the rebate period, and (ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for which payment was made under the State Plan for the rebate period.

(B) “Applicable percentage” defined For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning -

(i) before January 1, 1994, is 10 percent, and (ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs (1) Permissible restrictions


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(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization program shall comply with the requirements of paragraph (5). (B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -

(i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this section); (ii) the drug is contained in the list referred to in paragraph (2); (iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection (a)(4) of this section; or (iv) the State has excluded coverage of the drug from its formulary established in accordance with paragraph (4).

(2) List of drugs subject to restriction The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise restricted:

(A) Agents when used for anorexia, weight loss, or weight gain. (B) Agents when used to promote fertility. (C) Agents when used for cosmetic purposes or hair growth. (D) Agents when used for the symptomatic relief of cough and colds. (E) Agents when used to promote smoking cessation. (F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations. (G) Nonprescription drugs. (H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. (I) Barbiturates. (J) Benzodiazepines.

(3) Update of drug listings The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph (2) or their medical uses, which the Secretary has determined, based on data collected by surveillance and utilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriate use. (4) Requirements for formularies A State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s drug use review board established under subsection (g)(3) of this section). (B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any manufacturer which has entered into and complies with an agreement under subsection (a) of this section (other than any drug excluded from coverage or otherwise restricted under paragraph (2)). (C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate compendia described in subsection (k)(6) of this section),


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the excluded drug does not have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such treatment for such population over other drugs included in the formulary and there is a written explanation (available to the public) of the basis for the exclusion. (D) The State Plan permits coverage of a drug excluded from the formulary (other than any drug excluded from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that is consistent with paragraph (5). (E) The formulary meets such other requirements as the Secretary may impose in order to achieve program savings consistent with protecting the health of program beneficiaries. A prior authorization program established by a State under paragraph (5) is not a formulary subject to the requirements of this paragraph.

(5) Requirements of prior authorization programs A State Plan under this subchapter may require, as a condition of coverage or payment for a covered outpatient drug for which Federal financial participation is available in accordance with this section, with respect to drugs dispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically accepted indication (as defined in subsection (k)(6) of this section) only if the system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a request for prior authorization; and (B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by the Secretary).

(6) Other permissible restrictions A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or maximum quantities per prescription or on the number of refills, if such limitations are necessary to discourage waste, and may address instances of fraud or abuse by individuals in any manner authorized under this chapter. (e) Treatment of pharmacy reimbursement limits (1) In general During the period beginning on January 1, 1991, and ending on December 31, 1994 –

(A) a State may not reduce the payment limits established by regulation under this subchapter or any limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the dispensing fee for such a drug below the limits in effect as of January 1, 1991, and (B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on November 5, 1990, to reduce the limits described in subparagraph (A).

(2) Special rule If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not apply to such State until such State is in compliance with such regulations.


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(3) Effect on State maximum allowable cost limitations This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31, 1994, relating to any maximum allowable cost limitation established by a State for payment by the State for covered outpatient drugs, and rebates shall be made under this section without regard to whether or not payment by the State for such drugs is subject to such a limitation or the amount of such a limitation. (4) Establishment of upper payment limits The Secretary shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA has rated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all such additional formulations are rated as such and shall use only such formulations when determining any such upper limit. (f) Repealed and redesignated (g) Drug use review (1) In general

(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by not later than January 1, 1993, for a drug use review program described in paragraph (2) for covered outpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and (iii) are not likely to result in adverse medical results. The program shall be designed to educate physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients, or associated with specific drugs or groups of drugs, as well as potential and actual severe adverse reactions to drugs including education on therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. (B) The program shall assess data on drug use against predetermined standards, consistent with the following:

(i) compendia which shall consist of the following: (I) American Hospital Formulary Service Drug Information; (II) United States Pharmacopeia-Drug Information; and (III) the DRUGDex information System.

(ii) the peer-reviewed medical literature. (C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each State an amount equal to 75 per centum of so much of the sums expended by the State Plan during calendar years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug use review program which conforms to the requirements of this subsection. (D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to residents of nursing facilities which are in compliance with the drug regimen review procedures prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title, currently at section 483.60 of title 42, Code of Federal Regulations.

(2) Description of program Each drug use review program shall meet the following requirements for covered outpatient drugs:


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(A) Prospective drug review (i) The State plan shall provide for a review of drug therapy before each prescription is filled or delivered to an individual receiving benefits under this subchapter, typically at the point-of-sale or point of distribution. The review shall include screening for potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with nonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literature referred to in paragraph (1)(B) as its source of standards for such review. (ii) As part of the State’s prospective drug use review program under this subparagraph applicable State law shall establish standards for counseling of individuals receiving benefits under this subchapter by pharmacists which includes at least the following:

(I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapter or caregiver of such individual (in person, whenever practicable, or through access to a telephone service which is toll-free for long-distance calls) who presents a prescription, matters which in the exercise of the pharmacist’s professional judgment (consistent with State law respecting the provision of such information), the pharmacist deems significant including the following:

(aa) The name and description of the medication. (bb) The route, dosage form, dosage, route of administration, and duration of drug therapy. (cc) Special directions and precautions for preparation, administration and use by the patient. (dd) Common severe side or adverse effects or interactions and therapeutic contraindications that may be encountered, including their avoidance, and the action required if they occur. (ee) Techniques for self-monitoring drug therapy. (ff) Proper storage. (gg) Prescription refill information. (hh) Action to be taken in the event of a missed dose.

(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the following information regarding individuals receiving benefits under this subchapter:

(aa) Name, address, telephone number, date of birth (or age) and gender. (bb) Individual history where significant, including disease state or states, known allergies and drug reactions, and a comprehensive list of medications and relevant devices. (cc) Pharmacist comments relevant to the individual’s drug therapy. Nothing in this clause shall be construed as requiring a pharmacist to provide consultation when an individual receiving benefits under this subchapter or caregiver of such individual refuses such consultation.

(B) Retrospective drug use review The program shall provide, through its mechanized drug claims processing and information retrieval systems (approved by the Secretary under section 1396b(r) of this title) or otherwise, for the ongoing periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals receiving benefits under this subchapter, or associated with specific drugs or groups of drugs. (C) Application of standards The program shall, on an ongoing basis, assess data on drug use against explicit predetermined standards (using the compendia and literature referred to in paragraph (1)(B) as the source of standards for such assessment) including but not limited to monitoring for therapeutic


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appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical abuse/misuse and, as necessary, introduce remedial strategies, in order to improve the quality of care and to conserve program funds or personal expenditures. (D) Educational program The program shall, through its State drug use review board established under paragraph (3), either directly or through contracts with accredited health care educational institutions, State medical societies or State pharmacists associations/societies or other organizations as specified by the State, and using data provided by the State drug use review board on common drug therapy problems, provide for active and ongoing educational outreach programs (including the activities described in paragraph (3)(C)(iii) of this subsection) to educate practitioners on common drug therapy problems with the aim of improving prescribing or dispensing practices.

(3) State drug use review board

(A) Establishment Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the “DUR Board”) either directly or through a contract with a private organization. (B) Membership The membership of the DUR Board shall include health care professionals who have recognized knowledge and expertise in one or more of the following:

(i) The clinically appropriate prescribing of covered outpatient drugs. (ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs. (iii) Drug use review, evaluation, and intervention. (iv) Medical quality assurance. The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed and actively practicing physicians and at least 1/3 licensed and actively practicing pharmacists.

(C) Activities The activities of the DUR Board shall include but not be limited to the following:

(i) Retrospective DUR as defined in section. (ii) Application of standards as defined in paragraph (2)(C). (iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems or individuals identified in the course of retrospective drug use reviews performed under this subsection. Intervention programs shall include, in appropriate instances, at least:

(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists in the State of information concerning its duties, powers, and basis for its standards; (II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both) information and suggested changes in prescribing or dispensing practices, communicated in a manner designed to ensure the privacy of patient-related information; (III) use of face-to-face discussions between health care professionals who are experts in rational drug therapy and selected prescribers and pharmacists who have been targeted for educational intervention, including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up face-to-face discussions; and (IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluate interventions after an appropriate period of time to determine if the


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intervention improved the quality of drug therapy, to evaluate the success of the interventions and make modifications as necessary.

(D) Annual report Each State shall require the DUR Board to prepare a report on an annual basis. The State shall submit a report on an annual basis to the Secretary which shall include a description of the activities of the Board, including the nature and scope of the prospective and retrospective drug use review programs, a summary of the interventions used, an assessment of the impact of these educational interventions on quality of care, and an estimate of the cost savings generated as a result of such program. The Secretary shall utilize such report in evaluating the effectiveness of each State’s drug use review program.

(h) Electronic claims management (1) In general In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the Secretary shall encourage each State agency to establish, as its principal means of processing claims for covered outpatient drugs under this subchapter, a point-of-sale electronic claims management system, for the purpose of performing on-line, real time eligibility verifications, claims data capture, adjudication of claims, and assisting pharmacists (and other authorized persons) in applying for and receiving payment. (2) Encouragement In order to carry out paragraph (1) -

(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State Plan attributable to development of a system described in paragraph (1) shall receive Federal financial participation under section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90 percent) if the State acquires, through applicable competitive procurement process in the State, the most cost-effective telecommunications network and automatic data processing services and equipment; and (B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part 433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of Federal Regulations, the substitution of the State’s request for proposal in competitive procurement for advance planning and implementation documents otherwise required.

(i) Annual report (1) In general Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the Senate and the House of Representatives a report on the operation of this section in the preceding fiscal year. (2) Details Each report shall include information on –

(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and nonprescription covered outpatient drugs; (B) the total value of rebates received and number of manufacturers providing such rebates;


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(C) how the size of such rebates compare with the size of rebates offered to other purchasers of covered outpatient drugs; (D) the effect of inflation on the value of rebates required under this section; (E) trends in prices paid under this subchapter for covered outpatient drugs; and (F) Federal and State administrative costs associated with compliance with the provisions of this subchapter.

(j) Exemption of organized health care settings (1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid managed care organizations that contract under section 1396b(m) of this title, are not subject to the requirements of this section. (2) The State Plan shall provide that a hospital (providing medical assistance under such Plan) that dispenses covered outpatient drugs using drug formulary systems, and bills the Plan no more than the hospital’s purchasing costs for covered outpatient drugs (as determined under the State Plan) shall not be subject to the requirements of this section. (3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid by the institutions described in this subsection should not be taken into account for purposes of determining the best price as described in subsection (c) of this section. (k) Definitions In this section - (1) Average manufacturer price The term “average manufacturer price” means, with respect to a covered outpatient drug of a manufacturer for a rebate period, the average price paid to the manufacturer for the drug in the United States by wholesalers for drugs distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts. (2) Covered outpatient drug Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means -

(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title, a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and -

(i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) of such Act (21 U.S.C. 355(j)); (ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such a drug, and (II) which has not been the subject of a final determination by the Secretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or 304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21 U.S.C. 352(f), 355(a)); or (iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of


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the Code of Federal Regulations) to such a drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under section 505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the Secretary to withdraw approval of an application for such drug under such section because the Secretary has determined that the drug is less than effective for some or all conditions of use prescribed, recommended, or suggested in its labeling; and

(B) a biological product, other than a vaccine which -

(i) may only be dispensed upon prescription, (ii) is licensed under section 262 of this title, and (iii) is produced at an establishment licensed under such section to produce such product; and

(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356).

(3) Limiting definition The term “covered outpatient drug” does not include any drug, biological product, or insulin provided as part of, or as incident to and in the same setting as, any of the following (and for which payment may be made under this subchapter as part of payment for the following and not as direct reimbursement for the drug):

(A) Inpatient hospital services. (B) Hospice services. (C) Dental services, except that drugs for which the State Plan authorizes direct reimbursement to the dispensing dentist are covered outpatient drugs. (D) Physicians’ services. (E) Outpatient hospital services. (F) Nursing facility services and services provided by an intermediate care facility for the mentally retarded. (G) Other laboratory and x-ray services. (H) Renal dialysis. Such term also does not include any such drug or product for which a National Drug Code number is not required by the Food and Drug Administration or a drug or biological used for a medical indication which is not a medically accepted indication. Any drug, biological product, or insulin excluded from the definition of such term as a result of this paragraph shall be treated as a covered outpatient drug for purposes of determining the best price (as defined in subsection (C)(1)(C) of this section) for such drug, biological product, or insulin.

(4) Nonprescription drugs If a State Plan for medical assistance under this subchapter includes coverage of prescribed drugs as described in section 1396d(a)(12) of this title and permits coverage of drugs which may be sold without a prescription (commonly referred to as “over-the-counter” drugs), if they are prescribed by a physician (or other person authorized to prescribe under State law), such a drug shall be regarded as a covered outpatient drug. (5) Manufacturer


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The term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of prescription drug products, either directly or indirectly by extraction from substances of natural origin, or independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis, or (B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.

(6) Medically accepted indication The term “medically accepted indication” means any use for a covered outpatient drug which is approved under the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which is supported by one or more citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i) of this section. (7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug

(A) Defined (i) Multiple source drug The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not including any drug described in paragraph (5)) for which there are 2 or more drug products which -

(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”), (II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C) and as determined by the Food and Drug Administration, and (III) are sold or marketed in the State during the period.

(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source drug that was originally marketed under an original new drug application approved by the Food and Drug Administration. (iii) Noninnovator multiple source drug The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator multiple source drug. (iv) Single source drug The term “single source drug” means a covered outpatient drug which is produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application.

(B) Exception Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and bioequivalent, as defined in subparagraph (C). (C) Definitions For purposes of this paragraph -


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(i) drug products are pharmaceutically equivalent if the products contain identical amounts of the same active drug ingredient in the same dosage form and meet compendial or other applicable standards of strength, quality, purity, and identity; So in original. Probably should be “pharmaceutically”. (ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if they do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and (iii) a drug product is considered to be sold or marketed in a State if it appears in a published national listing of average wholesale prices selected by the Secretary, provided that the listed product is generally available to the public through retail pharmacies in that State.

(8) Rebate period The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a calendar quarter or other period specified by the Secretary with respect to the payment of rebates under such agreement. (9) State agency The term “State agency” means the agency designated under section 1396a(a)(5) of this title to administer or supervise the administration of the State Plan for medical assistance.


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D-1

Appendix D: Federal Upper Limits for Multiple Source Products


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SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-3

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 March 20, 2004. 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 March 20, 2004.

Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride Eq 200 mg base, Capsule, Oral 100 $0.4612 B Eq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Butalbital; Caffeine 500 mg; 50mg; 40 mg, Tablet, Oral 100 0.5399 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, 2.5 mg, Tablet, Oral 100 0.2190 B 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




D-4

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

Acetaminophen; Propoxyphene Napsylate 650 mg; 100 mg, Tablet, Oral 100 0.1800 R

Acetazolamide

250 mg, Tablet, Oral 100 0.2454 R

Acyclovir 200 mg, Capsule, Oral 100 0.1478 B 400 mg, Tablet, Oral 100 0.4425 B 800 mg, Tablet, Oral 100 0.8700 B

Albuterol

0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B

Albuterol Sulfate Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B 4 mg, Tablet, Oral 100 0.1425 B

Allopurinol

100 mg, Tablet, Oral 100 0.0784 B 300 mg, Tablet, Oral 100 0.1671 B

Alprazolam

0.25 mg, Tablet, Oral 100 0.0614 R 0.5 mg, Tablet, Oral 100 0.0698 B 1 mg, Tablet, Oral 100 0.0885 B 2 mg, Tablet, Oral 100 0.1745 R

Amantadine Hydrochloride

50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M

Amiloride Hydrochloride; Hydrochlorothiazide Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 B

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



D-5


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/5 ml, Powder for Reconstitution, Oral 100 0.0281 B 250 mg, Tablet, Chewable, Oral 100 0.1595 B

Ampicillin/Ampicillin Trihydrate

250 mg, Capsule, Oral 100 0.1736 B 500 mg, Capsule, Oral 100 0.2991 B

Aspirin; Butalbital; Caffeine

325 mg; 50 mg; 40 mg, Tablet, Oral 100 0.2400 R

Aspirin; Carisoprodol 325 mg; 200 mg, Tablet, Oral 100 0.3522 B

Atenolol

25 mg, Tablet, Oral 100 0.1595 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




D-6

Benztropine Mesylate

0.5 mg, Tablet, Oral 100 0.1227 B 1 mg, Tablet, Oral 100 0.1502 B 2 mg, Tablet, Oral 100 0.1930 B

Betamethasone Dipropionate

Eq 0.05% base, Cream, Topical 15 gm 0.2330 B Eq 0.05% base, Lotion, Topical 60 ml 0.1437 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


Carbamazepine

200 mg, Tablet, Oral 100 0.1388 R

Carbidopa; Levodopa 10 mg; 100 mg, Tablet, Oral 100 0.3644 B 25 mg; 100 mg, Tablet, Oral 100 0.4455 B 25 mg; 250 mg, Tablet, Oral 100 0.5145 B

Carisoprodol

350 mg, Tablet, Oral 100 0.3743 B


Carteolol Hydrochloride



D-7

1%, Solution/Drops, Ophthalmic 10 ml 3.6775 R

Cefaclor Eq 250 mg base, Capsule, Oral 100 0.6600 B Eq 500 mg base, Capsule, Oral 100 1.2900 B Eq 125 mg base/5 ml,

Powder for reconstitution, Oral 150 0.1107 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


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

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



D-8

Eq 300 mg base/ 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 0.1830 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 10 mg, Tablet, Oral 100 0.2728 B

Desonide

0.05%, Ointment, Topical 60 gm 0.4077 B 0.05%, Cream, Topical 100 0.2337 B

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate

0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm 1.0713 B

Diazepam 2 mg, Tablet, Oral 100 0.0423 B 5 mg, Tablet, Oral 100 0.0718 B 10 mg, Tablet, Oral 100 0.1417 B

Generic Name Upper Limit per Unit (Source) Diclofenac Potassiuim




D-9

Diclofenac Sodium 50 mg, Tablet, Delayed Release, Oral 100 0.4748 R 75 mg, Tablet, Delayed Release, Oral 100 0.5850 R

Dicyclomine Hydrochloride

10 mg, Capsule, Oral 100 0.1222 B 20 mg, Tablet, Oral 100 0.1185 B

Diltiazem Hydrochloride


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


Doxepin Hydrochloride

Eq 10 mg base, Capsule, Oral 100 0.0891 R Eq 25 mg base, Capsule, Oral 100 0.1822 B Eq 50 mg base, Capsule, Oral 100 0.1447 R Eq 75 mg base, Capsule, Oral 100 0.2052 R Eq 100 mg base, Capsule, Oral 100 0.4174 B Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1145 R

Doxycycline Hyclate

Eq 50 mg base, Capsule, Oral 50 0.0915 B Eq 100 mg base, Capsule, Oral 50 0.1050 B Eq 100 mg base, Tablet, Oral 50 0.1287 B

Doxycycline Hydrochloride

Eq 50 mg base, Capsule, Oral 50 0.0945 R Eq 100 mg base, Capsule, Oral 50 0.1215 R

Generic Name Upper Limit per Unit (Source) Enalapril Maleate

2.5 mg, Tablet, Oral, 100 0.3075 B 5 mg, Tablet, Oral, 100 0.5490 B 10 mg, Tablet, Oral, 100 0.6863 B



D-10

20 mg, Tablet, Oral, 100 0.9150 B Erythromycin

250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1538 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

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

Generic Name Upper Limit per Unit (Source) Fluoxetine Hydrochloride

10 mg, Capsule, Oral 100 0.5850 B 20 mg, Capsule, Oral 100 0.6000 R 40 mg Capsule, Oral 30 4.0125 B 20 mg/5ml, Solution, Oral 120 ml 0.7500 R



D-11

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


Flurbiprofen

100 mg, Tablet, Oral 100 0.3600 B

Flurbiprofen Sodium 0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 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 0.3800 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

1.5 mg, Tablet, Oral 100 0.2549 R 3 mg, Tablet, Oral 100 0.3202 R

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate

0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml Solution/Drops, Ophthalmic 10 ml 2.2185 B

Generic Name Upper Limit per Unit (Source) 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



D-12

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

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 0.0572 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 0.0367 B 25 mg, Tablet, Oral 100 0.7134 B

Hydroxyzine Pamoate Eq 25 mg HCL, Capsule, Oral 100 0.0892 B Eq 50 mg HCL, Capsule, Oral 100 0.1013 B

Ibuprofen


Generic Name Upper Limit per Unit (Source) Imipramine Hydrochloride


Indapamide

1.25 mg, Tablet, Oral 100 0.1035 B



D-13

2.5 mg, Tablet, Oral 100 0.1125 B

Ipratropium Bromide 0.02%, Solution for Inhalation, 2.500 ml, 25s 0.2340 R

Isoniazid

300 mg, Tablet, Oral 100 0.0890 B

Isosorbide Dinitrate 5 mg, Tablet, Oral 100 0.0198 R 10 mg, Tablet, Oral 100 0.0205 R 20 mg, Tablet, Oral 100 0.0375 R 2.5 mg, Tablet, Sublingual 100 0.0488 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 50 mg, Capsule, Oral 100 0.4749 B 75 mg, Capsule, Oral 100 0.4058 B

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

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



D-14

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 3.2012 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


Metformin Hydrochloride 500 mg, Tablet, Oral 100 0.3557 B 850 mg, Tablet, Oral 100 0.3863 B

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 0.1425 B



D-15

750 mg. Tablet, Oral 100 0.1792 B

Methotrexate Sodium Eq 2.5 mg base, Tablet, Oral 100 1.2637 B

Methylphenidate Hydrochloride


Methylprednisolone


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


Nadolol


Naltrexone Sodium


Naphazoline Hydrochloride 0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R



D-16

Naproxen

250 mg, Tablet, Oral 100 0.1044 R 375 mg, Tablet, Oral 100 0.1383 R 500 mg, Tablet, Oral 100 0.1805 B

Niacin 500 mg, Tablet, Oral 100 0.0390 B

Nicardipine Hydrochloride


Nifedipine

10 mg, Capsule, Oral 100 0.1875 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

Oxaprozin

600 mg, Tablet, Oral 100 0.6758 B

Generic Name Upper Limit per Unit (Source Oxazepam


30 mg, Capsule, Oral 100 1.2337 R

Oxybutynin Chloride 5 mg, Tablet, Oral 100 0.1260 R

Pentoxifylline

400 mg, Tablet, Extended Release, Oral 100 0.3147 B



D-17

Perphenazine 2 mg, Tablet, Oral 100 0.3473 R 4 mg, Tablet, Oral 100 0.3713 R 16 mg, Tablet, Oral 100 1.3833 B

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

Primidone 250 mg, Tablet, Oral 100 0.6956 R

Probenecid

500 mg, Tablet, Oral 100 0.7059 B

Prochlorperazine Maleate Eq 5 mg base, Tablet, Oral 100 0.3986 B Eq 10 mg base, Tablet, Oral 100 0.5766 B

Propafenone Hydrochloride


Generic Name Upper Limit per Unit (Source) Propranolol Hydrochloride


Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride 60 mg; 2.5 mg, Tablet, Oral 100 0.0336 B

Ranitidine Hydrochloride

Eq 150 mg base, Tablet, Oral, 100 0.3411 R Eq 300 mg base, Tablet, Oral 100 0.3180 B



D-18

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


Sulfasalazine

500 mg, Tablet, Oral 100 0.1565 B

Sulindac 150 mg, Tablet, Oral 100 0.3317 B 200 mg, Tablet, Oral 100 0.4289 B

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

Thioridazine Hydrochloride

10 mg, Tablet, Oral 100 0.2190 B 25 mg, Tablet, Oral 100 0.3030 B 50 mg, Tablet, Oral 100 0.3885 R 100 mg, Tablet, Oral 100 0.4941 B

Thiothixene

1 mg, Capsule, Oral 100 0.1388 B 2 mg, Capsule, Oral 100 0.1860 B 5 mg, Capsule, Oral 100 0.2963 B



D-19

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

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 0.0742 R 100 mg, Tablet, Oral 100 0.1140 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 0.2370 B 0.1%, Ointment, Topical 80 gm 0.0502 B

Triazolam

0.125 mg, Tablet, Oral 100 0.4041 B

Generic Name Upper Limit per Unit (Source) Trihexyphenidyl Hydrochloride


Tropicamide

0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B 1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B

Valproic Acid

250 mg, Capsule, Oral 100 0.5250 B 250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M

Verapamil Hydrochloride

120 mg, Capsule, Extended Release, Oral 100 0.8250 B



D-20

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 0.4838 B 240 mg, Tablet, Extended Release, Oral 100 0.4350 B


E-1

Appendix E: Glossary


E-2


E-3

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.


E-4

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.


E-5

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.


E-6

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.


E-7

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 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.


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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.


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Term Definition

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.

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.


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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.


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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.


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Term Definition

Dispensing or Prescribing Limits

Limitations on the number of prescriptions per month, or the amount of medication that may be prescribed in a given time frame.

Disproportionate Share Hospital (DSH)

A disproportionate share hospital (DSH) is a hospital that serves a disproportionate number of low-income patients with special needs and receives a payment adjustment for providing such services. In addition to certain requirements for the provision of obstetrical services to individuals entitled to medical assistance, a hospital is deemed to be a disproportionate share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at least one standard deviation above the mean Medicaid inpatient utilization rate for hospitals receiving Medicaid payments in the State, or 2) the hospital’s low-income utilization rate exceeds 25 percent.

Drug Detailing Presenting information about a brand name drug product to prescribers to educate them about its activity, uses, side effects, proper dosage and administration, etc.

Drug Formulary A listing of prescription medications which are preferred for use by a health plan and which may be dispensed through participating pharmacies to covered persons. This list is subject to periodic review and modification by the health plan. A plan that has adopted an “open or voluntary” formulary allows coverage for both formulary and non-formulary medications. A plan that has adopted a “closed, select or mandatory” formulary limits coverage to those drugs in the formulary.

Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine the appropriateness of drug therapy. There are three forms of DUE: prospective (before or at the time of prescription dispensing), concurrent (during the course of drug therapy), and retrospective (after the therapy has been completed). Same as “Drug Utilization Review.”

Drug Utilization The prescribing, dispensing, administering and ingestion or use of pharmaceutical products.

Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing patterns or patient drug utilization to determine the appropriateness of drug therapy. Most often focuses on over-utilization.

Dual Eligibles The term describes a population of low-income elderly and individuals with disabilities who qualify for both Medicare and Medicaid coverage. While Medicare covers basic health services, including physician and hospital care, dual eligibles rely on Medicaid to pay Medicare premiums and cost-sharing and to cover critical benefits Medicare does not cover, such as long-term care and prescription drugs. However starting in 2006, coverage of prescription drugs for dual eligibles will shift from Medicaid to Medicare.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

The EPSDT program covers screening and diagnostic services to determine physical or mental defects in recipients under age 21, as well as health care and other measures to correct or ameliorate any defects and chronic conditions discovered.

Electronic Data Interchange (EDI)

The computer-to-computer exchange of business or other information. The data may be in either a standardized or priority format.


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Term Definition

Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees at their place of work. The employer typically picks up all or part of the cost of these benefits.

Employee Retirement Income Security Act of 1974, Public Law 93-406 (ERISA)

A Federal act passed in 1974, that established new standards and reporting/disclosure requirements for employer-funded pension and health benefit programs. To date, self-funded health benefit plans operating under ERISA have been held to be exempt from State insurance laws.

Enrollment The total number of covered persons in a health plan. Also refers to the process by which a health plan signs up groups and individuals for membership, or the number of enrollees who sign up in any one group.

Estimated Acquisition Cost (EAC)

An estimate of the price generally, and currently, paid by providers for a drug marketed or sold by a particular manufacturer or labeler in the package size most frequently purchased by providers.

Exclusions Specific conditions or circumstances listed in the contract or employee benefit plan for which the policy or plan will not provide benefit payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with more than one health maintenance organization or preferred provider organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State agency for the covered medical expenses of eligible participants.

Experience Rating The process of setting rates based partially or in whole on previous claims experience and projected required revenues for a future policy year for a specific group or pool of groups.

Experimental, Investigational or Unproven Procedures

Medical, surgical, psychiatric, substance abuse or other 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.


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Term Definition

Federal Medical Assistance Percentage (FMAP)

The Federal Medical Assistance Percentage (FMAP) determines that Federal government’s share of medical assistance expenditures under each State’s Medicaid program. Each year, the FMAP is established by a formula that compares the State's average per capita income level with the national income average. States with a higher per capita income level are reimbursed a smaller share of their costs. By law, the FMAP cannot be lower than 50 percent or higher than 83 percent. The FMAP is defined in Section 1933d of the Social Security Act.

Federal Poverty Level (FPL) The Federal government’s working definition of poverty is used as the reference point for the income standard for Medicaid eligibility for certain categories of beneficiaries. The Federal Poverty Level is the administrative version of the poverty measure and is issued by the Department of Health and Human Services (HHS). It is a simplification of the poverty thresholds and are used in determining financial eligibility for certain Federal programs. The FPL is also referred to as the federal poverty guidelines.

Federal Upper Limits (FUL) The upper limit amount that Medicaid can reimburse for a drug product if there are three or more generic versions of the product rated therapeutically equivalent and at least three suppliers listed in the current editions of published national compendia. These limits are intended to assure that the Federal government acts as a prudent buyer of drugs. The upper limits program seeks to achieve savings by taking advantage of current market prices.

Federally Qualified Health Center (FQHC)

Federally Qualified Health Centers are facilities or programs more commonly known as Community Health Centers, Migrant Health Centers, and Health Care for The Homeless. These centers may qualify as Medicaid providers of services if: 1) The facility receives a grant under sections 329, 330, or 340 of The Public Health Services Act; 2) HRSA recommends, and the HHS Secretary determines, that the facility meets the requirements of the grant; or 3) The Secretary determines that a facility may qualify through waivers of the requirements (such a waiver cannot exceed two years).

Federally Qualified HMOs HMOs that meet certain Federally stipulated provisions aimed at protecting consumers: e.g., providing a broad range of basic health services, assuring financial solvency, and monitoring the quality of care. HMOs must apply to the Federal government for qualification. The Office of Prepaid Health Care of CMS administers the process.

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.


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Term Definition

First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon enrollment, without a deductible charge.

Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid agency.

Fiscal Intermediary The agent that has contracted with providers of service to process claims for reimbursement under health care coverage. In addition to handling financial matters, it may perform other functions such as providing consultative services or serving as a center for communication with providers and making audits of providers’ records.

Fiscal Year Any predetermined set of 12 months for which annual accounts are kept. The Federal government’s fiscal year extends from Oct. 1 to the following Sept. 30.

Fixed Fee An established “fee” schedule for pharmacy services allowed by certain government and private third-party programs in lieu of cost-of-doing business markups.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to choose providers whether or not they connect with the plans (often coupled with any willing provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”

Generic Drug A chemically equivalent copy of a brand name drug whose patent has expired. Drug formulations must be of identical composition with respect to the active ingredient (i.e., meet official standards of identity, purity, and quality of active ingredient). Also called generic equivalent or non-innovator multiple source drug.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand-name medication.

Global Target A financing method identical to a global budget except that no enforcement mechanism is used to keep providers and hospitals within budget (i.e., providers and hospitals will receive additional funding if their costs exceed their budgeted payments).

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.


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Term Definition

HCFA Common Procedural Coding System (HCPCS)

A listing of services, procedures and supplies offered by physicians and other providers. HCPCS includes current procedural terminology (CPT) codes, national alphanumeric codes and local alphanumeric codes. The national codes are developed by 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 Insurance Flexibility and Accountability (HIFA) Waiver

A Medicaid and State Children’s Health Insurance Program (SCHIP) demonstration waiver, using Section 1115 waiver authority, that offers States greater flexibility in setting benefits and cost-sharing for some groups of Medicaid beneficiaries. States can use the waiver to cut benefits and /or increase cost-sharing for certain Medicaid beneficiaries and invest resulting savings into expanding coverage of uninsured individuals through Medicaid and SCHIP.

Health Insuring Organization (HIO)

An entity that provides for or arranges for the provision of care and contracts on a prepaid capitated risk basis to provide a comprehensive set of services.

Health Maintenance Organizations (HMO’s)

(1) An entity that provides, offers or arranges for coverage of designated health services needed by plan members for a fixed, prepaid premium. There are four basic models of HMOs: staff model, group model, network model and individual practice association; (2) Under the Federal HMO Act, an entity must have three characteristics to call itself an HMO: (a) An organized system for providing healthcare or otherwise assuring healthcare delivery in a geographic area, (b) An agreed upon set of basic and supplemental health maintenance and treatment services, and (c) A voluntary enrolled group of people.

Health Plan An organization that provides a defined set of benefits; this term usually refers to an HMO-like entity, as opposed to an indemnity insurer.


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Term Definition

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 and Community-Based Waivers

See “Section 1915(c) Waivers.”

Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant to State and Federal laws to provide healthcare services in the home.

Home Health Services Services and items furnished to an individual who is under the care of a physician by a home health agency or by others under arrangements made by such agency. Services are furnished under a plan established and periodically reviewed by a physician. They are provided on a visiting basis in an individual’s home and include: nursing, physical therapy, dietary, counseling, and social services; part-time or intermittent skilled nursing care; physical, occupational, or speech therapy; medical social services, medical supplies and appliances (other than drugs and biologicals); home health aide services; and services of interns and residents.

Hospice A program that provides palliative and supportive care for terminally ill patients and their families, either directly or on a consulting basis with the patient's physician or another community agency. Originally a medieval name for a way station for crusaders where they could be replenished, refreshed, and cared for, hospice is used here for an organized program of care for people going through life's "last station." The whole family is considered the unit of care, and care extends through their period of mourning.

Indemnity Insurance An insurance program in which the insured person is reimbursed or the provider is paid for covered expenses after services are rendered.


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Term Definition

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 for the Mentally Retarded (ICF/MR)

The ICF/MR benefit is an optional Medicaid benefit for States. Section 1905(d) of the Social Security Act created this benefit to fund "institutions" (4 or more beds) for people with mental retardation, and specifies that these institutions must provide health and/or rehabilitative services.

International Classification of Diseases, 9th Edition (Clinical Modification) (ICD-9-CM)

A listing of diagnoses and identifying codes used by physicians for reporting diagnoses of health plan enrollees. The coding and terminology provide a uniform language that can accurately designate primary and secondary diagnoses and provide for reliable, consistent communications on claim forms.

Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are considered experimental and, therefore, may not be covered by insurance plans. The definition of experimental currently varies from plan to plan.

Laboratory and Radiological Services

Professional and technical laboratory and radiological services ordered by a licensed practitioner, provided in an office or similar facility (other than a hospital outpatient department or clinic) or by a qualified lab.

Legend Drug A drug that, by law, can be obtained only by prescription and bears the label, “Caution: Federal law prohibits dispensing without a prescription.” See “Prescription Medication.”

Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by an insurer. This amount serves as a cap on contractual liability and can be exceeded only in rare and unusual circumstances.


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Term Definition

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.

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.


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Term Definition

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.”

Medigap (Medicare Supplemental Insurance)

See “Medicare Supplemental Insurance.”

Members A participant in a health plan (member or eligible dependent). Also used to describe an individual specified within a subscriber contract that may receive health care services according to the terms of the subscriber policy. Also known as "beneficiary," "enrollee," "subscriber," or "insured."

Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain fee maximums for each procedure.


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Term Definition

Most Favored Nations Discount or Clause

A contractual agreement that stipulates that a vendor must provide to a particular payor the lowest prices that would be available to any purchaser. The Federal government often invokes most favored nation clauses for 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).

Network Plan A phrase that generally refers to arrangements where providers contract with payers or a managed care plan to provide services for patients enrolled in the managed care plan. See “Managed Care.”

Nurse-Midwife Services Nurse-midwife services are those concerned with the management of care of mothers and newborns throughout the maternity cycle. OBRA 1980 required that payment be made for providing nurse-midwife services to categorically needy recipients to the extent that the nurse-midwife is authorized to practice under State law or regulation. States are also required to offer direct reimbursement to nurse-midwives as one of the payment options. Nurse-midwives must be registered nurses who are either certified by an organization recognized by the Secretary of HHS or who have completed a program of study and clinical experience that has been approved by the Secretary.

Nursing Facility (NF) A facility in either freestanding or part of a hospital, that accepts patients in need of rehabilitation and medical care that is of a lesser intensity than that received in a hospital.

Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified nursing facility that meets standards set by Secretary of DHHS.

Other Practitioners’ Services Health care services of licensed practitioners other than physicians and dentists.

Out-of-Pocket Costs/Expenses (OOPs)

The portion of payments for health services required to be paid by the enrollee, including copayments, coinsurance and deductibles.

Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for him/herself and/or dependents: i.e., deductibles, copays and coinsurance - as defined per the contract. Once this limit is reached, benefits will increase to 100% for health services received during the rest of that calendar year. Some out-of-pocket costs (e.g., mental health, penalties for non-precertification, etc.) are not eligible for out-of-pocket limits.


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Term Definition

Outcome Measures Assessments which gauge the effect or results of treatment for a particular disease or condition. Outcome measures include such parameters as: the patient’s perception of restoration of function, quality of life and functional status, as well as objective measures of mortality, morbidity and health status.

Outcomes Management Systematically improving 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.


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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.

Pharmaceutical Benefits Manager (PBM)

An entity that is responsible for managing prescription benefits.

Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly licensed and qualified under the law of jurisdiction in which treatment is received.

Physician-Hospital Organization (PHO)

A legal entity formed by a hospital and a group of physicians to further mutual interests and to achieve market objectives. A PHO generally combines physicians and a hospital into a single organization for the purpose of obtaining payer contracts. Doctors maintain ownership of their practices and agree to accept managed care patients according to the terms of a professional service agreement with the PHO. The PHO serves as a collective negotiating and contracting unit. It is typically owned and governed jointly by a hospital and shareholder physicians.

Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service from a participating or non-participating provider, with different benefit levels associated with the use of participating providers. POS can be provided in several ways: an HMO may allow members to obtain limited services from non-participating providers; an HMO may provide 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.


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Term Definition

Practice Parameters See “Practice Guidelines.”

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if the provider’s care is significantly different from others with similar practices. If there is a significant difference, the practitioner’s practice is analyzed to determine the reasons for the variation and whether that practitioner’s practice patterns should be modified.

Pre-Certification Review See “Utilization Review.”

Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specified period immediately preceding the covered person’s effective date of coverage under the master group contract.

Preferred Provider Organization (PPO)

A program in which contracts are established with providers of medical care. Providers under such contracts are referred to as preferred providers. Usually, the benefit contract provides significantly better benefits (fewer copayments) for services received from preferred providers, thus encouraging covered persons to use these providers. Covered persons are generally allowed benefits for non-participating providers’ services, usually on an indemnity basis with significantly higher copayments. A PPO arrangement can be insured or self-funded. Providers may be, but are not necessarily, paid on a discounted fee-for-service basis.

Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriate specialties, as well as other professional and subprofessional personnel, who, for regular compensation, undertake to provide comprehensive care to an enrolled population for premium payments that are made in advance by the consumer and/or their employers.

Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either capitated risk or non-risk basis or the entity provides comprehensive services on a non-risk basis.

Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the prescription of a practitioner licensed by law to administer such drugs, and drugs dispensed by a licensed practitioner to his own patients. This item does not include a practitioner’s drug charges that are not separable from his other charges, or drugs covered by a hospital bill.

Prescription Medication A drug which has been approved by the Food and Drug Administration and which can, under Federal and State law, be dispensed only pursuant to a prescription order from a duly licensed prescriber, usually a physician.

Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and early treatment of conditions, generally including routine physical examinations, immunization and well person care.

Primary Care Basic or general healthcare traditionally provided by family practice, pediatrics and internal medicine. See also “Secondary Care.”

Primary Care Case Management (PCCM)

Managed care arrangements where primary care providers receive a per capita management fee to coordinate a patient's care in addition to reimbursement (fee-for-service or capitation) for the medical services they provide.


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Term Definition

Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner, pediatrician, and in some cases, OB/Gyn) in managed care organizations who determines whether the presenting patient needs to see a specialist or requires other non-routine services. See Care Coordinator.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a service or medication. Prior authorization does not guarantee coverage.

Prospective Financing Financing for health care services based on prices or budgets determined prior to the delivery of service. Payments can be per unit of service, per member, or per time period. In all its forms prospective financing differs from cost-based reimbursement, under which a provider is paid for costs incurred.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or any individual or group of individuals that provides a healthcare service.

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.


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Term Definition

Reasonable Cost In processing claims for health insurance benefits, intermediaries use CMS guidelines to determine the reasonable cost incurred by the individual providers in furnishing covered services to enrollees. The reasonable cost is based on the actual cost of providing such services, including direct and indirect costs of providers, excluding any costs that are unnecessary in the efficient delivery of services covered by the insurance program.

Rebate A monetary amount that is returned to a payer from a prescription drug manufacturer based upon utilization by a covered person or purchases by a provider.

Recipient A recipient of Medicaid is an individual who has been determined to be eligible for Medicaid and who has used medical services covered under Medicaid.

Referral The process of sending a patient from one practitioner to another for health care services. Health plans may require that designated primary care providers authorize a referral for coverage of specialty services.

Restrictive Formulary A term often used synonymously with closed formulary. See “Drug Formulary.”

Retrospective Review Determination of medical necessity and/or appropriate billing practice for services already rendered.

Risk Responsibility for paying for or otherwise providing a level of health care services based on an unpredictable need for these services.

Risk Contract (1) An agreement between a State Medicaid program and an HMO or competitive medical plan requiring the HMO to furnish at a minimum all Medicaid covered services to Medicaid eligible enrollees for an annually determined, fixed monthly payment rate from the State government. The HMO is then liable for services regardless of their extent, expense or degree. (2) An agreement between a provider and payer, or intermediary, on behalf of a payer, that requires the provider to furnish all specified services for a specified enrollee for a set fee, usually prepaid, and for a set period of time (usually one year). The provider is then liable for services regardless of their extent, expense or degree. Such stated limitations for such liability are stated in advance and may be subject to reinsurance.

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.”


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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 Section 1915(b) of the Social Security Act authorizes the Secretary of Health and Human Services to waive compliance with certain portions of the Medicaid statute that prevent a State from mandating Medicaid beneficiaries obtain their care from a single provider or health plan. Section 1915(b) waivers allow States to operate mandatory managed care programs in all or portions of the State while continuing to receive Federal Medicaid matching funds. Waivers must be approved by the Centers for Medicare & Medicaid Services (CMS).

Section 1915(c) Waivers Section 1915(c) of the Social Security Act authorizes the Secretary of Health and Human Services to allow State Medicaid programs to offer special services to beneficiaries at risk of institutionalization in a nursing facility or facility for the mentally retarded. These services, which would otherwise not qualify for Federal matching funds, include case management, homemaker/home health aide services, rehabilitation services, and respite care. They also include, in the case of individuals, with chronic mental illness, day treatment and partial hospitalization, psychosocial rehabilitation, and clinic services. Also know as home and community-based (HCBS) waivers.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a designated health service (e.g., pharmacies, clinical laboratories, and outpatient surgery) in which the provider or the provider’s immediate family member has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such as tobacco and alcohol.

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) See “Nursing Facility.”

Specified Low-Income Medicare Beneficiary (SLMB) Program

These individuals are entitled to Medicare Part A, have income of greater than 100% FPL, but less than 120% FPL and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for Medicaid as a dual eligible. Medicaid pays their Medicare Part B premiums only, but they are not eligible for Medicaid payment for their Medicare cost-sharing obligations.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual establishes Medicaid eligibility by reducing gross income through incurring medical expenses until net income (after medical expenses) meets Medicaid financial requirements.


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Term Definition

State Buy-In The term given to the process by which a State may provide Supplementary Medical Insurance coverage for its needy eligible persons through an agreement with the Federal government under which the State pays the premiums for them.

State Children’s Health Insurance Program (SCHIP)

As part of the Balanced Budget Act of 1997, Congress created SCHIP as a Federal/State partnership with the goal of expanding health insurance to children whose families earn too much money to be eligible for Medicaid, but not enough money to purchase private insurance. SCHIP is designed to provide coverage to "targeted low-income children." A "targeted low-income child" is one who resides in a family with income below 200% of the Federal Poverty Level (FPL) or whose family has an income 50% higher than the State's Medicaid eligibility threshold. Unlike Medicaid, SCHIP is a block grant awarded to the States each year. Children who are eligible for Medicaid are not eligible for SCHIP.

State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health services (e.g., in vitro fertilization) or services provided by certain health care providers (e.g., audiologists). Self-insureds are exempt from these requirements. There are over 800 mandates nationwide.

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.


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Term Definition

Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was prescribed, but which is deemed to be therapeutically equivalent. In most States such a practice requires the prescribing physician’s authorization before the substitution may occur. A pharmacy and therapeutics committee (P&T) most often approves the rationale for therapeutic equivalency prior to such practice.

Third-Party Administrator (TPA)

An independent person or corporate entity (third party) that administers group benefits, claims and administration for a self-insured company/group. A TPA does not underwrite the risk.

Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other government programs or insurance) which is or may be liable to pay all or part of the medical cost or injury, disease, or disability of an applicant or recipient of Medicaid.

Total Quality Management (TQM)

See “Continuous Quality Improvement.”

Title XIX See “ Medicaid.”

Universal Access The availability of affordable public or private insurance coverage for every United States citizen or legal resident. There is no guarantee, however, that all individuals will actually choose to purchase or have the funds to purchase coverage. See “Universal Coverage.”

Universal Coverage The guaranteed provision of at least basic health care services to every United States citizen or legal resident. See “Universal Access.”

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.


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Term Definition

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).”


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ACRONYMS

AABD Aid to Aged, Blind, and Disabled AAC Actual Acquisition Cost AHRQ Agency for Health Research and Quality AIDS Acquired Immune Deficiency Syndrome AMP Average Manufacturer Price ANSI American National Standards Institute ARF Area Resource File ASO Administrative Services Only AWP Any Willing Provider OR Average Wholesale Price BBA Balanced Budget Act of 1997 BIPA Benefits Improvement and Protection Act BLS Bureau of Labor Statistics CHIP See SCHIP CFR Code of Federal Regulations CMP Competitive Medical Plan CMS Centers for Medicare and Medicaid Services (formerly HCFA) CMSO CMS’ Center for Medicaid and State Operations CNAB Categorically Needy Aid to the Blind CNAFDC Categorically Needy Aid to Families with Dependent Children CNAPTD Categorically Needy Aid to the Permanently and Totally Disabled CNOAA Categorically Needy Old Age Assistance COBRA Consolidated Omnibus Reconciliation Act of 1985 COM-MCO Commercial Managed Care Organization CON Certificate of Need CPI Consumer Price Index CPR Customary Prevailing, and Reasonable (charges) CPT Current Procedural Terminology CQI Continuous Quality Improvement DAW Dispense As Written dba Doing Business As DEFRA Deficit Reduction Act of 1984 DESI Drug Efficacy Study and Implementation DHHS Department of Health and Human Services DRGs Diagnostic Related Groupings DSH Disproportionate Share Hospital DUE Drug Use Evaluation DUR Drug Utilization Review EAC Estimated Acquisition Cost EDI Electronic Data Interchange


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EPSDT Early and Periodic Screening, Diagnostic and Treatment ERISA Employee Retirement Income Security Act ESRD End Stage Renal Disease FDA Food and Drug Administration FFP Federal Financial Participation FFS Fee-for-Service FMAP Federal Medical Assistance Percentage FOC Freedom of Choice FPL Federal Poverty Level FQHC Federally Qualified Health Center FUL Federal Upper Limits FY Fiscal Year HCFA Health Care Financing Administration (see CMS) HCPCS HCFA Common Procedural Coding System HCPP Health Care Prepayment Plan HEDIS Health Plan Employer Data and Information Set HH Home Health HIFA Health Insurance Flexibility and Accountability HIO Health Insuring Organizations HIPAA Health Insurance Portability and Accountability Act HMO Health Maintenance Organization HRSA Health Resources and Services Administration ICF 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 NF Nursing Facility NP Nurse Practitioner OACT Office of the Actuary OASDI Old Age, Survivors, and Disability Insurance


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OBRA Omnibus Budget Reconciliation Act OHS Outpatient Hospital Services OMB Office of Management and Budget ORD Office of Research and Demonstrations OT Occupational Therapy OTC Over-the-Counter (drugs) P&T Pharmacy and Therapeutics Committee PA Physician’s Assistant OR Prior Authorization PBM Pharmaceutical Benefits Manager PCCM Primary Care Case Management PCF Program Characteristics File PCP Primary Care Physician PHP Prepaid Health Plan PMPM Per Member Per Month PHO Physician-Hospital Organization POS Point-of-Service PPO Preferred Provider Organization PRO Peer Review Organization ProPAC Prospective Payment Assessment Commission PT Physical Therapy QA/QI Quality Assurance/Quality Improvement QMB Qualified Medicare Beneficiary RHC Rural Health Clinic RPH Registered Pharmacist Rx Pharmaceutical SCHIP State Children’s Health Insurance Program SFO State Funds Only SLMB Specified Low Income Medicare Beneficiary SSA Social Security Administration SSI Supplemental Security Income SSP State Supplemental Payments TANF Temporary Assistance for Needy Families TDOC Total Days of Care TEFRA Tax Equity & Fiscal Responsibility Act Title XIX Title XIX of The Social Security Act (See Medicaid) TPA Third-Party Administrator TQM Total Quality Management UCR Usual, Customary and Reasonable UM Utilization Management UR Utilization Review WAC Weighted Average Cost OR Wholesale Acquisition Cost

Documents

Pharmaceutical Benefits Under State Medical Assistance Programs, 2003