Escolar Documentos
Profissional Documentos
Cultura Documentos
2002
Published by the
National Pharmaceutical Council, Inc.
1894 Preston White Drive
Reston, VA 20191-5433
Information for this compilation was acquired from multiple sources, including a
survey of Medicaid prescription drug programs administered for the National
Pharmaceutical Council by Muse & Associates, Washington, DC with assistance
from Compensation Solutions, LLC and StateScape. While we have checked all
secondary data in the book for consistency relative to the original source, we
have not validated the original data reported by the Centers for Medicare and
Medicaid Services (CMS) and other organizations.
The data were compiled and the book prepared for publication by Donald Muse,
Ph.D., David Goldenberg, Ph.D., Anne Marie Hummel, Steven Heath, M.P.A.,
Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A., Errica Philpott, Liz Segall,
and Tiffany Crawford of Muse & Associates. Paul Gavejian and Philip Farber
of Compensation Solutions prepared and conducted the 2001 survey. James
Elliott at StateScape supervised the compilation of information on State officials,
State professional associations, and expanded drug programs for elderly and
disabled beneficiaries. Gary Persinger and Kimberly Dietrich of the National
Pharmaceutical Council provided valuable input and support, including the
conceptualization of the methodology used in Section 1.
Pharmaceutical Benefits 2002
INTRODUCTION
The data used to create each edition of the Compilation are assembled from
many sources. The “Medicaid Compilation” incorporates information on each
State pharmacy program from an annual NPC survey of State Medicaid program
administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal
agencies and other organizations. Each year, finding and compiling current,
relevant information for inclusion in the Compilation presents a challenge.
Updating the data for the 2002 Compilation was no exception.
For example, in previous versions of the Compilation, a main data source was
the HCFA-2082, an annual report providing State-reported data on Medicaid
population characteristics, service utilization, and expenditures during a Federal
fiscal year. Historically, States summarized and reported data processed through
their Medicaid claims processing and payment operations unless they opted to
participate in the Medicaid Statistical Information System (MSIS) project. Prior
to Federal fiscal year 1999, MSIS was a voluntary program where States
participating in the MSIS project provided data tapes from their claims
processing systems to CMS in lieu of the HCFA-2082 tables. In accordance with
the Balanced Budget Act of 1997, all claims processed on or after January 1,
1999, had to be submitted electronically in the MSIS format and the HCFA-2082
ceased to be a Federal reporting requirement.
The U.S. Bureau of the Census has also lagged behind its normal schedule for
release of annual population and demographic data due to data processing
problems. Although a few tables showing total population counts by State for
2001 are available, the bulk of the more detailed data for 2001 have yet to be
released. Discussions with Census Bureau staff indicate that the additional 2001
data will not become available until sometime during 2003, at the same time that
data for 2002 are scheduled for release.
Data availability and the challenges of compiling relevant information have led
us to examine all available data sources and to select, from among the
alternatives, those data that, in our opinion, best represent the current snapshot of
In order to structure the material in a more logical manner, the reader will note
there has been some reorganization of the sequence of topics from previous
versions of the Compilation. For example, in order to provide a more complete
introduction of the Medicaid program to the reader, the overview of the
Medicaid program has been moved from Section 4 to Section 2. Also, since the
expanded drug programs are in addition to the standard Medicaid benefit
provided by each state, this information now appears as Section 6, located after
the profiles.
NPC gratefully acknowledges the cooperation and assistance of the many State
and Federal program officials and their staffs. With their cooperation, we were
able to achieve an 82 percent response rate to the 2002 Survey. Unfortunately,
not all States were able to submit revised/updated information. In such
instances, we have incorporated the most recently available data from other
sources. However, for these States, much of the information may reflect data
that have been presented in previous versions of the Compilation.
We would also like to thank Muse & Associates and their subcontractors,
Compensation Solutions and StateScape, for administering the survey, compiling
the information, and analyzing the data. We hope you continue to find the
information contained in this compilation useful and, as always, we welcome
your suggestions and comments.
Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council
SECTION 1:
IDENTIFYING MEDICAID
CHRONIC ILLNESS
POPULATIONS FOR CASE AND
DISEASE MANAGEMENT
PROGRAMS
Medicaid is the largest single health insurance program in the U.S. Total Medicaid spending was $202.4
billion in Federal Fiscal Year (FFY) 2000, which accounted for more than 15% of national health care
expenditures.1 Medicaid covered 44.3 million low-income children, their families, elderly people and
individuals with disabilities – approximately 15% of the U.S. population. The Medicaid program is
currently a major contributor to the fiscal crisis that many states are experiencing. It is second only to
education as a percentage of state budgets. Managing these very large programs and their budgets
requires an understanding of the forces that influence trends in Medicaid program spending. The purpose
of this section is to illustrate ways in which policy makers can identify high impact Medicaid groups as
the focus for case and disease management cost containment programs. High impact groups are groups
that are likely to show program savings when placed in case or disease management programs. We
believe that this method represents a significant tool for policy makers in their attempt to reduce program
costs without adversely affecting the Medicaid population’s access to quality care.
The analysis begins at the most aggregate level by an examination of overall Medicaid trends with
emphasis on the role of chronic illness in the growth of the program. This section builds on Section 1
from last year’s compendium in which Medicaid expenditures and the importance of chronic illness was
examined. We use the most recent data (2000) available from the Centers for Medicare and Medicaid
Services (CMS) for both expenditures and beneficiaries. We focus on one “typical” state, which allows
us to conduct the necessary in depth analysis.
SPENDING TRENDS
Overall, Medicaid expenditures have almost doubled in the last decade, from $108.2 billion in 1992 to
$202.4 billion in 2000; however, the spending growth rate has been affected by program changes during
this time period.2 As seen in Figure 1-1, the rate of growth dropped throughout most of the decade but
then started to rise in 1998. During the early to mid 1990’s, welfare reform, moderate growth of the
aged and disabled population, and an improved economy led to a reduction in spending growth; indeed,
all these led to changes in population size and mix effects. Also, increased use of managed care affected
utilization incentives and the supply of providers. More recently, just as in the private sector, Medicaid
expenditures have risen more rapidly. Among the most important factors explaining spending increases
is the increasing cost of providing care to elderly and disabled individuals.
$250 0.3
$202
$186 0.25
$200
$171
$160
$152 0.2
Growth Rate %
$144
$150 16.0% $134
Billions
$122
0.15
$100
$108 12.4% 7.4% 8.6% 8.8% 0.1
10.0% 7.7% 5.6%
$50 4.8%
0.05
$0 0
1992 1993 1994 1995 1996 1997 1998 1999 2000
Medicaid is the largest financier of health care in the United States in terms of number of beneficiaries.
In 2000, there were 44.3 million Medicaid beneficiaries.4 This represents an increase of about 66 percent
in the number of Medicaid recipients since 1991, when there were 28.3 million recipients.5 In the past, it
was automatically assumed that a person who was on welfare would qualify for the Medicaid program.
Besides the working poor and those on assistance, Medicaid coverage can be extended to low income
people who are elderly, blind, or disabled. In 2000, the majority of Medicaid funds, 69.7 percent of
expenditures, were spent on aged, blind, and disabled beneficiaries (who constitute only 24.8 percent of
persons served).6 In contrast, children made up 46.1 percent of the total beneficiaries in 2000, yet only
15.9 percent of all Medicaid expenditures went toward children.7 Figure 1-2 below shows the
disproportionate share of spending by the aged and disabled.
44.3 $168.3
100%
11.8
90%
Million
$117.2
80% Billion
70%
60%
32.5
50% Million
40%
30%
$51.1
20%
Billion
10%
0%
Beneficiaries Payments
* Figure 1-2 shows the 44.3 million Medicaid patients who received assistance, and the $168.3 billion in
expenditures, reflects the total Medicaid program costs when the expenses for items such as administration and
disproportionate share hospitals (DSH) are removed.
Because of the increasing burden of care for the elderly and disabled, long-term care services represent
the largest portion of Medicaid expenditures (Figure 1-3). These services include nursing facility
services, mental retardation facilities, and mental health institutions. Nursing facility services, the
largest component of the long-term care category, grew approximately 5.6 between FFY 1999 and FFY
2000.9 Spending for hospital and physician services rose only slightly and larger increases in spending
occurred for prescription drugs.
$60
1997
$50
44.2 44.3 45.6 1998
42.3
1999
$40
2000
Billions
$30
23.1 21.5 22.2 24.3 22.1 23.4
21.3 20.0
19.5
$20 16.6
12.0 13.5
$10
$0
Long Term Care^ Hospital - Physician† Prescription Drugs
Inpatient‡
* Excludes managed care payments; only major categories of spending are included
^ LTC (long-term care) = nursing facilities, mental health, and mental retardation facilities
‡ Direct payments for services
† Physician, dental, other practitioner, lab, clinic, EPSDT, outpatient hospital
Table 1-1 shows the total expenditures for prescription drugs for all Medicaid recipients in State X,
broken down by eligibility group. Again, it is the blind, disabled, and aged that consume the vast
majority of dollars in this category; 84.8 percent of the total when added together.
As Figure 1-4 demonstrates, the use of specific types of prescription drugs varies greatly among the
specific groups of beneficiaries. In Figure 1-4 “Antinfectives” include antibiotics,
“Antinfectives/Miscellaneous” include anti-parasitics, anti-virals (HIV/AIDS), fungicides, antiseptics,
etc.
30%
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20%
15%
10%
5%
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The next part of this section provides an analysis of chronic conditions that play a large role in
contributing to these increases in expenditures.
The purpose of this section is to focus on Medicaid Statistical Information System (MSIS) fee-for-
service data from one “typical” State and examine the importance of chronic diseases in Medicaid
spending. The diseases that were used for analysis were asthma, diabetes, hypertension, and depression
(ICD-9 codes were used to define the three medical conditions. Asthma = 490 - 496, diabetes = 250,
hypertension = 401- 405, and depression =296, 298.0, 300.4, 301.12, and 311). These diseases were
selected based on their incidence in the Medicaid population and their amenability to case and disease
management programs. The focus of our analysis is total Medicaid program costs for recipients with
these medical conditions.
The analysis utilizes MSIS data from one State we believe is a “typical” Medicaid State. The data cover
FFY 2000 & FFY 2001. MSIS data consists of four claims files and an eligibility file. The claims files
are inpatient, long-term care, prescription drug, and the “other” file. These files contain all claims paid
during each fiscal quarter. Obtaining the data required that a strict confidentiality agreement be signed
with the State. Hence, we will refer to “State X” as we show the results of the data analysis. A copy of
the data dictionary and a detailed overview of the MSIS files can be found at
http://cms.hhs.gov/medicaid/datasources.asp.
Based on the similarity of the State X and national distributions, we believe that State X is a reasonably
good proxy for what could be considered a “typical” Medicaid State. Although we cannot quantify the
analysis, we also looked at the eligibility, coverage and reimbursement policies of State X, including
their use of waivers. This analysis revealed no particularly unusual policies.
ANALYSIS
In an earlier section, we looked at some of the major trends in the Medicaid program. This section
outlines a methodology for examining the prevalence of chronic disease in the Medicaid fee-for-service
population and their total Medicaid program expenditures. To help assess the importance of chronic
illness in Medicaid growth and its potential for case and disease management programs, we asked the
following questions:
1. How many recipients had the chronic medical conditions of interest in State X?
2. What are the groups with these chronic diseases that appear to be most amenable to case and
disease management?
3. Can we identify particular groups that have high total and/or per capita expenditures where case
and disease management might have a high impact on expenditures?
The third part of the analysis involves our making particular judgments regarding who might be good
candidates for such programs. The methodology we propose makes these judgments based on our own
analytic experience and a considerable number of conversations with experts in the programmatic and
research areas. However, there may be many other methods – we propose just one method that identifies
recipients that suggest a closer look.
We start with the entire Medicaid population in State X and sequentially apply a series of screens that
remove Medicaid patients that may be less amenable to case and disease management than others. Once
we have limited the population due to those we feel are high impact recipients, we examine the potential
for one policy initiative in this final group. The process is summarized in Figure 1-5.
Figure 1-5: Flow Chart Depicting One Method of Identifying Beneficiaries with a Potential for
Disease Management in State X
MCO enrollees
88,712
$229 M
Cost/patient/yr: $1,611
Total Medicaid < 1 year eligibility
Population 203,901
$590 M
767,668 FFS enrollees Cost/patient/yr: $4,268
$5.7 B 678,956
Cost/patient/year: $5.5 B Medicare w/o full Medicaid
$5,113 Cost/patient/yr: $5,624 6,942
$10 M
Cost/patient/yr: $475
We started with the total Medicaid Population in State X, and sequentially eliminate populations. Each
of the steps is outlined below:
Step 2: Removed Medicaid recipients with less than a full year of Medicaid eligibility.
Rationale: Most policy options, in particular case and disease management programs, require that a
person be enrolled in them for at least six months, if not a full year. Enrolling persons with records
that show they migrate on and off the program would not be optimal for achieving the desired effects
and savings.
Step 3: We split the populations into those dually enrolled in Medicare and Medicaid and those with
Medicaid-only eligibility.
Rationale: Dual eligibles have high per capita spending. Although both populations have significant
expenditures, dual eligibles represent one of the most important potential high impact groups. The
MSIS data do not capture all claims for dual eligibles since Medicare is responsible for paying many
of their costs. Disease or case management efforts undertaken by Medicaid for this population
would likely benefit Medicare and cost Medicaid, so a waiver would need to be implemented to
make the undertaking mutually beneficial.
Step 4: Removal of patients over 75 years old, those in long term care facilities, and facilities for the
mentally retarded.
Rationale: Aged patients are more likely to become sick simply because of their advancing age.
Similarly, persons in institutions are very ill by definition and are covered by elaborate plan of care
requirements based on the Medicaid statute. In theory, the plan of care for each Medicaid recipient
would include a case or disease management program if that were deemed appropriate.
Step 5: The application of the screens resulted in 49.3 percent of total patient count being identified as
potential pool of patients for high impact cost savings. These patients had an average cost per patient per
year in Medicaid expenditures of $2,730. Table 1-3 shows the characteristics of the resultant group.
Another potential high impact groups that overlaps with this pool is the dually eligible recipients. The
method outlines here can also be used to identify this pool of patients.
The results in Table 1-3 show the high cost of chronic illness when four of the most prevalent diseases in
the Medicaid population in State X are examined through the filters shown in Figure 1-5.
Table 1-3: FFY 2000-2001 Summary of Primary Diagnosis Data for Selected Conditions in the
Medicaid Population of State X, and the Average Amount Spent on Each Patient Per Year
Disease
(Patients may have Number of Patients Medicaid $/patient/Year*
more than one disease)
Asthma/COPD 61,439 $ 5,506
Depression 33,589 $ 8,159
Hypertension 17,896 $ 12,033
Diabetes 10,623 $ 12,698
Unduplicated Total 95,794 $ 6,063
*Costs represent total for patients who have these diseases, not disease-specific costs
Table 1-4 shows the characteristics of recipients with chronic diseases who had nine or more unique
prescription drugs in 180 days and their costs. Unique prescriptions are defined as prescriptions for
unique compounds excluding refills, changes in strength, and generic equivalents.
Table 1-4: Patients with Nine or More Prescription Drugs in 180 Days
Disease
(Patients may have Number of Patients Medicaid $/patient/Year*
more than one disease)
Asthma/COPD 27,170 $ 9,737
Depression 16,921 $ 11,759
Hypertension 13,409 $ 14,231
Diabetes 8,639 $ 14,449
Total 42,632 $ 9,956
*Costs represent total for patients who have these diseases, not disease-specific costs
Of the beneficiaries who received nine or more prescriptions in 180 days, 39 percent were blind or
disabled, 40 percent were children, 20 percent were adults, and 1 percent aged with an average per
patient/per year cost of $8,742.
Table 1-5 repeats the analysis for Medicaid recipients who, in this case, received twenty or more unique
prescription drugs in 180 days. This group has much higher costs per patient per year than the
population with less prescription drug use.
Table 1-5: Patients with Twenty or More Prescription Drugs in 180 Days
Disease
(Patients may have Number of Patients Medicaid $/patient/Year*
more than one disease)
Asthma/COPD 5,985 $ 20,909
Depression 4,714 $ 19,437
Hypertension 5,111 $ 21,552
Diabetes 3,688 $ 21,443
Total 8,914 $ 20,093
*Costs represent total for patients who have these diseases, not disease-specific costs
Of the beneficiaries who received twenty or more prescriptions in 180 days, 76 percent were blind or
disabled, 6 percent were children, 15 percent were adults, and 3 percent were aged with an average per
patient / per year cost of $20,093.
States, such as Florida, which have focused on this population, have documented that case management
of these individuals identifies unnecessary utilization and that costs can be reduced.11
CONCLUSION
Against the backdrop of significant Medicaid growth over the last decade, this analysis indicates that a
large proportion of Medicaid expenditures are made for a small group of recipients who are chronically
ill, many of whom are amenable to case and disease management. We have demonstrated one way to
identify this high impact population. Clearly, other approaches exist. We believe that one way for
States to reduce potential overutilization and the resulting unnecessary expenditures in such groups is to
identify them using the methodology we have demonstrated and then explore different policy options
oriented toward case and disease management.
REFERENCES
1
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Historical
National Health Expenditures Tables, by Type of Service and Source of Funds: Calendar Years
1960-2001. available from http://www.cms.hhs.gov/statistics/nhe/historical/nhe01.zip; Internet.
2
Ibid.
3
Ibid.
4
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Table 4. Medicaid Beneficiaries, 2000. available from
http://cms.hhs.gov/medicaid/msis/00total.pdf; Internet.
5
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Table 1. Program Statistics, 1991, available from
http://cms.hhs.gov/medicaid/msis/mstats.asp; Internet.
6
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Tables 3 and 4. Medicaid Expenditures, and Medicaid Beneficiaries, 2000.
http://cms.hhs.gov/medicaid/msis/00total.pdf.
7
op. cit.: 1
8
Ibid.
9
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Table 5. Medicaid Expenditures by Type of Service for Maintenance Assistance Status and Basis
of Eligibility All States, 1999 & 2000. available from http://cms.hhs.gov/medicaid/msis/99total.pdf and
http://cms.hhs.gov/medicaid/msis/00total.pdf; Internet.
10
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Table 3. Medicaid Expenditures by Type of Service, 1999 and 2000 available from
http://cms.hhs.gov/medicaid/msis/99total.pdf and http://cms.hhs.gov/medicaid/msis/00total.pdf; and
Department of Health and Human Services. Centers for Medicare and Medicaid Services. Medicaid
Statistics, Table 10, Medicaid Medical Vendor Payments by Type of Service,1997 and 1998.
available from http://www.cms.gov/medicaid/msis/MCD97T10.pdf and
http://www.cms.gov/medicaid/msis/MCD98T10.pdf; Internet.
11
Medicaid Prescription Drug Spending Control Program Annual Report, State of Florida, Agency for
Health Care Administration, Jan. 2002, p. 23.
Section 2:
The Medicaid Program
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.”
• Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and
Disabled (this includes disabled children);
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.
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:
If a State chooses to include the “medically needy” population, the State Plan
must provide, as a minimum, the following services:
• Clinic services;
• Services of ICFs/MR;
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
• TB-related services for TB infected persons;
• Prosthetic devices; and
• Dental services.
States may provide home and community-based care waiver services to certain
individuals who are eligible for Medicaid. The services to be provided to these
persons may include case management, personal care services, respite care
services, adult day health services, homemaker/home health aide, habilitation,
and other services requested by the State and approved by CMS.
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):
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.
Other laboratory and X-ray services are professional and technical laboratory
and radiological services. These services must be:
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:
Screening:
• Comprehensive health and developmental history screening;
• Comprehensive unclothed physical examination;
• Appropriate vision testing;
• Appropriate hearing testing;
• Appropriate laboratory tests;
• Dental screening services furnished by direct referral to a dentist for children
beginning at 3 years of age.
Diagnosis and Treatment:
In addition to any diagnostic and treatment services included in the State
Medicaid Plan, the State must provide to eligible EPSDT recipients the
following services, the need for which is indicated by screening, even if the
services are not included in the Plan:
• Diagnosis of and treatment for defects in vision and hearing, including
eyeglasses and hearing aids;
• Dental care, at as early an age as necessary, needed for relief of pain and
infections, restoration of teeth and maintenance of dental health; and
• Appropriate immunizations. (If it is determined at the time of screening that
immunization is needed and appropriate to administer at the time of
screening, then immunization treatment must be provided at that time.)
The State Medicaid agency may provide for any other medical or remedial care
specified as a Medicaid service even if the agency does not otherwise provide for
these services to other recipients or provides for them in a lesser amount,
duration, or scope. This is an exception to the general rule that the amount,
duration, and scope of benefits must be the same for all categorically eligible
recipients, and reflects the importance attached to EPSDT services.
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.
FFP at the enhanced rate of 90 percent is also available for the cost of a
sterilization if a properly completed sterilization informed consent form, in
accordance with the requirements of 42 CFR Part 441, Subpart F, is submitted to
the State prior to payment of the claim.
FFP at the 90 percent rate is not available for the cost of a hysterectomy nor for
the costs related to other procedures performed for medical reasons, such as
removal of an intrauterine device due to infection. Only items and procedures
clearly provided or performed for family planning purposes may be matched at
the 90 percent rate. Transportation to a family planning service is not eligible
for the 90 percent match. Transportation must be claimed as either an
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
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:
Nurse-Midwife 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.
• The facility receives a grant under sections 329, 330, or 340 of the Public
Health Service Act;
• The Health Resources and Services Administration recommends, and the
HHS Secretary determines, that the facility meets the requirements of the
grant; or
• The Secretary determines that a facility may qualify through waivers of the
requirements. Such a waiver cannot exceed two years.
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.
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.
1. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
2. FY 2001 data have not been released for all states. Partial data are available in Appendix B.
*Hawaii did not report for FY 2000. Their FY 1999 data are used in this table.
Source: CMS, MSIS Report, FY 2000.
1. FY 2001 data have not been released for all states. Partial data are available in Appendix B.
*Hawaii did not report Medicaid eligibles for FY 2000. Their FY 1999 Medicaid eligibility data are used in this table.
Source: U.S. Department of Commerce, Bureau of the Census, Census 2000; CMS, MSIS, FY 2000.
100%
40%
53.6% 55.6% 55.8% 56.8% 57.6%
47.8%
20% 29.4%
40.1%
23.2%
14.4%
0%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for
Medicaid & State Operations. *Approximated numbers for 1995. Total Medicaid population was provided by the
Office of the Actuary, which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The managed
care population differs from the 11,619,929 reported in the 1995 report as the number represented enrollment of some
beneficiaries in more than one plan.
The most utilized of these plans are Comprehensive MCOs and Prepaid
Health Plans.
* Total number of enrollees includes 8,830,530 individuals enrolled in more than one managed care plan type. It also
includes individuals enrolled in State healthcare reform programs that expand eligibility beyond traditional Medicaid
eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for
Medicaid & State Operations.
The following tables provide an overview of Medicaid managed care enrollment at the State
level.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
“-” indicates Not Applicable, “N/A” indicates “No Answer” was received on the Survey.
Sources: As reported by State drug program administrators in the 2002 NPC Survey.
State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards.
*As of 2002, HealthMacs no longer participates in the Medicaid program in Mississippi.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1998; 1999; 2000; 2001 and 2002. DHHS, CMS, Center for Medicaid
& State Operations.
HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only Managed Care
Organization; PCCM=Primary Care Case Management; PHP=Prepaid Health Plan.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.
* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number
of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals
enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.
Individual State totals will not sum to total managed care enrollment (page 2-5) because State totals include individuals enrolled in more than one plan type
including dental, mental, and long-term care.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.
Section 1915(b) waivers are granted to give States the authority to conduct
Medicaid programs outside of the scope of the Medicaid statute, allowing them
to waive freedom of choice, statewide access to care, and comparability
requirements under Section 1902 of the Social Security Act. With a 1915(b)
waiver, a State can require mandatory enrollment of Medicaid recipients in
managed care plans. Section 1915(b) waivers cannot negatively impact
beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver).
Section 1915(b) waivers are typically limited to a targeted geographical area or
population, are approved for an initial period of two years, and can be renewed
in two-year increments if the State reapplies.
• Paragraph (b) (1) - Case Management: States are allowed to implement case
management systems which can be as simple as requiring each beneficiary to
choose a primary care provider or as comprehensive as mandating enrollment in
a prepaid health plan.
• Paragraph (b) (2) - Central Broker: Localities are allowed to act as a central
broker in assisting Medicaid eligibles in selecting among competing health care
plans, if such a restriction does not substantially impair access to medically
necessary services of adequate quality.
• Paragraph (b) (3) - Shared Cost Saving: States are allowed to share (through
provision of additional services) cost savings (resulting from use by the recipient
of more cost-effective medical care) with recipients of medical assistance under
the State Plan.
• Paragraph (b) (4) - Restrict Providers: States can limit the number of providers
of certain services. These waivers are sometimes referred to as selective
contracting waivers and are gaining in popularity. Recently approved 1915(b)(4)
waivers included programs to restrict the number of providers of transportation
services, organ transplants, and inpatient obstetrical care.
Refer to the table on page 2-13 for a listing of 1915(b) waivers.
benefits package. In order to expand their Medicaid programs even further than
under Section 1915(b) waivers, States apply for Section 1115 research and
demonstration waivers.
Section 1115 research and demonstration waivers release States from standard
Medicaid requirements, allowing them the flexibility to test substantially new
ideas of policy merit. Along with Section 1915(b) waivers, Section 1115 waivers
allowed States to waive freedom of choice, statewide access to care, and
comparability requirements. However, a Section 1115 waiver also allow States to
provide new and additional services, test new payment methods, offer benefits to
new and expanded populations, and contract with managed care organizations that
did not meet the necessary criteria of Section 1903 of the Social Security Act.
Currently, there are 17 Medicaid programs with Section 1115 waiver approvals:
Arizona, Arkansas, California, Delaware, Hawaii, Kentucky, Maryland,
Massachusetts, Minnesota, Missouri, New York, Oklahoma, Oregon, Rhode
Island, Tennessee, Vermont and Wisconsin. Refer to the table on page 2-34 for a
listing of implemented Section 1115 waivers.
1915(b) Statutes
State Program(s) Approved Utilized Implemented Expiration
st
Alabama Patient 1 1, 3, 4 01/1/97 12/26/02
Alaska 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 7/29/03
Central Coast Alliance for Health 1, 4 1/1/96 6/2/03
Health Plan of San Mateo 1, 4 11/30/87 8/26/04
Hudman 4 4/24/92 7/15/03
Managed Care Network 1, 2, 4 3/1/97 5/18/03
Medi-Cal Mental Health Care Field Test 4 4/1/95 7/29/03
Medi-Cal Specialty Mental Health Services Consolidation 4 3/15/95 11/19/02
California
Partnership Health Plan of California 1, 4 5/1/94 2/10/03
Primary Care Case Management Program 1, 4 8/1/84 2/4/04
Sacramento Geographic Managed Care 1, 2, 4 4/1/94 11/10/02
San Diego Geographic Managed Care 1, 2, 4 10/17/98 10/10/03
Santa Barbara Health Initiative 1, 4 9/1/83 1/11/03
Selective Provider Contracting Program 4 9/21/82 10/31/02
Two-Plan Model Program 1, 2, 4 1/23/96 11/8/03
Managed 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 5/30/04
Delaware 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 9/26/04
Florida Prepaid Mental Health Plan 1, 4 3/1/96 6/30/03
Statewide Inpatient Psychiatric Program 4 4/1/99 12/31/03
Georgia Better Health Care 1 10/1/93 3/14/03
Georgia Non-Emergency Transportation Broker Program 4 10/1/97 9/7/03
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 9/21/04
Illinois None -- -- --
Indiana Hoosier Healthwise 1 7/1/94 4/23/03
Iowa Iowa Plan for Behavioral Health 1, 3, 4 1/1/99 2/28/03
KMMC: HealthConnect Kansas 1, 2, 4 1/1/84 10/4/02
Kansas
KMMC: HealthWave 19 1, 2, 4 12/1/95 10/4/02
Kentucky Human Service Transportation 1, 4 6/1/98 3/7/03
Louisiana Community Care 1 6/1/92 3/25/03
Maine None -- -- --
Maryland None -- -- --
Massachusetts None -- -- --
Michigan Comprehensive Health Care 1, 2, 4 7/1/97 9/24/04
1915(b) Statutes
State Program(s) Approved Utilized Implemented Expiration
Specialty Community Mental Health Services Programs 1, 4 10/1/98 3/13/03
Minnesota Consolidated Chemical Dependency Treatment Fund 1, 4 1/1/88 3/23/03
Mississippi None -- -- --
Missouri MC+ Managed Care/1915(b) 1, 2, 4 9/1/95 3/14/04
Montana Passport to Health 1, 2 1/1/94 4/24/04
Nebraska Nebraska Health Connection Combined Waiver Program 1, 2, 3, 4 7/1/95 10/31/02
Nevada None -- -- --
New Hampshire None -- -- --
New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 9/30/02
New Mexico SALUD! 1,4 7/1/97 10/21/02
New York Non-Emergency Transportation 1, 4 7/1/96 11/14/02
ACCESS II /III1915(b) 1 7/1/98 11/08/02
North Carolina Carolina Access 1915(b) 1 4/1/91 11/08/02
Health Care Connection 1915(b) 1 7/1/96 11/08/02
North Dakota None -- -- --
Ohio PremierCare 1, 2, 4 7/1/01 6/30/03
Oklahoma None -- -- --
Oregon Transportation Program 4 9/1/94 7/25/03
Family Care Network 1 2/1/94 6/16/04
Pennsylvania
HealthChoices 1, 2, 3, 4 2/1/97 6/16/04
Puerto Rico None -- -- --
Rhode Island None -- -- --
South Carolina None -- -- --
South Dakota Prime 1 9/1/93 9/28/02
Tennessee None -- -- --
Lonestar Select I 4 9/1/94 9/3/04
Lonestar Select II 4 3/10/95 3/4/04
Texas NorthSTAR 1, 2, 4 11/5/03
11/1/99
STAR 1, 2, 3, 4 8/1/93 8/31/03
STAR Plus 1, 2, 3, 4 1/1/98 8/31/04
Choice of Health Care Delivery 1, 2, 4 7/1/82 7/23/03
Utah Non-Emergency Transportation 1, 4 7/1/01 9/18/04
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 12/26/02
Healthy Options 1, 4 10/1/93 2/24/03
Washington
The Integrated Mental Health Services 1, 4 7/1/93 11/4/04
Mountain Health Trust 1, 4 9/1/96 12/22/04
West Virginia
Physician Assured Access System 1 6/1/92 4/27/04
Wisconsin None -- -- --
Wyoming None -- -- --
Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002. Centers for
Medicare and Medicaid Services, Center for Medicaid & State Operations.
Section 3:
State Characteristics
STATE CHARACTERISTICS
The data in Section 3 have been compiled from a myriad of sources. These
include:
• CMS
• The U.S. Bureau of the Census
• The Bureau of Labor Statistics (BLS)
• The Health Resources and Services Administration (HRSA)
• The National Association of Boards of Pharmacy.
Because of the unevenness with which the various government agencies and
other organizations have released updated information, we have carefully
reviewed all possible information sources and made judgments on which data to
present. In the final analysis, we have included those data that, in our opinion,
best reflect the factors and characteristics on which we have reported. However,
certain limitations in the different sources have resulted in some inconsistencies
among the tables. The following examples illustrate this problem.
The table showing the age distribution of the population is derived from the 2001
Current Population Survey conducted by the U.S. Bureau of the Census. It is the
only 2001 age breakout on a State-by-State basis that the Bureau had released
while data collection for the 2002 Compilation was ongoing. Unfortunately, the
approximately 5 million individuals residing in “group quarters” were not
included. Hence, the total population figure (and the corresponding figures for
each State) presented in this table is lower than the population total in the table
showing insurance status.
The data on insurance status was compiled from the March Supplement to the
Current Population Survey, a collaborative effort by the Census Bureau and
BLS. Hence, the estimates on the number of Medicare and Medicaid
beneficiaries differ slightly from those published by CMS.
Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile.
LEGEND
Physicians, 2001
Physicians Office Based Percent Primary Care Percent
State Physicians Per 1,000 Pop. Physicians Office Based Physicians* Primary Care
National Total 727,573 2.6 484,184 66.55% 229,277 31.51%
Alabama 9,127 2.1 6,565 71.93% 3,092 33.88%
Alaska 1,273 2.1 924 72.58% 469 36.84%
Arizona 10,479 2.0 7,558 72.13% 3,198 30.52%
Arkansas 5,164 2.0 3,759 72.79% 1,868 36.17%
California 86,395 2.6 60,311 69.81% 27,535 31.87%
Colorado 10,434 2.4 7,581 72.66% 3,316 31.78%
Connecticut 12,150 3.7 7,672 63.14% 3,612 29.73%
Delaware 1,894 2.5 1,298 68.53% 585 30.89%
District of Columbia 4,222 7.9 1,989 47.11% 1,033 24.47%
Florida 38,785 2.4 29,026 74.84% 11,621 29.96%
Georgia 17,798 2.2 12,428 69.83% 5,545 31.16%
Hawaii 3,461 2.9 2,443 70.59% 1,093 31.58%
Idaho 2,069 1.6 1,706 82.46% 713 34.46%
Illinois 33,211 2.7 21,072 63.45% 11,231 33.82%
Indiana 12,242 2.1 8,878 72.52% 4,159 33.97%
Iowa 5,197 1.8 3,614 69.54% 1,819 35.00%
Kansas 5,741 2.2 4,015 69.94% 2,020 35.19%
Kentucky 8,656 2.2 6,314 72.94% 2,852 32.95%
Louisiana 11,386 2.6 7,607 66.81% 3,344 29.37%
Maine 3,140 2.5 2,288 72.87% 1,084 34.52%
Maryland 21,656 4.1 12,242 56.53% 5,889 27.19%
Massachusetts 26,916 4.4 15,074 56.00% 7,625 28.33%
Michigan 23,034 2.4 14,595 63.36% 7,359 31.95%
Minnesota 12,917 2.7 8,780 67.97% 4,731 36.63%
Mississippi 4,931 1.8 3,580 72.60% 1,580 32.04%
Missouri 13,120 2.4 8,412 64.12% 3,898 29.71%
Montana 1,878 2.1 1,550 82.53% 632 33.65%
Nebraska 3,893 2.3 2,667 68.51% 1,430 36.73%
Nevada 3,603 1.7 2,823 78.35% 1,124 31.20%
New Hampshire 3,011 2.5 2,163 71.84% 985 32.71%
New Jersey 25,410 3.1 16,903 66.52% 8,050 31.68%
New Mexico 4,059 2.3 2,689 66.25% 1,328 32.72%
New York 73,115 4.0 40,675 55.63% 22,101 30.23%
North Carolina 19,177 2.4 13,082 68.22% 6,000 31.29%
North Dakota 1,464 2.4 1,061 72.47% 561 38.32%
Ohio 27,579 2.5 18,246 66.16% 8,963 32.50%
Oklahoma 5,854 1.7 4,180 71.40% 1,964 33.55%
Oregon 8,027 2.4 6,000 74.75% 2,707 33.72%
Pennsylvania 36,150 3.0 22,952 63.49% 10,883 30.11%
Rhode Island 3,515 3.4 2,114 60.14% 1,108 31.52%
South Carolina 8,851 2.3 6,243 70.53% 2,869 32.41%
South Dakota 1,530 2.1 1,170 76.47% 560 36.60%
Tennessee 14,185 2.5 9,964 70.24% 4,502 31.74%
Texas 43,548 2.1 29,928 68.72% 13,144 30.18%
Utah 4,556 2.0 3,199 70.22% 1,399 30.71%
Vermont 2,032 3.4 1,271 62.55% 724 35.63%
Virginia 18,487 2.7 12,393 67.04% 5,847 31.63%
Washington 14,656 2.5 10,533 71.87% 4,926 33.61%
West Virginia 4,067 2.3 2,715 66.76% 1,403 34.50%
Wisconsin 12,645 2.4 9,234 73.02% 4,463 35.29%
Wyoming 883 1.8 698 79.05% 333 37.71%
*Primary care physicians include General Practice, General Family Practice, General Internal Medicine, and General Pediatrics
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File, February 2002.
Other Providers
Registered Nurses* Pharmacists** Pharmacists**
State Registered Nurses* per 1,000 (Licensed by State) per 1,000
National Total 2,021,813 7.8 352,727 1.3
Alabama 34,073 7.7 6,879 1.6
Alaska 4,914 7.8 577 0.9
Arizona 32,222 6.3 7,687 1.5
Arkansas 18,752 7 3,506 1.3
California 184,329 5.4 30,845 0.9
Colorado 31,695 7.4 5,317 1.2
Connecticut 32,073 9.4 4,393 1.3
Delaware 7,337 9.4 1,314 1.7
District of Columbia 9,583 16.8 1,564 2.9
Florida 125,439 7.8 20,052 1.3
Georgia 55,881 6.8 10,534 1.3
Hawaii 8,518 7 1,449 1.2
Idaho 8,230 6.4 1,530 1.2
Illinois 101,660 8.2 13,151 1.1
Indiana 46,244 7.6 8,597 1.4
Iowa 31,020 10.6 4,993 1.8
Kansas 23,779 8.8 3,494 1.3
Kentucky 33,655 8.3 4,746 1.2
Louisiana 37,275 8.3 5,839 1.3
Maine 13,072 10.3 1,267 1.0
Maryland 45,323 8.6 6,937 1.3
Massachusetts 75,795 11.9 9,940 1.6
Michigan 79,353 8 11,322 1.2
Minnesota 47,102 9.6 5,853 1.2
Mississippi 21,338 7.5 3,483 1.3
Missouri 53,730 9.6 7,123 1.3
Montana 7,327 8.1 1,463 1.7
Nebraska 16,399 9.6 2,555 1.5
Nevada 10,384 5.2 8,012 3.9
New Hampshire 11,321 9.2 1,886 1.5
New Jersey 67,280 8 16,245 2.0
New Mexico 11,932 6.6 2,434 1.4
New York 160,009 8.4 18,448 1.0
North Carolina 69,057 8.6 9,397 1.2
North Dakota 7,039 11 2,089 3.4
Ohio 100,144 8.8 14,250 1.3
Oklahoma 21,905 6.3 4,713 1.4
Oregon 27,121 7.9 4,079 1.2
Pennsylvania 123,997 10.1 17,439 1.5
Rhode Island 11,542 11 1,788 1.8
South Carolina 29,226 7.3 5,052 1.3
South Dakota 8,511 11.3 1,401 1.9
Tennessee 49,626 8.7 7,388 1.3
Texas 126,436 6.1 20,803 1.0
Utah 13,229 5.9 1,546 0.7
Vermont 5,829 9.6 830 1.4
Virginia 50,359 7.1 8,438 1.2
Washington 43,482 7.4 6,718 1.1
West Virginia 15,523 8.6 2,975 1.7
Wisconsin 47,895 8.9 5,737 1.1
Wyoming 3,849 7.8 1005 2.1
*As of March 2000. ** As of June 30, 2002.
Source: U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions,
Division of Nursing, February 2001 and 2002-2003 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
Section 4:
Pharmacy Program
Characteristics
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
• 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 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
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.
1
Rebates have not been subtracted from these figures.
1
Rebates have not been subtracted from these figures.
1
Rebates have not been subtracted from these figures.
1
Percentages are based on figures that have not had rebates subtracted from them.
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Due to inconsistencies, Vermont data are not included in this table.
Source: CMS, State Drug Utilization Data, FY 2001.
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Due to inconsistencies, Vermont data are not included in this table.
Source: CMS, State Drug Utilization Data, FY 2001.
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Due to inconsistencies, Vermont data are not included in this table.
Source: CMS, State Drug Utilization Data, FY 2000.
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
* 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.
*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2002 NPC Survey. 2
CMS, CMS-64 Report, FY 2001.
*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, HCFA-64 Report, FY 1997-FY 2001.
*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, CMS-64 Report, FY 1996 – FY 2001.
*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, CMS-64 Report, FY 2001
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 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
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.
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.
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.
• 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
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.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA = Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization, DME = Durable Medical Equipment
Source: As reported by State drug program administrators in the 2002 NPC Survey.
Coverage of Injectables
Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children
Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
**Reviewer also includes Medical Claims Examiner.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered, PA Required Covered
Alaska Covered Covered, PA Required Not Covered
Arizona* - - -
Arkansas Covered Partial Coverage, PA Required Not Covered
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Covered Not Covered
District of Columbia N/A N/A N/A
Florida Covered Covered Partial Coverage
Georgia Covered, PA Required Covered, PA Required Not covered
Hawaii Covered, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Idaho Covered, PA Required Covered, PA Required Not Covered
Illinois N/A Covered Not Covered
Indiana** N/A N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Partial Coverage, PA Required
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered Covered, PA Required Partial Coverage
Maine Covered Covered, PA Required Covered, PA Required
Maryland Covered Covered Not Covered
Massachusetts Covered Partial Coverage, PA Required Not Covered
Michigan Not Covered Covered Not Covered
Minnesota Covered Covered, PA Required Not Covered
Mississippi Covered Covered, PA Required Not Covered
Missouri Covered Covered Not Covered
Montana Covered Partial Coverage, PA Required Partial Coverage, PA Required
Nebraska Covered Partial Coverage, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered Covered, PA Required
New Jersey Partial Coverage Covered PA for ADD Diagnosis
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered Covered
North Dakota Covered Covered Partial Coverage, PA Required
Ohio Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Oklahoma Not Covered Covered, PA Required Not Covered
Oregon Covered Covered Covered
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered Covered, PA Required
South Carolina Covered Covered Covered
South Dakota Covered Covered Covered
Tennessee* - - -
Texas Covered Covered Not Covered
Utah Partial Coverage, PA Required Covered Covered, PA Required
Vermont Covered Covered Covered
Virginia Not Covered Partial Coverage Partial Coverage, PA Required
Washington Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
West Virginia Covered Partial Coverage, PA Required Not Covered
Wisconsin Covered Covered, PA Required Covered
Wyoming Not Covered Covered, Some require PA Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
** All coverage in accordance with OBRA'90 and OBRA'93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*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
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*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
Source: As reported by State drug program administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
PRODUR = Prospective Drug Utilization Review System
Source: As reported by State drug program administrators in the 2002 NPC Survey.
Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 30 day supply per Rx
Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics
Arizona* - -
Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month, maximum 100 day supply for most medications
Colorado Yes 30 day quantity supply per Rx; 100 day supply for maint. meds. Other limits for stadol & oxycontin
Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds
Florida Yes 4 brand name Rxs per month (with exceptions)
Georgia Yes 31 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override)
Hawaii Yes 30 day supply or 100 unit doses/50# gms per Rx
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control
Illinois Yes Medically appropriate monthly quantity
Indiana Yes 34 day supply for maintenance drugs
Iowa No Maximum 30 day supply except select maintenance drugs (90 days)
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per
recipient per month
Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription
Maryland Yes 34 day supply per Rx; 2 refills per Rx
Massachusetts Yes Maximum 5 refills per prescription
Michigan Yes 100 day supply, No refills for Schedule II drugs; Schedule III & V, 5 refills per 180 days
Minnesota Yes Max 3 month supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum
Missouri Yes 34 day supply or 100 unit doses; up to 90 day per Rx maximum
Montana Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications.
New Hampshire Yes 30 day supply, 90 day supply on maintenance medications
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No 34 day supply, except contraceptives (100 days)
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 34 day supply per Rx, with exceptions; 6 Rx per month
North Dakota Yes 34 day supply per Rx; max 12 refills per script; one refill on PPIs
Ohio Yes 34 day supply (acute) and 102 unit doses (chronic)
Oklahoma Yes 3 Rx per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 15 day supply for initial Rx for chronic conditions
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override)
South Dakota No -
Tennessee* - -
Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills
Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx
Virginia No 34 day supply per Rx
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 34 day supply; 5 refills per Rx with quantity limits on some drugs
Wisconsin Yes 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period
Wyoming No Quantity limits on some medications as deemed clinically appropriate.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
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:
While emergency services are excluded from cost sharing, States may apply for
waivers of nominal amounts for non-emergency services furnished in hospital
emergency rooms. Such a waiver allows States to impose a copayment amount
up to twice the current maximum for such services. Approval of a waiver request
by CMS is based partly on the State’s assurance that recipients will have access
to alternative sources of care.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
Mandatory Substitution
Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost
State Generic Substitution Multi-Source Required Multi-Source Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas No Yes No
California No No Yes
Colorado No No No
Connecticut $0.50 No No
Delaware No - -
District of Columbia No No Yes
Florida No Yes No
Georgia $0.50 Yes (brand PA required) No
Hawaii No Yes (if AB rated & not against State law/regs) No
Idaho No Yes No
Illinois No No Yes
Indiana No Yes Yes
Iowa No Yes Yes
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland No Yes Yes
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes No
Mississippi No Yes No
Missouri No No No
Montana No Yes No
Nebraska No No No
Nevada No Yes No
New Hampshire No Yes No
New Jersey No Yes No
New Mexico No No Yes
New York $1.00 Yes No
North Carolina No Yes Yes
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes No
South Dakota $10.00 No No
Tennessee* - - -
Texas No Yes No
Utah No Yes No
Vermont No Yes No
Virginia No Yes No
Washington No Yes No
West Virginia No Yes No
Wisconsin No Yes No
Wyoming No Yes No
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.
Source: 12001-2002 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug program
administrators in the 2002 NPC Survey.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002# NPC Survey.
Section 5:
State Pharmacy Program
Profiles
Section 6:
State Pharmacy
Assistance Programs
New
Senior Prescription Drug Discount Program 2000
Hampshire
Pharmaceutical Assistance to the Aged and Disabled
1975
New Jersey (PAAD)
Senior Gold Prescription Discount Program 2001
Senior Prescription Drug Program 2002†
New Mexico
Prescription Drug Waiver Program 2003†
Elderly Pharmaceutical Insurance Coverage (EPIC)
New York 1987
Program
Prescription Drug Assistance Program 1999
North Carolina
Senior Care (formerly Carolina CaRxes) 2001
Ohio Golden Buckeye Prescription Drug Program 2002†
Oregon Senior Prescription Drug Assistance Program 2001†
Pharmaceutical Assistance Contract for the Elderly
1984
Pennsylvania (PACE)
PACE Needs Enhancement Tier (PACENET) 1996
Rhode Island Pharmaceutical Assistance to the Elderly
Rhode Island 1985
(RIPAE)
South Carolina SilveRxCard Senior Prescription Drug Program 2000
South Dakota Senior Citizen Prescription Drug Program 2003
Texas State Prescription Drug Program 2001†
VSCRIPT 1989
VSCRIPT Expanded 1999
Vermont
Vermont Health Access Plan (VHAP) 1996
Healthy Vermonters Program 2002†
West Virginia Gold Mountaineer Discount Card Program 2000
Wisconsin SeniorCare Prescription Drug Assistance
Wisconsin 2001
Program
Wyoming Prescription Drug Assistance Program 2002
The following pages provide profiles of the State pharmacy assistance programs.
Details were provided by State contacts on program characteristics, including
eligibility criteria, funding and reimbursement information, and drug coverage.
Supplemental information was obtained from special surveys of State programs in
addition to the National Conference of State Legislatures (NCSL) website,
http://www.ncsl.org/programs/health/drugaid.htm, a good source for the most up-to-
date information.
Arizona
Prescription Medication Coverage Pilot Program
Program Type: Discount
Law Enacted: 2001∗
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All FDA-approved drugs purchased within the U.S.
Drug Coverage Restrictions: Only FDA-approved drugs purchased within the U.S.
PROGRAM CONTACT
∗
This program has not been implemented because funding for the program was repealed in a special budget session. The law
creating the program is set to expire on October 1, 2003.
Arizona
Arizona Prescription Discount Program
Program Type: Discount
Year Operational: 2003
Projected Number of Recipients: 600,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Arkansas
ARx Senior Program
(Formerly Prescription Drug Access Improvement Act)
Program Type: Direct Assistance (1115 Waiver)
Law Enacted: 2001∗
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund and Federal matching funds
Budget: Not Available
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Not Available
Enrollment Fee: $25.00 per year
Deductible Amount: None
Copayment Amount: $10.00 for generic drugs and $20.00 for brand-name drugs
Dispensing Fee: Not Available
DRUGS COVERAGE
PROGRAM CONTACT
∗
Program implementation is contingent upon CMS approval of 1115 waiver application. As of December 2002, no
communications from CMS had been received. As a result, no projected implementation date for this program was available at the
time of publication.
California
Discount Prescription Medication Program
Program Type: State-Negotiated Discounts
Year Operational: 2000
Estimated Eligibles (November 2002): 1.3 million
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income levels Eligible Income Level (Married): All income levels
Other Eligibility Notes: Program covers pharmaceuticals not covered by a private insurer. Anyone who
has a Medicare card is eligible.
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs and compound drugs not covered
PROGRAM CONTACT
∗
Price inquires do not always result in sales because customers may elect not to purchase a pharmaceutical once its price has been
quoted.
California
Golden Bear State Pharmacy Assistance Program
Program Type: State-Negotiated Discounts
Projected Operational Date: not available*
Estimated Eligibles (November 2002): 1 to 3 million
ELIGIBILITY CRITERIA
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.
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Prescription drugs for which the State has negotiated manufacturer
discounts that supplement the Medi-Cal discount already mandated
under the California Discount Prescription Medication Program.
Drug Coverage Restrictions: Only prescription drugs with manufacturer-negotiated discounts.
PROGRAM CONTACT
Connecticut
Pharmaceutical Assistance Contract to the Elderly and Disabled
(ConnPACE)
Program Type: Direct Assistance
Year Operational: 1986
Number of Recipients (January 2003): 50,037
(Elderly: 43,193; Disabled: 6,844)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Delaware
Nemours Health Clinic Pharmaceutical Assistance Program
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (November 2002): 8,616
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Due to severe budgetary constraints, covered drugs are chosen
individually, based on physician recommendations.
Drug Coverage Restrictions: As many recommended drugs as allowed by the budget are purchased
and made available to enrollees.
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply.
PROGRAM CONTACT
Delaware
Prescription Drug Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (December 2002): 5,510
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: Open
Drugs Covered: Same as Medicaid (medically necessary prescription drugs)
Drug Coverage Restrictions: Only drugs from manufacturers that agree to participate in State rebate
program.
PROGRAM CONTACT
Florida
Silver SaveRx∗
Program Type: Direct Assistance (1115 waiver)
Year Operational: 2002
Number of Enrollees (May 2003): 46,312
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund, Federal matching funds, and
manufacturer rebates
Budget (FY 03): $109.0 million
Cost per Enrollee : Not Available
# of Rx’s Per Enrollee: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13.25%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the preferred
drug list, and $15.00 for brand name drugs not on the preferred drug
list
Dispensing Fee: $4.23
Notes: Enrollees receive a cash benefit of up to $160.00 per month.
DRUGS COVERAGE
PROGRAM CONTACT
∗
On August 1, 2002, Florida replaced its state-funded Pharmaceutical Expense Assistance Program with the Ron Silver Senior Drug
Program, now known as the Silver SaveRx.
Florida
Medicare Prescription Discount Program∗
Program Type: Discount
Year Operational: 2000
Estimated Participants: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Anyone who has a Medicare card is eligible.
DRUGS COVERAGE
Formulary: None
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: None
PROGRAM CONTACT
∗
By law Florida pharmacies are required to provide this discount in order to participate in Medicaid.
Hawaii
Hawaii Rx
Program Type: Direct Discount
Projected Operational Date: July 1, 2004
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Open to all Hawaii residents, regardless of income.
DRUGS COVERAGE
PROGRAM CONTACT
Hawaii
Medicaid Prescription Drug Expansion Program
Program Type: Direct Discount
Projected Operational Date: Not Available*
Projected Number of Recipients: Not Available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 300 % FPL Eligible Income Level (Married): 300% FPL
Other Eligibility Notes:
DRUGS COVERAGE
PROGRAM CONTACT
*
Not yet operational. Program is comparable to Maine Rx program, which U.S. Supreme Court ruled could go into effect (May 19,
2003, see laws.findlaw.com/us/000/01-188.html for full text of ruling).
Illinois
Pharmaceutical Assistance Program, “Circuitbreaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (May 2003): 57,444
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: Preferred product formulary
Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease, Parkinson’s
disease, glaucoma, lung disease and smoking-related diseases, cardiovascular,
arthritis, diabetes, and osteoporosis
Drug Coverage Restrictions Participants are able to receive brand-name drugs even if generics are
available provided the doctor marks “dispense as written” on the prescription
and the drug is classified as a “Narrow Therapeutic Index Drug.”
PROGRAM CONTACT
Susan Rohrer Phone: 217/785-5905
Illinois Department of Revenue Fax: 217/524-9213
P.O. Box 19021 E-mail: srohrer@revenue.state.il.us
Springfield, IL 62794-9021
Illinois
Illinois Rx SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (May 2003): 170,482
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Illinois
Senior Citizens and Disabled Persons Prescription Drug Discount
Program
Program Type: Discount
Projected Operational Date: 2003
Projected Number of Recipients: not available
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): all ages
Eligible Income Level (Single): all Eligible Income Level (Married): all
Other Eligibility Notes: Circuitbreaker participants will be automatically enrolled
DRUGS COVERAGE
Formulary: Not available
Drugs Covered: Not available
Drug Coverage Restrictions: Not available
PROGRAM CONTACT
Indiana
Indiana Prescription Drug Program, “HoosierRx”
Program Type: Point of Sale
Year Operational: 2000
Number of Recipients (May 2003): 14,156
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible
Eligible Income Level (Single): 144% of FPL Eligible Income Level (Married): 135% of FPL
Other Eligibility Notes: Must be an Indiana resident for at least 90 days in the past 12 months,
without prescription drug coverage through an insurance plan,
Medicaid or Medicaid with a spend-down. Benefit is available for one
year. Recipients must submit a new application to re-enroll.
DRUGS COVERAGE
Formulary: None
Drugs Covered: All legend drugs, as well as insulin
Drug Coverage Restrictions: OTC drugs, fertility enhancement drugs and cosmetic drugs
PROGRAM CONTACT
Lola Sawyerr Phone: 317/233-0587
HoosierRx Fax: 317/232-7382
Family & Social Services Administration Email: lsawyerr@fssa.state.in.us
402 W. Washington Street
W-386, MS-07
Indianapolis, IN 46204-2739
Iowa
Iowa Priority Prescription Savings Program
Program Type: Negotiated Discount
Year Operational: 2002
Number of Enrollees (December 2002): 25,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): See notes Eligibility Age (Disabled): See notes
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Open to all Medicare eligibles. Medicaid recipients are not eligible.
DRUGS COVERAGE
Formulary: Preferred drug list
Drugs Covered: Allergy (antihistamines, nasal steroids), cholesterol lowering agents,
dermatological products (topical steroids), hypertension/high blood
pressure and cardiovascular (ACE inhibitors, alpha/beta blockers,
angiotensin receptor blockers, potassium supplements, nitrates),
diabetes (biguanides), arthritis and analgesia (COX-2 inhibitors),
asthma (Beta-2 agonists, leukotiene blockers), enlarged prostate
treatment, osteoporosis treatment, glaucoma
Drug Coverage Restrictions: None
PROGRAM CONTACT
David Fries Phone: 515/327-5405, ext. 203
Iowa Prescription Drug Corporation Fax: 515/327-5422
1231 8th Street, Suite 232 Email: info@iowapriority.org
West Des Moines, IA 50265
Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (September 2002): 1,286
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare, and
prescription drugs that treat chronic illness
Drug Coverage Restrictions: Program does not cover over-the-counter and lifestyle drugs.
PROGRAM CONTACT
Maine
Maine Rx
Program Type: Discount
Law Enacted: 2000∗
Estimated Eligibles (FY 02): Approximately 325,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: All Maine residents who do not have third-party drug coverage are
eligible.
DRUGS COVERAGE
PROGRAM CONTACT
∗
On May 19, 2003, the U.S. Supreme Court ruled the Maine Rx Program could go into effect (see laws.findlaw.com/us/000/01-
188.html for full text of ruling). At press time, however, it is anticipated that MaineRx will be abandoned and replaced by MaineRx
Plus.
Maine
Maine Rx Plus
Program Type: Discount
Law Enacted: 2003∗
Estimated Eligibles: Approximately 275,000
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): $31,400 Eligible Income Level (Married): $42,420
(350% FPL) (350% fPL)
Other Eligibility Notes: Discounts would also be extended to families whose prescription drug
costs are at least 5% of their household income or whose medical
expenses are at least 15% of their household income.
DRUGS COVERAGE
PROGRAM CONTACT
∗
On May 19, 2003, the U.S. Supreme Court ruled the Maine Rx Program could go into effect (see laws.findlaw.com/us/000/01-
188.html for full text of ruling). At press time, however, it is anticipated that MaineRx Plus will replace MaineRx.
Maine
Healthy Maine Prescription Drug Program
Program Type: Subsidy and Discount (1115 Waiver)±
Year Operational: 2001
Number of Recipients (September 2002): 115,000 (36,000 subsidy and 79,000 discount)
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL
Other Eligibility Notes: All Maine residents with incomes up to 300% of FPL are eligible.
Individuals with full Maine Care benefits are not eligible. It is
estimated that 225,000 residents are eligible for the Healthy Maine
Program.
DRUGS COVERAGE
PROGRAM CONTACT
±
Discount program struck down by federal court 12/24/02
∗
This budget is allocated for both Healthy Maine and the Maine Low Cost Drugs for the Elderly and Disabled Program (DEL).
Maine
Low Cost Drugs for the Elderly and Disabled Program (DEL)∗
Program Type: Subsidy and Discount
Year Operational: 2001
Number of Recipients (December 2002): 37,802
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
The Maine Low Cost Drugs for the Elderly Program is operated within the Healthy Maine Prescription Drug Program.
∗∗
This budget is allocated for both the Healthy Maine Prescription Drug Program and DEL.
PROGRAM CONTACT
Maryland
Maryland Pharmacy Assistance Program
Program Type: Direct Assistance
Year Operational: 1979
Projected Number of Recipients (FY 03): 47,700
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
∗
Eligible Income Level (Single): $10,000 Eligible Income Level (Married): $10,850∗∗
Other Eligibility Notes: No age restrictions on eligibility. The following groups are ineligible
for participation: people detained in a correctional (Federal, State,
local) system, Medicaid recipients, and non-residents. $4500
maximum assets.
DRUGS COVERAGE
Formulary: Closed formulary
Drugs Covered: Specified categories of maintenance drugs used to treat chronic
conditions, anti-infective drugs, and insulin syringes and needles
Drug Coverage Restrictions: Prior authorization for certain medications, including steroids and some
controlled substances. 75% utilization required for prescription refill.
PROGRAM CONTACT
Paul A. Roeger Phone: 410/767-5394
Division Chief, Office of Operations & Eligibility Fax: 410/333-5027
Department of Health and Mental Hygiene E-mail: roegerp@dhmh.state.md.us
201 West Preston Street
Baltimore, MD 21201
∗
Eligible income/asset scale for 1-person household.
∗∗
Eligible income/asset scale for 2-person household.
Maryland
Short-Term Prescription Drug Subsidy Plan
Program Type: Direct Assistance
Year Operational: 2001∗
Number of Recipients (December 2002): 29,490
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 300% of FPL Eligible Income Level (Married): 300% of FPL
Other Eligibility Notes: Program open to all Medicare recipients.
DRUGS COVERAGE
Formulary: Open formulary
Drugs Covered: Most generic and brand drugs approved by the Food and Drug
Administration (FDA) are included under this program.
Drug Coverage Restrictions: Anorexants are excluded. Over the counter drugs are excluded.
Quantity limits on certain drugs such as Viagra, migraine medicines
and Oxycontin. Prior authorizations on certain drugs such as growth
hormones.
PROGRAM CONTACT
Robin Vahle Phone: 410/998-5444
Health and Mental Hygiene E-mail: robin.vahle@carefirst.com
201 West Preston Street
Baltimore, MD 21201
∗
The program is ending June 30, 2003.
Maryland
Maryland Pharmacy Discount Program
Program Type: Discount (1115 Waiver)
Projected Operational Date: July 1, 2003
Projected Number of Recipients: 105,000
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund and Federal matching funds
Budget: Not Available
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Medicaid price less rebates
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 65% of the Medicaid price
Dispensing Fee: $1.00 per prescription
DRUGS COVERAGE
Formulary: Open
Drugs Covered: Anything included under Medicaid
Drug Coverage Restrictions: Same as Medicaid
PROGRAM CONTACT
Massachusetts
Prescription Advantage+
Program Type: Direct Assistance
Year Operational: 2001∗
Number of Recipients (August 2002): 83,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Michigan
Elder Prescription Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (May 2003): 13,034
ELIGIBILITY CRITERIA
Copayment Amount: If a brand name drug is prescribed and dispensed when a generically
equivalent drug is available, a $15.00 copayment in addition to the
monthly out-of-pocket share is charged.
Dispensing Fee: $3.77
DRUGS COVERAGE
Formulary: Drugs not on the Michigan Pharmaceutical Products List (MPPL) may
require prior authorization before they are paid for by EPIC. The use
of generic drugs is encouraged.
Drugs Covered: Most prescription drugs plus insulin and syringes for diabetics, with
some exceptions.
Drug Coverage Restrictions: The EPIC program does not cover the following types of drugs:
products used for weight loss or weight gain; fertility or infertility
drugs; drugs used to treat erectile dysfunction; drugs or products used
for contraception; products used to promote hair growth or for other
cosmetic purposes; drugs used to treat the skin aging process; smoking
cessation products; cold and cough preparations; fluoride preparations;
experimental and investigational drugs; DESI drugs;
vitamins/minerals, alone or in combination; dietary formulas or
nutritional supplements; central nervous system (CNS) stimulants;
Acquired Immunodeficiency Syndrome (AIDS) drugs/injectables and
orals; injectable drugs; allergy serums; compounds; over-the-counter
(OTC) drugs except for prescription insulin and OTC drugs with
prescriptions used for approved step therapy programs; miscellaneous
products associated with a specific drug administration, except for
diabetes needles and syringes; drugs produced by manufacturers not
participating in the rebate program; non-Food and Drug
Administration (FDA) approved drugs; and drugs for which the
manufacturer seeks to require as a condition of sale that associated
tests or monitoring services be purchased exclusively from the
manufacturer or its designee.
PROGRAM CONTACT
Minnesota
Prescription Drug Program∗
Program Type: Direct Assistance
Year Operational: 1999
Number of Enrollees (November 2002): 6,180
(Elderly: 5,230; Disabled: 950)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
∗
Formerly the Senior Citizen Drug Program.
Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs rebate
agreement with Department of Human Services. Covers over-the-
counter drugs for antacid, insulin products, smoking cessation
products, lice medication and vitamins.
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered.
PROGRAM CONTACT
Missouri
SeniorRx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (November 2002): 29,722
ELIGIBILITY CRITERIA
Funding Source: Funding comes from the Missouri SenioRx Fund, which consists of all
rebates received through the program; funds that are appropriated to it
by the general assembly; and funds from Federal or other sources.
Budget (FY 02-03): $35 million
Cost Per Enrollee (FY 02): $1,178.00
# of Rx’s Per Enrollee: Not Available
Manufacturer Rebate Type: 15% of AWP
Ingredient Cost Calculation: AWP – 20%
Enrollment Fee: $25.00 to $35.00, depending on income level
Deductible Amount: $250.00 to $500.00, depending on income level
Copayment Amount: 40% of prescription cost
Dispensing Fee: $4.09
Notes: Maximum annual benefit of $5,000.00
DRUGS COVERAGE
Formulary: None
Drugs Covered: Most prescription medications used for outpatient purposes;
Prescription insulin; prescription strength prenatal vitamins; fluoride
preparations; prescription compounds; Drug Efficacy Study
Implementation (DESI) drugs.
Drug Coverage Restrictions: The following drugs are not covered: drugs manufactured by
companies that do not participate in the Missouri SenioRx rebate
program; over-the-counter (OTC) products; drugs used for weight gain
or anorexia; drugs used to promote fertility; cosmetic and hair growth
agents; cough and cold preparations; prescription strength vitamins;
barbiturates; benzodiazepines; insulin syringes and diabetic supplies;
food supplements; and medical equipment, devices and supplies. Use
of generics is encouraged.
PROGRAM CONTACT
Montana
Prescription Drug Expansion Program
Program Type: Discount
Projected Operational Date: 2004
Projected Number of Recipients: not available
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Not available
Nevada
Senior Rx
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (November 2002): 7,500
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
New Hampshire
Senior Prescription Drug Discount Program
Program Type: Discount
Year Operational: 2000
Number of Enrollees (November 2002): 77,132
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: All prescription drugs
Drug Coverage Restrictions: Over-the-counter drugs are not covered
PROGRAM CONTACT
New Jersey
Pharmaceutical Assistance to the Aged and Disabled (PAAD)
Program Type: Direct Assistance
Year Operational: 1975
Projected Number of Recipients (FY 2003): 217,484
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing
materials, and injectables used in treatment of multiple sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. DESI drugs are not covered.
PROGRAM CONTACT
New Jersey
Senior Gold Prescription Discount Program
Program Type: Direct Assistance
Year Operational: 2001
Projected Number of Recipients (FY 03): 61,972
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing
materials, and injectables used in treatment of multiple sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. DESI drugs are not covered.
PROGRAM CONTACT
New Mexico
Senior Prescription Drug Program
Program Type: Discount
Projected Operational Date: Unknown∗
Number of Recipients: N/A
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
∗
Because of difficulties in locating funding for the program, the projected operational date of the program is unknown.
∗∗
On December 4, 2002, the State Agency on Aging issued a statement committing $30,000 for fund administration costs.
New Mexico
Prescription Drug Waiver Program
Program Type: Direct Assistance
Projected Operational Date: Unknown
Number of Recipients: N/A
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
New York
Elderly Pharmaceutical Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (November 2002): 297,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All legend drugs, insulin and insulin syringes and needles
Drug Coverage Restrictions: DESI drugs and non-participating manufacturers excluded.
PROGRAM CONTACT
North Carolina
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2000∗
Number of Recipients (FY 2002): 1,800∗∗
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
∗
This program will be ending on June 2, 2003. Enrollees will be eligible for Senior Care
∗∗
Enrollment was closed on March 1, 2002 due to budget limitations.
North Carolina
Senior Care∗
Program Type: Direct Assistance
Year Operational: 2002∗∗
Number of Recipients: 4,000∗∗∗
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): Not eligible
Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: 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.
DRUGS COVERAGE
Formulary: Limited formulary (category based)
Drugs Covered: All drugs used to treat cardiovascular disease and/or diabetes
Drug Coverage Restrictions: This program will not pay for over-the-counter drugs or potassium
supplements.
PROGRAM CONTACT
Michael Keough Phone: 919/733-2040
Department of Health and Human Services
2001 Mail Service Center
Raleigh, NC 27699
∗
Previously referred to as Carolina CaRxes in State legislation.
∗∗
Program benefits began on November 1, 2002. This program replaces the pilot program, North Carolina’s Prescription Drug
Assistance Program.
∗∗∗
Full enrollment is expected to be approximately 100,000.
Ohio
Golden Buckeye Prescription Drug Program
Program Type: Negotiated Discounts
Projected Operational Date: 2003
Estimated Eligibles: up to 500,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: Drugs for which the PBM has negotiated rebates with manufacturers.
Drug Coverage Restrictions: None
PROGRAM CONTACT
Oregon
Senior Prescription Drug Assistance Program
Program Type: Discount
Projected Operational Date: not available*
Projected Number of Recipients: up to 100,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All legend drugs.
PROGRAM CONTACT
*
Postponed due to lack of funds.
Pennsylvania
Pharmaceutical Assistance Contract for the Elderly (PACE)
Type of Program: Direct Assistance
Year Operational: 1984
Number of Recipients (May 2003): 192,384
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Thomas Snedden Phone: 717/787-7313
Director, PACE Program Fax: 717/772-2730
PA Department of Aging E-mail: tsnedden@aging.state.pa.us
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919
Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (May 2003): 32,142
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Rhode Island
Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE)
Program Type: Direct Assistance, Discount
Year Operational: 1985
Number of Enrollees (July 2002): 39,568
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 55-65
Eligible Income Level (Single): 420% of FPL Eligible Income Level (Married): 420% of FPL
Other Eligibility Notes: Income levels exclude income spent on medical expenses if greater
than 3% of total income. Eligible social security disability recipients
between the ages of 55-65 may receive the program’s discount price or
the Federal MAC price for their prescriptions, whichever is lower;
they do not receive a subsidy.
DRUGS COVERAGE
Formulary: Open formulary
Drugs Covered: Drugs for Alzheimer’s disease, anti-infectives, arthritis, asthma and
chronic respiratory conditions, cancer, circulatory insufficiency,
depression, diabetes (including insulin syringes), heart problems, high
cholesterol, hypertension, Parkinson’s disease, glaucoma, prescription
mineral and vitamin supplements for renal patients, urinary
incontinence, and osteoporosis
Drug Coverage Restrictions: Non-cosmetic Food and Drug Administration approved drugs that
were not previously listed are covered at the program’s discount price
or at the Federal MAC price, whichever is lower.
PROGRAM CONTACT
Dennis Costa Phone: 401/462-3000
Rhode Island Dept. Of Elderly Affairs E-mail: dennis@dea.state.ri.us
Benjamin Rush Building #55
35 Howard Avenue
Cranston, RI 02920
South Carolina
SilveRxCard Senior Prescription Drug Program
Program Type: Direct Assistance (1115 waiver)∗
Year Operational: 2003
Number of Enrollees (November 2002): 42,000
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
∗
The SilveRxCard program previously operated as a non-CMS waiver program funded only by State revenue. The waiver program
begins on January 1, 2003.
South Dakota
Senior Citizen Prescription Drug Benefit Program
Program Type: Discount
Year Operational: Not Yet Operational
Number of Enrollees: Not Available
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Not Available
Texas
State Prescription Drug Program
Program Type: State-Subsidy
Law Enacted: 2001∗
Estimated Eligibles: N/A
ELIGIBILITY CRITERIA
Funding Source: State General Revenue Fund, unless funds are available under Federal
law to fund all or part of the program
Budget (FY 02-03): None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Not Available
Ingredient Cost Calculation: Not Available
Enrollment Fee: Not Available
Deductible Amount: Not Available
Copayment Amount: Not Available
Dispensing Fee: Not Available
Notes: According to statute, the Health and Human Services Commission
may require a cost-sharing payment.
DRUGS COVERAGE
∗
Since implementation of this program is contingent on funding availability, and no funding was forthcoming in FY 2002-03, no
action has been taken to implement the program. The Texas Health and Human Resources Commission is seeking an appropriation
of $35 million in the FY 2003-04 budget.
Notes: The Health and Human Services Commission may require that, unless
the practitioner’s signature on a prescription clearly indicates that the
prescription must be dispensed as written, the pharmacist may select a
generic equivalent of the prescribed drugs. The Health and Human
Resources Commission is also authorized to establish a formulary,
prior authorization requirements, and a drug utilization program.
PROGRAM CONTACT
Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Recipients (October 2002): 3,032
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
∗
This program was integrated into the VHAP (1115 waiver) program in 1999.
Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients: 3,200
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Vermont
Vermont Health Access Plan (VHAP)
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1996
Number of Recipients (November 2002): 11,550
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
Vermont
*
Healthy Vermonters Program
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (November 2002): 7,140
(Healthy Vermonters: 440; VSCRIPT, VSCRIPT Expanded participants: 6,700)
ELIGIBILITY CRITERIA
DRUGS COVERAGE
PROGRAM CONTACT
* The Healthy Maine program, which allowed seniors to purchase prescriptions through a Medicaid waiver, was halted by a U.S. Court of Appeals ruling on
December 24, 2002. The Healthy Vermonters Program may be affected by this ruling. Currently, participants receive the Medicaid rate for prescription drugs, with
no additional discounts. Additional discounts were planned based on manufacturers’ rebates and the State’s contribution.
West Virginia
Gold Mountaineer Discount Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (October 2002): 17,061
ELIGIBILITY CRITERIA
DRUGS COVERAGE
Formulary: None
Drugs Covered: All FDA Federal legend pharmaceuticals and diabetic supplies
Drug Coverage Restrictions: None
PROGRAM CONTACT
Wisconsin
Wisconsin SeniorCare Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (December 2002): 73,000
ELIGIBILITY CRITERIA
Funding Source: State funded, unless funds are available under Federal law to fund all
or part of the program
Budget (FY 02-03): $49.9 million
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Not Available
Enrollment Fee: $20.00
Deductible Amount: $500.00 (unless household income is less than 160% of FPL, in which
case no deductible is required)
Copayment Amount: $5.00 for generic drugs, $15.00 for name-brand drugs
Dispensing Fee: Not Available
DRUGS COVERAGE
Formulary: None
Drugs Covered: Most prescription drugs
Drug Coverage Restrictions: The program does not cover: prescription drugs administered in a
physician’s office; drugs that are experimental or have a cosmetic, not
a medical, purpose; over-the-counter drugs such as vitamins and
aspirin, even if prescribed, except for insulin; prescription drugs for
which prior authorizations has been denied. If a drug is available in
generic form, the brand-name form is covered only when medically
necessary. Reimbursement for most drugs is limited to a 34-day
supply. Some maintenance drugs may be provided in a 100-day
supply.
PROGRAM CONTACT
Wyoming
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2002∗
Number of Recipients (November 2002): 9,120
ELIGIBILITY CRITERIA
Eligibility Age (Elderly): All ages Eligibility Age (Disabled): All ages
Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL
Other Eligible Groups: Medicaid enrollees are not eligible. No more than $1000 in resources,
home and one car exempt.
DRUGS COVERAGE
PROGRAM CONTACT
∗
Absorbed the Minimum Medical Program.
ALABAMA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2000 and Alabama Medicaid Statistical Information System, FY 2001.
Note: Alabama estimates 2002 drug expenditures to be approximately $451 million and the number of Medicaid drug recipients to be
505,000.
D. PROVISIONS RELATING TO DRUGS Prescription Refill Limit: 30 day supply, maximum of five
Benefit Design refills.
Unit Dose: Unit dose packaging reimbursable. Cognitive Services: Clozaril care management fee of
$3.00.
Formulary/Prior Authorization
Prior Authorization: State currently has a formal prior Does not use MCOs to deliver services to Medicaid
authorization procedure. Review by Medicaid’s Medical recipients.
Medicaid Drug Rebate Contacts 501 Dexter Avenue; P.O. Box 5624
Montgomery, AL 36103
Gladys Gray, Associate Director
334/242-5619
Alabama Medicaid Agency
501 Dexter Avenue Title XIX Medical Care Advisory Committee
P.O. Box 5624
Alabama State Government Representatives
Montgomery AL 36103-5624
Dr. Milissa Mauser-Galvin
T: 334/242-2327
Executive Director, Department of Senior Services
F: 334/353-7014
P.O. Box 301851
E-mail: ggray@medicaid.state.al.us
Montgomery, AL 36130-1851
Claims Submission Contact 334/242-5743
Keith Hollis
Bill Fuller, Commissioner
Account Manager, EDS
Alabama Department of Human Resources
301 Technacenter Dr.
50 Ripley Street, 2nd Floor
Montgomery, AL 36117
Montgomery, AL 36130
334/215-0111
334/242-1160
Medicaid Managed Care Contact
Kathy Sawyer, Commissioner
Kim Davis-Allen
Alabama Department of Health and Mental Retardation
Director, Managed Care
P.O. Box 301410
Alabama Medicaid Agency
Montgomery, AL 36130-1410
501 Dexter Avenue
334/242-3107
Montgomery, AL 36103-5624
334/242-5011
Donald Williamson, M.D.
Mail Order Pharmacy Program
State Health Officer
None P.O. Box 303017
Montgomery, AL 36130-3017
Disease Management Program/Initiative Contact 334/206-5200
Mary H. Finch
Associate Medical Director Steve Shivers
Alabama Medicaid Agency Alabama Department of Rehabilitation Services
501 Dexter Avenue 2129 East South Boulevard
Montgomery, AL 36103-5624 Montgomery, AL 36116-2455
334/242-5610 334/281-8780
Physician-Administered Drug Program Contact Medical Association of State of Alabama
Mary G. McIntyre, M.D. Marsha D. Raulerson, M.D.
334/242-5574 1205 Belleville Avenue
Brewton, AL 36426-1304
Alabama Medicaid Agency Officials 251/867-3609
Mike Lewis
Commissioner Wilburn Smith, Jr., M.D.
Alabama Medicaid Agency 2023 Normandie Drive
501 Dexter Avenue Montgomery, AL 36111
P.O. Box 5624 334/281-2633
Montgomery, AL 36103-5624
T: 334/242-5600 Cary J. Kuhlmann, Executive Director
F: 334/242-0556 Medical Association of the State of Alabama
E-mail: Almedicaid@medicaid.state.al.us P.O. Box 1900-C
Montgomery, AL 36104
334/263-6441
334/271-6214 334/273-4404
William S. Eley, II
Executive Director
1211 Carmichael Way
Montgomery, AL 36106-3672
T: 334/271-4222
F: 334/271-5423
E-mail: aparx@aparx.org
Internet Address: www.aparx.org
ALASKA
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
Source: CMS, MSIS Report, FY 2000 and FY 2001.
D. PROVISIONS RELATING TO DRUGS Monthly Quantity Limit: Prescriptions are limited to 30-day
supplies. Dispensing of generic multi-source product is
Benefit Design required. Maximum number of units for about 50
therapeutic classes and 40 narcotic analgesics.
Drug Benefit Product Coverage: Products covered:
cosmetics (covered with restrictions); prescribed insulin; Drug Utilization Review
disposable needles and syringe combinations used for
insulin; blood glucose test strips; urine ketone test strips; PRODUR system implemented in June 1995. State
and total parental nutrition. Prior authorization required for: currently has a DUR Board that meets nine times per year.
Clorazil; Lupron Depot; ADC infant vitamins; some DME; Pharmacy Payment and Patient Cost Sharing
Synagis; Pauretin; and Actig Naltrexone. Products not
covered: fertility drugs; experimental drugs; and intedialytic Dispensing Fee: No less than $3.45 and no more than the
parenteral nutrition. 90th percentile of all dispensing fees determined under the
formula:
Over-the Counter Product Coverage: Products covered
with restrictions: topical products (vasatrace ointment). 1) $23,192 added to the number resulting from
Products not covered: allergy, asthma, and sinus products; multiplying total prescriptions filled by that pharmacy
analgesics; cough and cold preparations, digestive products; in the previous calendar year by 5.070;
feminine products; and smoke deterrent products.
2) to 1), add the result of multiplying total Medicaid
Therapeutic Category Coverage: Categories covered: prescriptions filled in the previous calendar year by
anabolic steroids; antibiotics; anticoagulants; 12.44;
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-psychotics; 3) from 2), subtract the result of multiplying the total floor
anxiolytics, sedatives, and hypnotics; cardiac drugs; space volume of the pharmacy in sq. ft. by 2.103;
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive agents; 4) divide 3) by total prescriptions filled by that pharmacy
miscellaneous GI drugs; sympathominetics (adrenergic);
and thyroid agents. Partial coverage for: anoretics; 5) add $0.73 to 4)
prescribed cold medications. Prior authorization required
for: analgesics, antipyretics, and NSAIDs; growth Ingredient Reimbursement Basis: EAC = AWP - 5%.
hormones. Categories not covered: amphetamines (except
for narcolepsy and hyperactivity); prescribed smoking Maximum Allowable Cost: State imposes Federal Upper
deterrents; cough suppressants; DESI drugs; vitamins Limits on generic drugs. Override requires “Brand
(except prenatal); and vitamins with fluoride. Medically Necessary” and the reason of necessity.
Coverage of Injectables: Injectable medicines reimbursable Incentive Fee: None.
through the Prescription Drug Program and through
physician payment when used in physician offices. No
Cognitive Services: Does not pay for cognitive services.
information provided on reimbursement for non-self-
administered injectable medicines in home health care or in
Patient Cost Sharing: $2.00 copayment for branded and
extended care facilities.
generic products.
Vaccines: Vaccines reimbursable at cost as part of EPSDT
services and the Vaccines for Children Program.
E. USE OF MANAGED CARE
ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
of primary care physicians was established to perform the
AHCCCS FEATURES gatekeeping function for the system.
The Arizona Health Care Cost-Containment System Prepaid Capitated Financing
(AHCCCS) is a Title XIX (Medicaid) demonstration
project, jointly funded by the federal government and the It was the intent of the AHCCCS legislation that health
State of Arizona. Begun in October 1982, it serves as a plans and their providers offer all covered services to
model for providing medical services to the indigent in a groups of members within a geographical area for a fixed
managed care system rather than through fee-for-service price, for a definite period. The law allowed for the
arrangements. Typically, Medicaid programs have establishment of a statewide bidding process to
incorporated the traditional hallmarks of the U.S. health accomplish this. Services are provided on a county-by-
care system: namely, independent providers and fee-for- county basis, by prepaid health plans. Providers may bid
service reimbursement. In contrast, organized health on a prepaid capitated basis for covered services to be
plans and capitation mark the AHCCCS model. provided within a particular county. The law allows for
expansion and contraction of bids to achieve the best
In traditional Medicaid programs, the States assume possible system. In the event there are insufficient bids
responsibility for contracting with individual pharmacies for a given area, the legislation permits capped fee-for-
and reimbursing them. In the AHCCCS model however, service arrangements. It is intended, however, that capped
the State contracts instead with pre-paid health plans, fee-for-service will be authorized as a last resort only.
HMOs and HMO-like entities. These plans are paid on a
capitation basis and are responsible for providing all of In essence, AHCCCS prepaid health plans (PHPs), health
the services covered by the program. Thus, the delivery maintenance organizations (HMOs), and other types of
of pharmacy services is the responsibility of each prepaid organized health delivery systems charge a fixed fee per
plan. individual enrolled (i.e., a capitation rate) and assume
responsibility for providing a broad array of health care
GENERAL INFORMATION services to members. The plan or contractor is then “at
risk” to deliver the necessary services within the capitated
The Arizona Health Care Cost Containment System amount. AHCCS receives federal, state, and county funds
(AHCCCS), developed in Senate Bill 1001, was passed by to operate, plus some monies from Arizona’s tobacco tax.
the Legislature and signed by the Governor in November Competitive Bidding Process
1981. It contained six major mechanisms for restraining
health care costs at the same time ensuring that The statewide competitive aspect of the bid process for
appropriate levels of quality health care services are selecting providers and offering prepaid capitated services
provided to eligible persons in a dignified fashion. The is the most unique feature of the AHCCCS model. A
goal of these 6 items was to contribute to the competition of this magnitude had never been attempted
establishment of health care financing that is less in any other State. The AHCCCS administration believes
expensive than conventional fee-for-service systems. The competitive bidding for health care service contracts, as
six mechanisms were: opposed to conventional negotiation processes, provides
• Primary Care Physicians Acting as Gatekeepers accessible cost-effective delivery of health care without
• Prepaid Capitated Financing sacrificing quality performance.
• Competitive Bidding Process
• Cost Sharing The AHCCCS administration issues an invitation to
• Limitations on Freedom-of-Choice qualified health plans once every five years. Qualified
health plans may bid to offer the full range of AHCCCS
• Capitation of the State by the Federal
services in one or more counties.
Government
Primary Care Physicians as Gatekeepers Cost Sharing
AHCCCS legislation provided that all members must be The fourth major device for containing costs in the
under the care and supervision of a primary care physician AHCCCS model is a provision for cost sharing by users.
who assumed the role of gatekeeper. A statewide network A statewide co-payment schedule was developed for this
purpose, and the medically needy participate in The second mode of participation is on a capped fee-for-
coinsurance cost sharing. It is expected that the service basis. Here, providers agree to accept capped fee
imposition of nominal co-payments will ensure optimal payments as payments in full for services provided on a
effectiveness in the area of service utilization. The co- FFS basis.
payment schedule accomplishes three objectives:
Functions of the AHCCCS Administration
curtailment of over-utilization; enhancement of patient
dignity; and service utilization by members for truly
The Arizona Health Care Containment System
needed health care. There is no co-payment for drugs and
Administration (AHCCCSA) contracts with full benefit
medication, prenatal care including all obstetrical visits,
capitated health plans to serve AHCCCS members
members in long care facilities and for visits scheduled by
through a network of providers.
the primary care physician or practitioner, and not at the
request of the member. Contracting Health Plans
Limitations On Freedom-of-Choice Under the Contracting Health Plan arrangement, plans are
defined in terms of explicit groups of providers organized
The fifth major item for containing costs is a restriction on as entities that are more formal. These consortia, or
provider/physician selection by AHCCCS members. formal entities, are capable of providing the full range of
Unlike conventional delivery models, Arizona does not AHCCCS benefits within a defined service area for all
rely on fee-for-service arrangements. The goal is to have AHCCCS members who elect to join the plans, up to a
the state completely blanketed with prepaid capitated predetermined capacity. This is the dominant mode of
arrangements. Members are linked to selected or assigned operation within AHCCCS -- with two or more competing
plans for definite durations of time. Freedom-of-choice is plans wherever possible.
permitted to the extent practicable for members to select
the particular group with which to enroll, as well as the The Contracting Health Plans are delivery systems, not
primary care physician within the selected group. Capped simply insurance plans, but they need not be Health
fee-for-service health service arrangements are used as a Maintenance Organizations by any legal or conventional
last resort, and only in areas not covered by prepaid definition of the term. The AHCCCS legislation provides
capitated plans. for the creation of provider consortia for the purpose of
participation in the program. The Contracting Health Plan
CAPITATION BY THE FEDERAL may be a loosely organized system, but it must be capable
GOVERNMENT of providing the full range of AHCCCS benefits to a
defined population at a capitation rate.
The State of Arizona will itself be capitated by the Federal
Government and therefore will be at financial risk for The Organizational Role of AHCCCS
containing health care costs. Capitation rates will be Administration
established according to sound actuarial principles, and
will represent no more than 95 percent of the estimated The AHCCCS Administration has been charged with the
cost of services delivered in Arizona under conventional general implementation and monitoring of the AHCCCS
fee-for-service arrangements. Capitation provides a key program.
incentive for the State to monitor health care costs on a
careful and continuous basis. The AHCCCS Administration develops the Rules and
Regulations; manages the health plan bidding processes;
awards the contracts; provides technical assistance to
IMPLEMENTATION OF AHCCCS
providers for the purpose of forming consortia to contract
with AHCCCS; and monitors the overall operation of the
AHCCCS is based on plans that have been tested, in part,
program.
on smaller scales in different areas of the country. By
combining a number of key mechanisms on a statewide The Operational Role of the AHCCCS
basis, AHCCCS represents a novel health care model. Administration
The purpose of this section is to present a discussion of
how the key concepts embodied in the AHCCCS Organizationally, the AHCCCS Administration assumes
legislation will be implemented and rendered operational. responsibility for the oversight of every day operations.
Provider Participation
The AHCCCS Administration has overall responsibility
for the following activity areas:
Providers may participate in AHCCCS in 2 different
ways. First, they may contract with prepaid capitated plans • Eligibility Oversight
as either full or partial benefit providers. • Procurement of Health Plans
• Quality Management
1
ARKANSAS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
1 The State of Arkansas did not respond to the 2002 NPC Survey. Using CMS data and other source materials, we have, to the extent
possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the Arkansas Medicaid program to
assess the accuracy and currency of the information included.
CALIFORNIA
*Total Other Expenditures/ Recipients include foster care children, demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
Unit Dose: Unit dose packaging reimbursable. The patient’s physician or pharmacist may request prior
Formulary/Prior Authorization authorization from the field office Medi-Cal consultant for
approval of unlisted drugs or for listed drugs that are
Formulary: Modified closed formulary. Medi-Cal List restricted to specific use(s). This is done by completing a
of Contract Drugs: Over 600 drugs in differing strengths Treatment Authorization Request (TAR) form. Providers
and dosage forms listed generically. Patients can get prior may appeal prior authorization decisions within 60 days of
authorization for unlisted drugs or for listed drugs that are notification to the local field office and then to field
restricted to specific use(s), if medically justified. services headquarters if necessary. Beneficiaries also have
the ability to request a hearing to review the denial and Prescription Charge Formula: Reimbursement is based
must do so within 90 days of notification. on the lowest of:
COLORADO
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: CMS, MSIS Report, FY 2000 and Colorado Medicaid Statistical Information System, FY 2001.
Drug Benefit Product Coverage: Products covered: Monthly Quantity Limit: New prescriptions for chronic or
prescribed insulin. Products covered with restriction: total acute conditions are prescribed at the discretion of the
parenteral nutrition (prior authorization). Products not physician. Normal quantity limit is a 30-day supply.
covered: cosmetics; DESI drugs; fertility drugs; However, reasonable amounts for more than a 30-day
prescribed vitamins (except prenatal); interdialytic supply for chronic conditions are recommended.
parental nutrition products; and experimental drugs. Maximum supply is 100 days for maintenance medication.
Disposable needles and syringe combinations used for
insulin; blood glucose test strips; and urine ketone test Other Limits: Stadol: limit of 4 bottles per month.
strips are considered DME and do not fall under the Oxycontin: 2 tablet (any strength) per day limit without
State’s drug benefit. prior authorization.
as defined below or the MAC or the high volume EAC, (1) Single source manufacturers;
whichever is less.
(2) High volume Medicaid recipient utilization;
The ingredient cost for institutional and government (3) Interchangeability problems with multiple source
pharmacies is defined as the actual cost of acquisition for
drugs;
the drug dispensed or the MAC, or the high volume EAC,
whichever is less. (4) Package sizes in excess of 100.
Maximum Allowable Cost: State imposes Federal Upper Drug Pricing: The Department will maintain a drug-
Limits as well as State-specific limits on generic drugs. pricing file that will be updated at least monthly. The
Override requires prior authorization(Med Watch form). average wholesale price of a drug as determined by the
Department, MAC, and high volume EAC, will be the
The State MAC is the maximum ingredient cost allowed basis for setting the prices in the drug pricing file.
by the Department for certain multiple-source drugs. The
establishment of a MAC is subject, but not limited to, the The Department will determine the average wholesale
following considerations: price that will be placed in the drug-pricing file as
follows:
(1) Multiple manufacturers;
(1) The average wholesale price as it appears in the Red
(2) Broad wholesale price span;
Book, its supplements, and Medi-Span will be the first
(3) Availability of drugs to retailers at the selected cost; source. However, if there is a difference between the two
published average wholesale prices, the Department will
(4) High volume of Medicaid recipient utilization;
set the price as the published amount which is the closest
(5) Bioequivalence or interchangeability. to the lowest average price charged by two drug
wholesalers doing business in Colorado.
When federal MAC limits for multiple source drugs are
announced, they will be adopted if they are less than State (2) If there is a price change which does not appear
MACs or if no State MACs exist. immediately in the Red Book, its supplements, or in Medi-
Span, then the Department will set the average wholesale
The ingredient cost of any drug subject to MAC shall be price by averaging the wholesale prices of three drug
limited to MAC or wholesale price as determined by the wholesalers doing business in Colorado, until the price is
Department, whichever is less. Exceptions that will allow published in the Red Book, its supplements, or in Medi-
reimbursement greater than MAC for a drug entity are Span.
obtained through a prior authorization mechanism. An
exception will be granted if the patient’s response to the (3) If the prices or changes do not appear in the
generic drug is not therapeutic, an allergic reaction is publications or the wholesalers’ records, then the
involved, or any similar situation exists. distributors’ or manufacturers’ prices will be adjusted to
the wholesale pricing level and used in the drug pricing
If a recipient requests a brand name for a prescription that file as the price of the drug.
is subject to MAC, then he/she may pay the ingredient
cost difference between the MAC and brand name drug. If the difference between the pharmacist’s invoice
The recipient must sign the prescription stating that he/she purchase price and the average wholesale price which
is willing to pay the difference in ingredient cost to the appears in the Red Book, its supplements, or Medi-Span
pharmacy. The pharmacy will be paid MAC plus a exceeds 18%, then the Department may adopt a lower
dispensing fee or reimbursement charges, whichever is price after a survey is conducted to determine the validity
lower. of the published prices. The price from the distributor or
manufacturer will be adjusted the same as in 3 above.
High volume Estimated Acquisition Cost (EAC):
Reimbursement for single source drugs or certain multiple Special Note: The Maximum Allowable Cost shall be
source drugs which are most frequently prescribed will be determined by the Division of Medical Assistance, based
based upon average wholesale prices (AWP) minus upon professional determination of a quality product
13.5%, or direct manufacturers’ prices for package sizes available at the least expense possible.
containing quantities greater than 100 dosage units or less
if not available in 100’s.
- Shelf package size oral tablet and capsule medications United Healthcare
in quantities of 100 only or smaller when not available in 6251 Greenwood Plaza Blvd, Suite 200
package size of 100. Englewood, Colorado 80111-4910
- Prescriptions for less than minimum amounts will be 303/267/3594
denied reimbursement of the professional fee unless the
physician notified the Department in writing of the F. STATE CONTACTS
medical need for amounts less than a 30-day supply. Medicaid Drug Program Administrator
Medical consultation determines the decision.
Dima Ahram, Pharm.D.
Incentive Fee: None. Department of Health Care Policy and Financing
1575 Sherman Street, 5th Floor
Patient Cost Sharing: Co-pay is $3.00 for brand name Denver, CO 80203
products and $0.75 for generic. T: 303/866-2468
F: 303/866-2573
Cognitive Services: Does not pay for cognitive services. E-mail: dima.ahram@state.co.us
DUR Contact
E. USE OF MANAGED CARE
Dima Ahram, Pharm.D., 303/866-2468
Over 260,000 Medicaid recipients were enrolled in
Prescription Price Updating
managed care in FY 2001. Recipients receive
pharmaceutical benefits through the State. First Data Bank
1111 Bayhill Drive, Suite 350
Managed Care Organizations
San Bruno, CA 94066
Total Long-term Care T: 650/588-5454
303 East 17th Avenue Suite 650 F: 650/827-4578
Denver, Colorado 80203
Medicaid Drug Rebate Contacts
303/896-4664
Vince Sherry
HMO Colorado Drug Rebate Manager
700 Broadway Department of Health Care Policy and Financing
Denver, Colorado 80273 1575 Sherman Street, 5th Floor
303/831-2374 Denver, CO 80203
T: 303/866-5408
Kaiser Permanente F: 303/866-2573
10350 East Dakota Avenue
Claims Submission Contact
Denver, Colorado 80905
303/344-7250 ACS, Inc.
600 17th Street
Rocky Mountain HMO Suite 600 North
2775 Crossroads boulevard Denver CO 80202
Grand Junction, Colorado 81506 T: 800/237-0757
800/843-0719 F: 303/534-0439
Colorado Access
600 South Cherry STREET Suite 800
Denver, Colorado 80222
303/355-6707
CONNECTICUT
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 Data are preliminary and subject to change.
State of Connecticut Department of Social Services through Formulary: Open formulary, however, the following
five regional offices and nine sub-offices. products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility drugs;
D. PROVISIONS RELATING TO DRUGS smoking cessation products; DESI drugs, and drugs
available free from the Department of Health Services.
Benefit Design
Prior Authorization: State does not currently have a prior
Drug Benefit Product Coverage: Products covered: authorization procedure.
prescribed insulin, disposable needles and syringe
combinations for insulin; blood glucose test strips; urine Prescribing or Dispensing Limitations
ketone test strips; total parenteral nutrition (except in Prescription Refill Limit: 5 refills per prescription except
NH); and interdialytic parenteral nutrition (except in NH). for oral contraceptives, which have a 12-month limit.
Products not covered: cosmetics; fertility drugs;
experimental drugs; and weight loss products. Monthly Quantity Limit: Maximum 240 tablets or
capsules/30 day supply. Oral contraceptives: 3 months
Over-the-Counter Product Coverage: Products covered: supply may be dispensed at one time.
cough and cold preparations (children < 19 years) and
topical products. Products covered with restrictions: Physicians are encouraged to prescribe drugs generically,
digestive products (non H2 antagonists) – liquid generics when possible.
only; and digestive products (H2 antagonists) – legend Drug Utilization Review
drugs not covered; birth control products; antihistamines;
and decongestants. Products not covered: smoking PRODUR system implemented September 1996. Retro
deterrent products; allergy, asthma and sinus products; DUR since September 1991; the state currently has a 9
analgesics; feminine products; iron; calcium; and some member DUR Board with a quarterly review.
trace elements. For nursing home patients, the department Pharmacy Payment and Patient Cost Sharing
will not pay for OTC drugs used in nursing facilities (such
drugs are covered in the per diem rate). Some drugs Dispensing Fee: $3.85, effective 9/1/02.
require diagnosis for reimbursement such as CNS
stimulants for ADD and narcolepsy. Ingredient Reimbursement Basis: EAC = AWP-12%.
Special rules for Factor VIII (AAC + 8%), OTCs (AWP x #
Therapeutic Category Coverage: Therapeutic categories units x 1.15), and neutral and parenteral nutritionals (AWP
covered: anabolic steroids; analgesics, antipyretics, x # units x 1.15).
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Prescription Charge Formula: Federal MAC or EAC plus
antilipemic agents; anti-psychotics; anxiolytics, sedatives, dispensing fee; or usual and customary if lower. Special
and hypnotics; cardiac drugs; chemotherapy agents; rules for blood factor VIII and enteral/parenteral nutrition
prescribed cold medications; contraceptives; ENT anti- products.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; sympathominetics (adrenergic); thyroid agents; Maximum Allowable Cost: State imposes Federal Upper
and growth hormones. Therapeutic categories not Limits on generic drugs. Override requires “Brand
covered: anorectics and prescribed smoking deterrents. Medically Necessary.”
Coverage of Injectables: Injectable medicines reimbursable Incentive Fee: The Department will pay an incentive
through physician payment when used in home health care, professional dispensing fee of $0.50 per prescription, in
extended care facilities, and in physicians offices. addition to any other dispensing fee, for substituting a
generically equivalent drug product.
Vaccines: Vaccines reimbursable as part of the Children
Health Insurance Program. Patient Cost Sharing: None.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.
1
DELAWARE
1 The State of Delaware did not respond to the 2002 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated the
Profile and the tables in other sections of the Compilation. Users should contact the Delaware Medicaid program to assess the accuracy and currency of the
information included.
Vaccines: Vaccines reimbursable under the Vaccines for First State Health Plan
Children program and the CHIP program. 1801 Rockland Road, Suite 300
Wilmington, DE 19803
Unit Dose: Unit dose packaging not reimbursable. No 302/576-7603
price based on AWP.
Formulary/Prior Authorization
Formulary: Open formulary.
Teresa Corbo
114 Vincent Circle
Middletown, DE 19709
Health and Social Services Department Officials John A. Forrest, Jr., M.D.
195 Lynnhaven Drive
Vincent P. Meconi
Dover, DE 19904
Secretary
Dept. of Health & Social Services
Mark Meister
1901 N. Dupont Highway
Medical Society of Delaware
New Castle, DE 19720
1925 Lovering Avenue
T: 302/421-6705
Wilmington, DE 19806
F: 302/255-4429
E-mail: vmeconi@state.de.us
Olga Ramirez
Community Legal Aid Society, Inc.
Elaine Archangelo
100 W. 10th Street, Suite 801
Director
Wilmington, DE 19801
Division of Social Services
Dept. of Health & Social Services
Penny D. Chelucci
1901 N. Dupont Highway
Mental Health Consumer Coalition
New Castle, DE 19720
100 W. 10th Street
T: 302/255-9668
Community Service Bldg., Suite 303
F: 302/255-4433
Wilmington, DE 19801
E-mail: earchangelo@state.de.us
Joseph Letnaunchyn
Medical Advisory Committee Members
Delaware Health Care Association
Susan Ebner 1280 S. Governor’s Avenue
2 Dove Place Dover, DE 19901
Wyoming, DE 19934
Al Pilong
Anne Aldridge, M.D. Vice President for Ambulatory Care
671 Clifton Dr. Bayhealth Medical Center/Kent General Hospital
Bear, DE 19701 640 S. State Street
Dover, DE 19901
Caroline Vecchiolla
Scott Levin Healthcare Consulting George English
60 Blacksmith Road Blue Cross Blue Shield of DE
Newtown, PA 18940 One Brandywine Plaza
Wilmington, DE 19899
Neil McLaughlin, Director
Fernhook Community Mental Health Michael Glacken, M.D.
14 Central Avenue Medical Director
New Castle, DE 19720 Connections, CSP
500 West 10th St.
Richard Cherrin Wilmington, DE 19801
Visiting Nurses Association
205 N. Pembrey Drive Daniese McMullin-Powell
Wilmington, DE 19806 A.D.A.P.T
24 S. Old Baltimore Pike
Kevin Sheahan Newark, DE 19702
DuPont Pediatrics at Rodney
1726 S. Governors Avenue Leonard Nitowski, M.D.
Dover, DE 19901 Doctors for Emergency Services
PO Box 3048
Bob Welch Wilmington, DE 19804
Bureau Health Planning & Resource Management
Jesse Cooper Building, Suite 160 Julia M. Pillsbury, D.O.
Dover, DE 19901 Center for Pediatric and Adolescent Medicine
125-1 Greentree Drive
Dover, DE 19904
DISTRICT OF COLUMBIA 1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
The District of Columbia Department of Health (DOH), Prescription Charge Formula: The lesser of: Upper limit
Medical Assistance Administration. established by HCFA or the AWP-10% plus the
dispensing fee or usual and customary to the public.
D. PROVISIONS RELATING TO DRUGS
Maximum Allowable Cost: State imposes Federal Upper
Benefit Design Limits on generic drugs. Override requires “Brand
Medically Necessary” with explanation.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Incentive Fee: None.
combinations used for insulin; and ferrous sulfate. Prior
authorization required for: injectable drugs administered Patient Cost Sharing: $1.00 copay by recipient. Does not
on an outpatient basis; anorexic drugs for treatment of apply to recipients under 18, prescriptions for family
narcolepsy and minimal brain dysfunction in children; planning, nursing home patients, or pregnancy related.
acute anti-ulcer drugs, and brand NSAIDS. Products not
covered: all other non-legend items. Cognitive Services: Does not pay for cognitive services.
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
FLORIDA
Agency for Health Care Administration. Claims Formulary: Preferred Drug List (PDL) with mandatory
processing and payment by contract with fiscal agent. limits and exclusions. All covered drugs are available
through the preferred drug process. General exclusions
D. PROVISIONS RELATING TO DRUGS include restrictions on use, prior authorization and
physician profiling. Specific limits and exclusions include:
Benefit Design
1. Vitamins and phosphate binders only for dialysis
Drug Benefit Product Coverage: Products covered: patients.
prescribed insulin; disposable needles and syringe 2. Prostheses; appliances; devices; and personal care
combinations used for insulin; blood glucose test strips; items.
total parenteral nutrition; and urine ketone test strips for 3. Non-legend drugs (except for prescribed insulin,
children under age 21. Prior authorization required for: pancreatic enzymes, buffered and enteric coated
Cytogam; Proleukin; Serostim; Albumin; Neutrexin; aspirin when prescribed as an anti-inflammatory
Provigil; Zoloft 50mg; Paxil 10mg; Panretin gel; agent only, and single entity hematinics).
Regranex (long term care); Botox; and nutritional 4. Anorexants unless the drug is prescribed for an
supplements. Products not covered: cosmetics; fertility indication other than obesity (i.e. narcolepsy,
drugs; experimental drugs; and interdialytic parenteral hyperkinesis).
nutrition. 5. Drugs with questionable efficacy as rated by FDA
(DESI).
Over-the-Counter Product Coverage: Products covered: 6. Investigational and experimental items.
smoking deterrent products (8-12 weeks/yr); iron 7. Oral vitamins with exception of fluorinated pediatric
supplements; Guaifenesin; and vaginal antifungals. vitamins prescribed for pediatric patients, vitamins
Products covered with restriction: analgesics for dialysis patients, prenatal vitamins.
(asprin/Tylenol for anti-inflammatory use); feminine 8. Nursing home floor stock drugs.
products (prior Rx products only). Products not covered:
allergy, asthma, and sinus products; cough and cold Prior Authorization: State currently has a formal prior
preparations; digestive products (including H2 authorization procedure. An appeal hearing request is
antagonists); and topical products. required to appeal prior authorization decisions.
Prescribing or Dispensing Limitations
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, Prescription Refill Limit:
NSAIDs; antibiotics; anticoagulants; anticonvulsants; anti-
depressants; antidiabetic agents; antihistamines; 1. Limited to four brand name RX’s per month.
antilipemic agents; antipsychotics; anxiolytics, sedatives, Exemptions are: Anti-Retrovirals for HIV, Anti-
and hypnotics; cardiac drugs; chemotherapy agents; Psychotics, Depressants and Convulsants, Family
contraceptives; ENT anti-inflammatory agents; estrogens; Planning, and Diabetic supplies and insulin,
hypotensive agents; misc. GI drugs; prescribed smoking unlimited generic prescriptions.
deterrents (only children under 21 years); 2. Drugs not included in the Preferred Drug list (PDL)
sympathominetics (adrenergic); and thyroid agents. Partial require PA. Anti-retrovirals and mental health are
coverage for: anoretics; prescribed cold medications. exempted.
Prior authorization required for: growth hormones; drugs 3. Maintenance medication should be dispensed and
not included on the Medicaid preferred drug list; and billed for at least a one-month supply.
brand name prescriptions beyond the four brand cap 4. Refills must be authorized by the prescriber and can
unless exempted. be made for up to one year, except that controlled
substances can be refilled only in accordance with
Coverage of Injectables: Injectable medicines Federal and State regulations.
reimbursable through the Prescription Drug Program 5. Nutritional supplements are covered with prior
when used in home health care and extended care authorization when the patient is otherwise at risk of
facilities, and through physician payment when used in hospitalization.
physician offices. 6. Other third parties, including Medicare, must be
billed first.
Vaccines: Vaccines reimbursable as part of the Vaccines Drug Utilization Review
for Children Program.
PRODUR system implemented in July 1993. State
Unit Dose: Unit dose packaging reimbursable. 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 Discovery Plan
Pharmacy Association, which performs the reviews, share Contact: Robert Wychulis
the administration of the program. 3520 Thomasville Road, Suite 200
Tallahassee, FL 32308
Heritage information systems contracts to provide DUR 850/894-0100 ext. 801
and prescriber pattern profiling and clinical review
assistance. Florida 1st Health Plans, Inc.
Contact: Frank Willis
Pharmacy Payment and Patient Cost Sharing
3425 Lake Alfred Road
Winter Haven, FL 33881
Dispensing Fee: $4.23, effective 3/11/86.
941/293-0785
Nursing Home Fee $4.73, effective 7/1/01 Foundation Health,
A Florida Health Plan, Inc.
Ingredient Reimbursement Basis: AWP-13.25 % or WAC Contact: Michael Comerford
+ 7%. 1340 Concord Terrace
Sunrise, FL 33323
Prescription Charge Formula: Lower of: 800/422-7335
1. FUL (Federal Upper Limits or State MAC) plus
dispensing fee. Healthease
2. EAC plus dispensing fee. Contact: Christopher O’Connor
3. Usual and customary charge. 6800 N. Dale Mabry Hwy., Suite 168
4. In-house unit dose diff. + 0.015/dose. Tampa, FL 33614-3988
813/290-6358
Maximum Allowable Cost: State imposes Federal Upper
Limits and State-specific limits on generic drugs. Healthy Palm Beaches, Inc.
Provisions for MAC override by physicians only if listed
on negative formulary. Humana Family
Contact: Patricia L. Hubrig
Incentive Fee: No incentive fee. c/o Humana Medical Plan, Inc.
3400 Lakeside Drive, 5th Floor
Patient Cost Sharing: No copayment Miramar, FL 33027
305/626-5616
Cognitive Services: Does not pay for cognitive services.
Jackson Memorial Health Plan
E. USE OF MANAGED CARE Contact: Taryn Davis
1801 NW 9th Ave., Suite 700
Approximately 600,000 Medicaid recipients (30% of all Miami, FL 33136
recipients) received pharmaceutical benefits through 305/575-3700
managed care plans (inclusion of such benefits is
mandated under State law) in 2001. MedChoice Health Plan
Managed Care Organizations Contact: Jeffery G. Keiser
5300 West Atlantic Avenue
Alpha Health Plan, Inc. Delray Beach, FL 33484-8190
561/496-0505
Beacon Health Plans, Inc.
Contact: Ana M. Berenguer Neighborhood Health Partnership, Inc.
2511 Ponce de Leon Blvd., 5th Floor Contact: Heidi Etzold
Coral Gables, FL 33134 7600 Corporate Center Dr., Suite 300
305/774-2599 Miami, Fl 33126-1216
305/715-4318
GEORGIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Source: CMS, MSIS Report, FY 2000 and FY 2001.
Vaccines: Vaccines reimbursable as part of the EPSDT Does not use MCOs to deliver services to Medicaid
service and as part of the Vaccines for Children Program. recipients.
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
HAWAII
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Note: Hawaii estimates 2002 drug expenditures to be $80 million.
ACS
Heather Bodiford
James Lumeng, M.D. (Medicine/Pathology) Attn: Hawaii Medicaid
850 West Hind Drive, #114 9040 Roswell, Road, Suite 700
Honolulu, HI 96821 Atlanta, Georgia 30350
Aileen Hiramatsu
Administrator, Med-Quest Division
Department of Human Services
P.O. Box 700190
Kapolei, HI 96809-0339
T: 808/692-8050
F: 808/586-4890
E-mail: AHiramatsu@medicaid.dhs.state.hi.us
Executive Officers of State Medical and
Pharmaceutical Societies
Hawaii Medical Association
Paula Arcena
Executive Director
1360 S. Beretania Street, Suite 100
Honolulu, HI 96814-1520
T: 808/536-7702
F: 808/528-2376
E-mail: paula_arcena@hma-assn.org
Internet address: www.hmaonline.net
IDAHO
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Benefit Design
Drug Utilization Review
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Contracted DUR through Idaho State University.
combinations for insulin. Products not covered: cosmetics; PRODUR system implemented January 1998. State
fertility drugs; experimental drugs; and interdialytic currently has a DUR board with a quarterly review.
parenteral nutrition. Note: blood glucose test strips; urine
ketone test strips; and total parenteral nutrition are DME Pharmacy Payment and Patient Cost Sharing
items and do not fall under the pharmacy program. Dispensing Fee: $4.94 ($5.54 for unit dose), effective
March 1999.
OTC Coverage: Products covered: permethrin; oral iron
salts; insulin and insulin syringes. Products not covered: Ingredient Reimbursement Basis: EAC = AWP-12% as
allergy, asthma, and sinus; analgesics, cough and cold determined by First DataBank Data File Service or
preparations; digestive products; feminine products; manufacturer direct price for selected manufacturers.
topical products; and smoking deterrent products.
Prescription Charge Formula: Lower of FUL, SMAC or
Therapeutic Category Coverage: Therapeutic categories EAC plus a dispensing fee or provider’s usual and
covered: antibiotics; anticoagulants; anticonvulsants; customary price to the general public.
antidepressants; antidiabetic agents; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and hypnotics; Maximum Allowable Cost: State imposes Federal Upper
cardiac drugs; chemotherapy agents; prescribed cold Limits and State-specific limits on generic drugs. Override
medications; contraceptives; ENT anti-inflammatory requires prior authorization. Pharmacy must provide
agents; estrogens; growth hormones hypotensive agents; invoice or pharmacy showing that they are charging below
misc. sympathominetics (adrenergic); and thyroid agents. cost.
Prior authorization required for: anabolic steroids;
analgesics; antipyretics, and NSAIDs; antihistamines; Incentive Fee: None.
misc. GI drugs; amphetamines; provigil; aldara; synagis;
regranex; retinoids; andragel; prolastin; and brand names Patient Cost Sharing: No copayment.
of FUL and SMAC drugs. Therapeutic categories not
covered: anorectics and prescribed smoking deterrents. Cognitive Services: Does not pay for cognitive services.
Coverage of Injectables: Injectable medicines
E. USE OF MANAGED CARE
reimbursable through the Prescription Drug Program
when used in home health care and extended care
Does not use MCOs to deliver services to Medicaid
facilities, and through physician payment when used in
recipients. Some Medicaid recipients are enrolled in
physicians offices.
primary care case management and receive their benefits
from the state.
Vaccines: Vaccines reimbursable as part of the EPSDT
Service, The Children’s Health Insurance Program, and
the Vaccines for Children Program.
E-mail: condie@velocitus.net
Bill Foxcroft Internet Address: www.idahopharmacy.org
Idaho Primary Care Association
Idaho Osteopathic Medical Association -Inactive
Bonnie Haines
Idaho Hospital Association
State Board of Pharmacy
Richard K. Markuson
Linda Johnson
Executive Director
(Individual)
3380 Americana Terrace, Suite 320
Boise, ID 83720-0067
Deedra Kucera
T: 208/334-2356
(Aged Community)
F: 208/334-3536
E-mail: rmarkuson@bop.state.id.us
Mark Leeper
Internet address: www.state.id.us.bop
(Disabled Community)
Idaho Hospital Association
Marla Lewis
Steven A. Millard
Kootenai County Welfare Department
President
615 North Seventh Street
Randy Robinson
P.O. Box 1278
Legal Aid-Lewiston
Boise, ID 83701
T: 208/338-5100
Robert VandeMerwe
F: 208/338-7800
Idaho HealthCare Association
E-mail: info@teamiha.org
Internet address: www.teamiha.org
Bob Seehusen
Idaho Medical Association
Mitzi Smith
St. Luke’s Hospital
1
ILLINOIS
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
1 The State of Illinois did not respond to either the 2001 or 2002 NPC Surveys. Using CMS data and other source materials, we have to the extent possible,
updated the Profile and the tables in other sections of the Compilation. Users should contact The Illinois Medicaid program to assess the accuracy and
currency of the information included.
OTC Coverage: Products covered: analgesics and Pharmacy Payment and Patient Cost Sharing
smoking deterrent products. Products requiring prior Dispensing Fee: $4.00 for branded drugs; $5.10 for
authorization: allergy, asthma, and sinus products; generics. Effective 7/1/00.
digestive products (non-H2 antagonist); and topical
products. Products not covered: cough and cold Ingredient Reimbursement Basis: EAC = B: AWP-11%;
preparations; digestive products (H2 antagonists) and G: AWP-20%.
feminine products.
Prescription Charge Formula: Lowest of 1) usual and
Therapeutic Category Coverage: Categories covered: customary, 2) Department's MAC plus fee. Professional
analgesics, antipyretics, and NSAIDs; antibiotics; fee: $3.58 up to EAC of $35.80; above EAC of $35.80,
anticogulants; anticonvulsants; anti-depressants; fee is 10% of EAC.
antidiabetic agents; antilipemic agents; anti-psychotics;
cardiac drugs; chemotherapy agents; contraceptives; Maximum Allowable Cost: State imposes Federal Upper
hypotensive agents; misc. GI drugs; prescribed smoking Limits as well as State-specific limits on generic drugs.
deterrents; sympathominetics (adrenergic); and thyroid Generics priced at the lower of the NDC, FUL, state
agents. Partial coverage: antihistamines; anxiolytics, MAC, or AWP-20%. Override requires prior
sedatives, and hypnotics; and estrogens. Prior authorization.
authorization required: ENT anti-inflammatory agents;
growth hormones; and Cox II’s. Products not covered: Incentive Fee: None.
anoretics and prescribed cold medications.
Patient Cost Sharing: $1.00 for both branded drugs and
Coverage of Injectables: Injectable medicines generics.
reimbursable through the Prescription Drug Program
when used in home health care and extended care facilities Cognitive Services: Does not pay for cognitive services.
and through both the Prescription Drug Program and
physician payment when used in physician offices.
E. USE OF MANAGED CARE
Vaccines: Vaccines are reimbursable as part of the Approximately 140,000 Medicaid recipients were
Vaccines for Children Program. voluntarily enrolled in MCOs in 2001. Recipients receive
pharmaceutical benefits through managed care plans.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.
INDIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other
Aged Blind/ Child Adult Aged Blind/ Child Adult SFO
Disabled
Disabled
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Drug Benefit Product Coverage: Products covered: All Maximum Allowable Cost: State imposes Federal Upper
FDA-approved legend drugs from rebating labelers, Limits as well as State-specific limits on generic drugs.
excluding those products specifically non-covered by state “Brand Medically Necessary” requires prior authorization
law (e.g., cosmetics; enhancement drugs; and as of September 2001.
experimental drugs).
Incentive Fee: None.
Over-the-Counter Product Coverage: Indiana has a
Medicaid OTC drug formulary. Listed drugs are Patient Cost Sharing: Copayment varies from $0.50 to
reimbursed based on State MAC. $3.00 for branded drugs and is $0.50 for generic drugs.
IOWA
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on are preliminary and subject to change.
Timothy J. Gibson
Area Manager, Central Iowa
Joe Cunningham
Waukon, IA
563/568-6315
KANSAS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and
unknown.
**2001 data are preliminary and subject to change.
KENTUCKY
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 Data are preliminary and subject to change.
Vaccines: Vaccines reimbursable in the cost of the Patient Cost Sharing: $1.00
physician visit as part of EPSDT service, Children’s
Health Insurance Program, Vaccines for Children Cognitive Services: Does not pay for cognitive services.
Program and through the Pharmacy Program.
Approximately 153,000 total Medicaid recipients were Richard Arnold, M.D. (Chair)
enrolled in MCOs in FY 2002. Recipients receive George Rodgers Jr., M.D. (Vice-Chair)
pharmaceutical benefits through both the state and Phillip Baier, O.D.
managed care plans. Patricia Freeman, R.Ph., Ph.D.
James S. Davis, M.D.
Managed Care Organization Karen Barnes, M.D.
Passport Health Plan Vaughn Payne, M.D.
Joyce Schifano, Executive Director John Spencer, Pharm.D.
Edward Sorace, P.A.-C.
F. STATE CONTACTS Misha Glendening, A.R.N.P.
Pam Koob, Ph.D. A.R.N.P.
Medicaid Drug Program Administrator Kevin Wemett (non-voting)
Troy Koch, Pharm.D., M.B.A.
Pharmacy Director Drugs Technical Advisory Committee
Department for Medicaid Services Steve Adams, R.Ph.
CHR Building, 6 W-A 217 Lexington Street
275 East Main Street Lancaster, KY 40444
Frankfort, KY 40621
T: 502/564-7940 Ralph Bouvette, R.Ph., Ph.D., J.D.
F: 502/564-0509 102 Enterprise Drive
E-mail: Troy.Koch@mail.state.ky.us Frankfort, KY 40601
Internet Address : www.chs.state.ky.us/dms
Prior Authorization Contact C. Joseph Carr, R.Ph.
Troy Koch, Pharm.D., 502/564-7940 119 W. 22nd Street
Owensboro, KY 42303
Pharmacy and Therapeutics Advisory Committee
Robert C. Hughes, M.D. (Chair) Clarence Sullivan, Pharm.D.
Truman Perry, M.D. 1095 Tatesbrook Drive
Dale E. Toney, M.D. Lexington, KY 40517
Christopher A. Cunha, M.D.
Carol Lee Steltenkamp, M.D., M.B.A. Rick Sutton, R.Ph.
Connie Gayle White, M.D. (Vice-Chair) 275 Spring Valley
Teresa Gevedon, M.D. Paducah, KY 42003
Carmel Wallace, M.D.
Janet Poe Wright, Pharm.D. Prescription Price Updating
Kimberly S. Croley, Pharm.D. UNYSIS Provider Services
R. Michael Cayce, R.Ph. P.O. Box 2100
Troy Koch, Pharm.D., M.B.A. (non-voting) Frankfort, KY 40602
T: 502/226-1140
DUR Contact F: 502/226-1860
Debra Bahr, R.Ph.
Pharmacy Services Program Manager Medicaid Drug Rebate Contact
Department for Medicaid Services Betsy Scott
CHR Building, 6 W-A Department for Medicaid Services
275 East Main Street CHR Building, 6 E-B
Frankfort, KY 40621 275 East Main Street
T: 502/564-7940 Frankfort, KY 40621
F: 502/564-0509 T: 502/564-5472
E-mail: Debra.Bahr@mail.state.ky.us F: 502/564-3232
E-mail: Betsy.Scott@mail.state.ky.us
Executive Officers of State Medical and Kentucky Association of Health Care Facilities
Pharmaceutical Societies Rich Miller, President
Kentucky Medical Association 9403 Mill Brook Road
William T. Applegate Louisville, KY 40223
4965 U.S. Highway 42, Suite 2000 T: 502/425-5000
Louisville, KY 40222-6301 F: 502/425-3431
T: 502/426-6200 E-mail: rmiller@kahcf.org
F: 502/426-6877 Internet address: www.kahcf.org
Internet address: www.kyma.org
LOUISIANA
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Drug Benefit Product Coverage: Products covered: PRODUR system implemented in April 1996.
prescribed insulin; disposable needles and syringe Pharmacy Payment and Patient Cost Sharing
combinations used for insulin; blood glucose test strips;
and urine ketone test strips. Products covered as DME: Dispensing Fee: $5.77 maximum, effective 7/1/94.
total parenteral nutrition and interdialytic parenteral
nutrition. Products not covered: cosmetics; DESI drugs; Ingredient Reimbursement Basis: EAC = AWP-13.5% for
fertility drugs; and experimental drugs. Also, cough and Independent Pharmacies. AWP - 15% for chain
cold preparation and anoretics. pharmacies. (Chain pharmacies are defined as ownership
of more than fifteen (15) Medicaid enrolled pharmacies
Over-the-Counter Product Coverage: Products covered: under common ownership.)
allergy, asthma, and sinus products; analgesics; cough and
cold preparations; digestive products; feminine products; Prescription Charge Formula: Medicaid reimbursement
topical products; and smoking deterrent products. for pharmacy services will be based on the lower of:
MAINE
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and
unknown.
**2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report FY 2000 and CMS, HCFA-64 Report, FY 2001.
Over-the-Counter Product Coverage: Products covered: PRODUR system implemented in 1995. State currently
allergy, asthma, and sinus products (limited coverage has a DUR Board that meets 10 times per year.
after 1/1/01); analgesics (limited coverage after 1/1/01);
cough and cold preparations (limited coverage after Pharmacy Payment and Patient Cost Sharing
1/1/01); digestive products (non H2 antagonists), H2
antagonists (limited coverage after 1/1/01); topical Dispensing Fee: $3.35 for stock supply, or for solutions
products; smoking deterrent products (by Rx only); or lotions involving no weighing. $4.35 for compounding
feminine products (limited coverage). ointments and for solutions/lotions involving weighing
one or more ingredients and making home IV solutions.
Therapeutic Category Coverage: Therapeutic categories $5.35 for compounding handmade supplies, pwd. papers,
covered: anabolic steroids; antibiotics (prior authorization capsules and tablet priturates and for mixing home TPN
required for zyvox); anticoagulants; anticonvulsants; hyperalimentation.
antidiabetic agents; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; hypotensive Ingredient Reimbursement Basis: EAC = AWP - 13%.
agents; sympathominetics (adrenergic); and thyroid
agents. Partial Coverage: anti-depressants (prior Prescription Charge Formula: Lowest of usual and
authorization required. Prior authorization required for: customary, FUL, AWP-13%, or Maine MAC. Maine
analgesics, antipyretics, NSAIDs; anoretics; antihistamine MAC includes approximately 50 drug products in
drugs; antilipemic agents; anti-psychotics; anxiolytics, addition to FUL products.
sedatives, and hypnotics; cardiac drugs; prescribed cold
medications; growth hormones and misc. GI drugs; Maximum Allowable Cost: State imposes Federal Upper
prescribed smoking deterrents; injectable arthritis Limits as well as State-specific limits on generic drugs.
medications; acute migraine medications; Synvisc; Override requires “medically necessary” or “brand
antifungals; EPO; and Synagis, and erectile dysfunction medically necessary” by the physician and prior
products. authorization for some drugs.
Coverage of Injectables: Injectable medicines Incentive Fee: None.
reimbursable through the Prescription Drug Program
when used in home health care and extended care Patient Cost Sharing: Sliding copay scale based on cost:
facilities and through physician payment when used in $0.50 to $3.00.
physician offices.
Cognitive Services: State does not pay for cognitive
services.
Vaccines: Vaccines reimbursable based on cost as part of
the EPSDT service (admin. fees) and as part of the
Children’s Health Insurance Program.
MARYLAND
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Drug Benefit Product Coverage: Products covered: Prior authorization required from the HealthChoice and
legend drugs; prescribed insulin; disposable needles used Acute Care Administration when the usual and customary
for insulin; total parenteral nutrition; and interdialytic charge exceeds $100 and the prescribed amount is a 34-
parenteral nutrition. Products not covered: cosmetics; day supply or more. Preauthorization is needed for any
fertility drugs; experimental drugs; syringe combinations prescription with a usual and customary charge exceeding
used for insulin; blood glucose test strips; urine ketone $400. Prior authorization is also needed for early refills,
test strips; DESI drugs; prescriptions and injections for nutritional supplements, brand medically necessary and
central nervous system stimulants; food supplements or excessive quantities.
infant formulas; products for which Federal Financial
Participation is not allowed, i.e., "less than effective" Prescribing or Dispensing Limitations
drugs and products whose manufacturers have not signed
rebate agreements; and certain other items as specified in
the state's Medicaid plan. Prescription Refill Limit: Maximum of two refills. The
original prescription and its refills may not exceed a 100-
Over-the-Counter Product Coverage: Products covered: day supply except for birth control pills and oral sodium
contraceptives; oral ferrous sulfate; and aspirin for fluoride preparations. Refills may not be dispensed after
arthritis. Products not covered: allergy, asthma and sinus 100 days of date of original prescription except for birth
products; analgesics; cough and cold preparations; control pills and oral sodium fluoride preparations
digestive products (H2 and non-H2 antagonists); feminine
products (except contraceptives); topical products; and Monthly Quantity Limit: The amount of medication to be
smoking deterrent products. dispensed on a prescription at one time is limited to a less
than 34-day supply except for specific maintenance drugs
Therapeutic Category Coverage: Therapeutic categories for chronic conditions, where up to a 100-day supply may
covered: anabolic steroids; analgesics, antipyretics, be dispensed at one time.
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Drug Utilization Review
antidepressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; PRODUR system implemented January 1993. State
prescribed cold medications; contraceptives; ENT anti- currently has a DUR Board with a quarterly review.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; prescribed smoking deterrents;
Pharmacy Payment and Patient Cost Sharing
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: growth hormones; synagis; and
Dispensing Fee: $4.21 as of July 1, 1996.
nutritional supplements for tube-fed recipients.
Therapeutic categories not covered: anorectics. Ingredient Reimbursement Basis: Estimated
Acquisition Cost (EAC) equals/lowest of:
Coverage of Injectables: Injectable medicines 1. Wholesale Acquisition Cost (WAC) plus 10%.
reimbursable through the Prescription Drug Program
when used in home health care, and through both the 2. Direct cost plus 10%.
Prescription Drug Program and physician payment when 3. Distributor's price plus 10%.
used in physician offices. No information provided on
reimbursement for non-self-administered injectable 4. Average Wholesale Price (AWP) minus 10%.
medicines in extended care facilities.
Prescription Charge Formula: Reimbursement will be the
Vaccines: Vaccines reimbursable as part of the Vaccines lower of: (1) the calculated ingredient cost plus a
for Children Program. dispensing fee; (2) the usual and customary fee.
MASSACHUSETTS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance and basis of eligibility are unavailable.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.
1
MICHIGAN
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN) Other
Aged Blind/ Child Adult Aged Blind/ Child Adult SFO
Disabled Disabled
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1 The State of Michigan did not respond to either the 2001 or 2002 NPC Surveys. Using CMS data and other source materials, we have, to the extent
possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the Michigan Medicaid program to assess the accuracy
and currency of the information included.
Therapeutic Category Coverage: Therapeutic categories Dispensing Fee: $3.72, effective 8/1/90.
covered: analgesics, antipyretics, NSAIDs; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Ingredient Reimbursement Basis: 1-4 stores = AWP-
antidiabetic agents; antihistamine drugs; antilipemic 13.5%, 5 or more stores = AWP-15.1%.
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; contraceptives; ENT anti- Prescription Charge Formula: Reimbursement for
inflammatory agents; estrogens; hypotensive agents; misc. legend drugs is limited to the lower of:
GI drugs; sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: chemotherapy 1. AWP-13.5% for 1 to 4 stores & AWP-15.1% for 5 or
agents; growth hormones; and prescribed smoking more stores or LTC, plus dispensing fee minus
deterrents. Therapeutic categories not covered: anabolic selected $1.00 patient copay, or
steroids; anorectics; and prescribed cold medications. 2. The MAC rate, plus dispensing fee, or
Coverage of Injectables: Injectable medicines 3. The provider’s usual and customary charge to the
reimbursable through the Prescription Drug Program when general public.
used in home health care and extended care facilities, and
through physician payment when used in physician Maximum Allowable Cost: State imposes Federal Upper
offices. Limits as well as State-specific limits on generic drugs.
800 drugs are listed on the State-specific MAC list.
Vaccines: Vaccines reimbursable at cost plus a fee/or Override requires “Dispense as Written” and prior
vaccine replacement as part of the EPSDT service and the authorization.
Children Health Insurance Program.
Incentive Fee: None.
Unit Dose: Unit dose packaging reimbursable.
Patient Cost Sharing: Ambulatory recipients age 21 and Community Choice Michigan
older are required to pay a $1.00 copayment for most 2369 Woodlake Drive
legend drugs. If the recipient is unable to pay a required Okemos, MI 48864
copayment on the date of service, the pharmacy cannot 517/349-9922
refuse to render the service. However, the pharmacy may 800/390-7102
bill the recipient for the copayment amount, and he/she is
responsible for paying it. If the recipient fails to pay a Great Lakes Health Plan, Inc.
copayment, the pharmacy could, in the future, refuse to 17117 W. Nine Mile, Suite 1600
serve the recipient as a Medicaid recipient. Southfield, MI 48075
248/559-5656
Drugs not requiring a co-payment include pregnancy- 800/903-5253
related and family planning products.
Health Plan of Michigan
Recipients are not required to make a copayment if: 17515 W. Nine Mile, Suite 650
Southfield, MI 48075
− They are under age 21, or 248/557-3700
− They reside in a long-term care facility (nursing 888/437-0606
home, hospital long-term care facility, or medical care
facility), or HealthPlus Partners, Inc.
2050 S. Linden Road
− Health Maintenance Organization (HMO), or a P.O. Box 1700
capitated Clinic Plan. Flint, MI 48501-1700
810/230-2222
Cognitive Services: Does not pay for cognitive services. 800/322-9161
MINNESOTA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable.
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive services.
reimbursable through the pharmacy benefit when
dispensed by a pharmacy and through physician payment E. USE OF MANAGED CARE
when used in physician offices.
Approximately 340,000 Medicaid recipients were
Vaccines: Vaccines reimbursable when billed as part of enrolled in MCOs in FY 2001. Recipients receive
EPSDT Services, the Children’s Health Insurance pharmaceutical benefits through managed care plans.
Program, and the Vaccines for Children Program.
Medica
P.O. Box 9310 Medicaid DUR Board
Mail Route 80920 Physicians
Minneapolis, MN 55440-9310 Michael F. Koch, M.D.
T: 952/992-3200 Director, Child Psychiatry
F: 952/992-3198 Hennepin County Medical Center
701 Park Avenue South
Metropolitan Health Plan Minneapolis, MN 55402
822 South 3rd Street, Suite 140
Minneapolis, MN 55415 Andrew R. Baron, M.D.
T: 612/347-8584 1930 17th Street South
F: 612/904-4493 St. Cloud, MN 56301
Roger E. Hofer, M.D.
UCare Minnesota Mayo Clinic
P.O. Box 52 200 SW First Street
Minneapolis, MN 55440-0052 Rochester, MN 55905
T: 612/626-3300
F: 612/676-6555 Health Care Professional
Marilyn M. Ulseth, MS., RN., CNP.
South County Health Alliance 2909-33rd Ave South
303 South Cedar Street Minneapolis, MN 55406
Owatonna, MN 55060
T: 507/444-7770 Pharmacists
F: 507/444-7774 Lynne M. Schneider, R.Ph.
12910 37th Avenue North
Plymouth, MN 55441
None
MISSISSIPPI
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Therapeutic Category Coverage: Therapeutic categories Prescription Refill Limit: Limited to five (5).
covered: anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; anti- Monthly Quantities Limit: 34-day supply or 100 units or
psychotics; anxiolytics, sedatives, and hypnotics; cardiac doses, whichever is greater. Birth control pills may be
drugs; chemotherapy agents; prescribed cold medications; supplied in 3-month quantities.
contraceptives; ENT anti-inflammatory agents; estrogens;
Monthly Prescription Limit: Total prescriptions dispensed
hypotensive agents; prescribed smoking deterrents,
per month per recipient are limited to 5. Two additional
antilipemic agents (PA required for xenical);
prescriptions per month may be allowed with prior
sympathominetics (adrenergic); and thyroid agents. Prior
authorization.
authorization required for: analgesics, antipyretics,
NSAIDs; antihistamines; misc. GI drugs; and growth
hormones. Partial coverage: Products not covered: Drug Utilization Review
weight loss drugs; nutritional products; fertility drugs;
vitamins and minerals (except prenatal); and DESI drugs. PRODUR system implemented in 1993.
1
MISSOURI
**Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1 The state of Missouri did not respond to the 2002 NPC Survey. Using CMS data and other source materials, we have, to the extent
possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the Missouri Medicaid program to
assess the accuracy and currency of the information included.
($5.00 copayment for certain 1115 waiver Missouri Care Health Plan
populations (see Pharmacy Bulletin).) 2404 Forum Blvd.
Columbia, MO 65203
Copayment retained by pharmacist. 573/441-2100
MONTANA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on recipients and expenditures by maintenance assistance status and basis of eligibility are unavailable.
Cognitive Services: Does not pay for cognitive services. Prior Authorization Contact
Mark Eichler, R.Ph.
E. USE OF MANAGED CARE DUR Coordinator
Mountain-Pacific Quality Health Foundation
HMO availability began November 1995, to FAIM 3404 Cooney Drive
recipients. SSI and SSI-related clients were eligible to Helena, MT 59602
enroll October 1, 1997. HMO coverage ended June 30, T: 406/443-4020
2000. F: 406/443-4585
E-mail: meichler@mpqhf.org
F. STATE CONTACTS
DUR Contact
State Drug Program Administrator Mark Eichler, R.Ph.
Dan Peterson T: 406/443-4020
Pharmacy Program Officer
Department of Public Health and Human Services Montana DUR Board
Medicaid Services Bureau
P.O. Box 202951 Mark Eichler, R.Ph., FASCP
1400 Broadway DUR Coordinator
Helena, MT 59620-2951
T: 406/444-2738 V. Lee Harrison, M.D.
F: 406/444-1861 Richard Sargent, M.D.
E-mail: danpeterson@state.mt.us Nathan A. Munn, M.D.
Internet address: www.dphhs.state.mt.us Marcella Barnhill, R.Ph.
Lori Fitzgerald, Pharm. D.
NEBRASKA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data provided by State Department of Health and Human Services, Finance and Support, Medicaid Division.
Source: CMS, MSIS Report, FY 2000 and Nebraska Medicaid Statistical information System, FY 2001.
D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging not reimbursable.
Drug Benefit Product Coverage: Products covered: Formulary: Open formulary. General exclusions include:
Legend Drugs, Compound prescriptions, prescribed
1. More than a three-month supply of birth control
insulin with prior approval (i.e., must be medically
tablets;
necessary on pre-filled syringes). Products covered under
the supplier program: disposable needles used for insulin; 2. Experimental drugs or non-FDA approved drugs;
blood glucose test strips; urine ketone test strips; total
parenteral nutrition; and interdialytic parenteral nutrition. 3. Drugs or items when the prescribed use is not for a
Products not covered: DESI drugs, drugs for weight medically accepted indication;
control; cosmetics; fertility drugs; and experimental 4. Liquors (any alcoholic beverages);
drugs. Prior authorization required for: methadone; IV
infusions; and protein replacement supplements. 5. DESI drugs and all identical, related, or similar
drugs;
Over-the-Counter Product Coverage: Products covered: 6. Personal care items (e.g. non-medical mouthwashes,
(must be prescribed and subject to rebate) allergy, asthma, deodorants, talcum powders, bath powders, soaps,
and sinus products; analgesics; topical products; cough dentrifices, eye washes, and contact solutions);
and cold preparations; digestive products; and feminine
products. Products not covered: smoking deterrent 7. Medical supplies and certain drugs for nursing
products. facility and intermediate care facility for the mentally
retarded (IDF/MR) patients;
Therapeutic Category Coverage: Therapeutic categories 8. Over-the-counter (OTC) drugs not listed on the
covered: anabolic steroids; anticoagulants; Department’s Drug Name/License number Listing
anticonvulsants; antilipemic agents; anti-psychotics; microfiche;
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications; 9. Baby foods or metabolic agents (Lofenalac, etc.,)
contraceptives; ENT anti-inflammatory agents; estrogens; normally supplied by the Nebraska Department of
hypotensive agents; sympathominetics (adrenergic); and Health;
thyroid agents. Prior authorization required for: 10. Drugs distributed or manufactured by certain drug
analgesics, antipyretics, NSAIDs; antibiotics (Zyvox); manufacturers or labelers that have not agreed to
anti-depressants (Zoloft, 50mg); antidiabetic agents participate in the drug rebate program.
(Glucovance); antihistamine (low sedating); growth
hormones; misc. GI drugs (PPIs); sunscreens; Drugs, items, or manufacturers that are identifiable as
Erythropoetin (e.g., Epogen, Procrit); modified versions non-covered are so designated on the NE-POP system,
of FUL or SMAC drugs; convenience packaged drugs and on the Department’s Drug Name/License Number
(e.g., Refresh Ophthalmic 0.3 ml and Novalin penfil Listing microfiche.
insulin); drugs to prevent or treat Respiratory Syncytial
Virus Immune Globulin (e.g., Palivizumab, RSV-IG); and Prior Authorization: State currently has a formal prior
drugs for sexual dysfunction (e.g., Sildenafil, authorization procedure. The Department requires that
Alprostadil). Partial coverage for: auxiolytics, sedatives, authorization be granted prior to payment for certain
and hypnotics. Therapeutic categories not covered: products. Prior authorization can be verified through the
anorectics and prescribed smoking deterrents. NE-POP System, or by contacting the Department. (or its
designated contractor) if authorization is not verified
Coverage of Injectables: Injectables reimbursable through through the NE-POP System.
the Pharmacy program when used in home health care
and extended care facilities and through physician
Prescribing or Dispensing Limitations
payment when used in physician offices.
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 Managed Care Organizations
units, whichever is greater. 31-days for injectables.
Share Advantage
United HealthPlans of the Midlands
Drug Utilization Review 2717 North 118th Circle
Omaha, NE 68164
PRODUR system implemented in April 1995. State
currently has a DUR Board with a monthly review.
Primary Care +
Blue Cross/Blue Shield of Nebraska
Pharmacy Payment and Patient Cost Sharing P.O. Box 241739
Omaha, NE 68124
Dispensing Fee: $3.27 - $5.00. The Nebraska
Department of Health and Human Services assigns a Value Options Mental Health
dispensing fee to each individual pharmacy based on 10330 Regency Parkway
location, services, volume, and other third-party Omaha, NE 68114
participation. The fee is calculated from information
obtained through the Department’s Prescription Survey.
F. STATE OFFICIALS
Ingredient Reimbursement Basis: EAC = AWP - 11%.
State Drug Program Administrator
Direct price for some pharmaceutical companies.
Dyke Anderson R.Ph
Prescription Charge Formula: Lower of: Pharmacy Consultant
Health and Human Services
1. Product cost (EAC, SMAC, or FUL) plus a 301 Centennial Mall South
dispensing fee, or 5th Floor-NSOB
2. The usual and customary price to the general public. P.O. Box 95026
Lincoln, NE 68509-5026
Listed OTCs are reimbursed at the lower of: T: 402/471-9379
1. Product cost (EAC, SMAC, or FUL) plus a F: 402/471-9092
dispensing fee, E-mail: dyke.Anderson@hhss.state.ne.us
Internet address: www.hhs.state.ne.us
2. The usual and customary shelf price to the general
public, or Health and Human Services Department Officials
3. Product cost (EAC, SMAC, or FUL) plus a 50% Richard Raymond, M.D., Chief Medical Official
mark-up. Department of Health and Human Services
301 Centennial Mall South
Maximum Allowable Cost: State imposes Federal Upper Lincoln, NE 68509
Limits as well as State-specific limits on generic drugs. 402/471-9105
Approximately 1,000 drugs are listed on the State-specific
MAC list. Override requires a “Medically Necessary” Robert J. Seiffert, Administrator
form signed by the physician. Medicaid Division
402/471-3121
Incentive Fee: None.
Ms. Kris Azimi
Patient Cost Sharing: Copayment = $2.00. Utilization Review Consultant
402/471-9365
Cognitive Services: Does not pay for cognitive services.
Christine Wright, M.D., Medical Director
E. USE OF MANAGED CARE Medicaid Division
402/471-9136
Approximately 156,000 unduplicated Medicaid recipients
were enrolled in managed care in 2001. Recipient Prior Authorization Contact
enrolled in MCOs receive pharmaceutical services
through the State. Dyke Anderson, R.Ph.
402/471-9379
Pat Snyder
Executive Director
Nebraska Health Care Assoc.
421 South 9th Street, Suite 137
Lincoln, NE 68508
NEVADA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2000 and Nevada Medicaid Statistical Information System, FY 2001.
NEW HAMPSHIRE
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: CMS, MSIS Report, FY 2000 and New Hampshire Medicaid Statistical Information System, FY 2001.
NEW JERSEY 1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1 The State of New Jersey did not respond to the 2002 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated
the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid program to assess the accuracy and currency
of the information included.
Unit Dose: Unit dose packaging reimbursable in long- Patient Cost Sharing: None.
term care facilities only, not in retail settings (unless u/d
is only way item is packaged). Cognitive Services: State pays for cognitive services.
Formulary/Prior Authorization
E. USE OF MANAGED CARE
Formulary: Open formulary. General exclusions include Approximately 460,000 Medicaid recipients received
experimental drugs, cosmetics, fertility drugs, DESI pharmacy benefits through managed care in 2001. All
drugs, and drugs for which FFP is not available (OBRA receive pharmaceutical benefits from MCOs.
'90).
NEW MEXICO
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unknown.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal prior
authorization procedure screening for drug classes.
Benefit Design
Prescribing or Dispensing Limitations
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: 34-day supply maximum,
combinations used for insulin; blood glucose test strips; excluding birth control pills (1 year). Number of refills
urine ketone test strips; total parenteral nutrition; and must conform to applicable state and federal laws.
interdialytic parenteral nutrition (covered with
restrictions). Prior Authorization required for:
amphetamines and stimulants for ADD (adults only); Drug Utilization Review
nutritional supplements. Products not covered: drugs for
treatment of tuberculosis; cosmetics; experimental drugs; PRODUR system implemented in October 1993.
fertility drugs; drugs and immunizations available from
any other source; medications supplied by the New Pharmacy Payment and Patient Cost Sharing
Mexico State Hospital to clients on convalescent leave
from hospital; hormones; stimulants; drugs classified by Dispensing Fee: $3.65, effective 6/12/02.
FDA as “ineffective;” and hypnotic drugs (barbiturates).
Over-the-Counter Product Coverage: Products Covered: Ingredient Reimbursement Basis: EAC = AWP-12.5%,
insulin; antacids for active gastric and duodenal ulcers; effective 7/1/97.
infant vitamin drops for up to 1 year; Salicylates and
acetaminophen; vitamins; iron; minerals; and Prescription Charge Formula: Prescriptions reimbursed
pediculocides; laxatives, stool softeners, calcium, nicotine at the lesser of the following:
replacement, ibuprofen, antihistamines, decongestants,
1. Cost (EAC or MAC) dispensed plus a dispensing fee
expectorants, cough suppressants, anti-candida, and
or,
antifungals. Products covered with restriction: topical
products (specific therapeutic categories). Products not 2. The usual and customary charge by the pharmacy to
covered: personal care items (i.e., over-the-counter the general public.
shampoo and soap); feminie products.
Maximum Allowable Cost: State imposes Federal Upper
Therapeutic Category Coverage: Products Covered: Limits as well as State-specific limits on generic drugs.
anabolic steroids; analgesics; antipyretics; and NSAIDs; Override requires “Medically Necessary” or “Brand
antibiotics; anticoagulants; anticonvulsants; Necessary.” Also prescriber is not prohibited from generic
antidepressants; antidiabetic agents, antihistamines; substitution and, if due to drug shortage, requesting
antilipemic agents; anti-psychotics; anxyolitics, sedatives, reimbursement at the brand level.
and hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT anti- Incentive Fee: None.
inflammatory agents; estrogens; growth hormones;
hypotensive agents; misc. GI drugs; prescribed smoking Patient Cost Sharing: No copayment, except for CHIP
deterrents; and sympathominetics (Adrenergic-prior clients and working disabled clients.
authorization required for adults); and thyroid agents.
Partial coverage for: Viagra (prior authorization required). Cognitive Services: Does not pay for cognitive services.
Carolyn Ingram
Prior Authorization Contact Director
Neal Solomon, M.P.H., R.Ph. Medicaid Assistance Division
505/827-3174 T: 505/827-3106
F: 505/827-3185
E-mail: carolyn.ingram@state.nm.us
Medicaid Drug Rebate Contact
Sonya Miera Medical Advisory Committee Members
Drug Rebate Program Administrator
Medical Assistance Division Linda Sechovec
P.O. Box 2348 Executive Director
Santa Fe, NM 87504-2348 NM Health Care
T: 505/827-7777 6400 Uptown Blvd., NE, Suite 520-W
F: 505/827-3185 Albuquerque, NM 87110
NEW YORK
* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: CMS, MSIS Report, FY 2000 and New York Medicaid Statistical Information System, FY 2001.
Department Designee
Lydia Kosinski, R.Ph. Disease Management Program/Initiative Contact
Karen A. Fuller, Ph.D.
Director, Bureau of Program Guidance
Prescription Price Updating
NYS Department of Health
Carl T. Cioppa, Pharm.D. Office of Medicaid Management
Pharmacy Operations Manager 99 Washington Ave, Suite 606
Pharmacy Policy and Operations Albany, NY 12210-2806
NYS Dept. of Health, Office of Medicaid Management T: 518/474-9219
99 Washington Ave., Suite 606 F: 518/473-5508
Albany, NY 12210 E-mail: kaf01@health.state.ny.us
T: 518/486-3209
F: 518/473-5508
E-mail: ctc02@health.state.ny.us Mail Order Pharmacy Program
None
Medicaid Drug Rebate Contacts
Audit & Policy: Mark-Richard Butt, 518/486-3209 Expanded Drug Program Contact
Disputes: Joseph Maiello, 518/486-3209 Julie Naglieri
PRODUR: Dennis Pidgeon, 518/474-6866 Acting Director
NYS Department of Health Program
Elderly Prescription Insurance Coverage (EPIC)
Claims Submission Contact
1 Corporate Plaza, Suite 101
eMed NY 260 Washington Ave., Ext.
Computer Sciences Corporation (CSC) Albany, NY 12203
One CSC Way T: 518/452-6828
Rensselaer, NY 12144 F: 518/452-6882
800/343-9000 E-mail: jab15@health.state.ny.us
E-mail: general@emedny.org Internet Address :
www.health.state.ny.us/nysdoh/epic/faq.htm
Medicaid Managed Care Contact
Physician-Administered Drug Program Contact
Elizabeth Macfarlane
Director, Bureau of Managed Care Program Planning Karen A. Fuller, Ph.D., 518/474-9219
NYS Department of Health, Office of Managed Care
Room 1927, Corning Tower ESP Department of Health Officials
Albany, NY 12237-0064
T: 518/473-0122 Antonia C. Novello, M.D, M.P.H., Dr. Ph.
F: 518/474-5886 Commissioner
E-mail: eag01@health.state.ny.us NYS Department of Health
Corning Tower
The Governor Nelson A Rockefeller Empire State Plaza
Disease Management/Patient Education
Albany, NY 12237
Programs
T: 518/474-2011
Disease/Medical State: AIDS/HIV F: 518/474-5450
Program Name: Aids Intervention Management Program E-mail: acn01@health.state.ny.us
Program Sponser: AIDS Institute, NYSDOH
Title XIX Medical Care Advisory Committee New York State Board of Pharmacy
Lawrence H. Mokhiber
Ruben P. Cowart, D.D.S., (Chairman) Executive Secretary
Michael C. Alfano, D.M.D.
89 Washington Avenue, Second Floor W
John Angerosa, M.D.
Albany, NY 12234-1000
Steven E. Barnes, D.O.
T: 518/474-3848
David Cerniglia, D.C. F : 518/473-6995
Norman R. Loomis, M.D. E-mail : pharmbd@mail.nysed.gov
Hugo M. Morales, M.D., P.C.
Internet Address: www.nysed.gov/prof/pharm.htm
Tanton Mustapha, M.D.
Leon Nadrowski, M.D.
Healthcare Association of New York State
Dennis P. Norfleet, M.D.
Daniel Sisto
Elena Padilla, Ph.D. President
Michael P.M. Poud, M.D. 74 North Pearl Street
Robert A. Schwartz, M.D.
Albany, NY 12207
Gavin Setzen, M.D.
T: 518/431-7800
Kathleen Benson Smith
F: 518/431-7915
Patricia Stevens, Deputy Commissioner, NYS Office of
E-mail: dsisto@hanys.org
Temporary and Disability Assistance (DSS Internet Address: www.hanys.org
Representative)
Roger W. Trifthauser, D.D.S., M.S.
Greater New York Hospital Association
Ellen M. Vossler, D.D.S
Subsidiaries and Affiliates
Kenneth E. Raske
President
Executive Officers of State Medical and 555 W. 57th Street
Pharmaceutical Societies 15th Floor
Medical Society of the State of New York New York, NY 10019
Charles Aswad, M.D. T: 212/246-7100
Executive Vice President F: 212/262-6350
420 Lakeville Road E-mail: raske@gnyha.org
P.O. Box 5404 Internet Address: www.gnyha.org
Lake Success, NY 11042-5404
T: 516/488-6100
F: 516-488-1267
E-mail: mssny@mssny.org
Internet Address: www.mssny.org
NORTH CAROLINA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2000 and North Carolina Statistical Information System, FY 2001.
Note: North Carolina estimates 2002 drug expenditures to be $1.056 billion and the number of Medicaid recipients to be
941,491.
Drug Benefit Product Coverage: Products covered: Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
prescribed insulin; total parenteral nutrition; and
interdialytic parenteral nutrition. Product covered under Ingredient Reimbursement Basis: EAC = AWP-10%.
DME: disposable needles and syringe combinations used
for insulin; blood glucose test strip; and urine ketone test Prescription Charge Formula: The lowest price of AWP
strips. Products not covered: cosmetics; fertility drugs; minus 10%, state MAC or federal MAC, and a
OTC drugs (with exceptions) and experimental drugs; dispensing fee for each different drug dispensed during a
month, or AWP plus the lowest dispensing fee accepted
Over-the-Counter Product Coverage: North Carolina from other third party payers. The pharmacist filling the
does not provide coverage for OTC products except for original prescription will not be reimbursed for refills for
prescribed insulin products. the same drug within a calendar month.
Therapeutic Category Coverage: North Carolina Maximum Allowable Cost: State imposes Federal Upper
provides coverage for all therapeutic categories except Limits as well as State-specific maximum allowable cost
products used for cosmetic purposes; fertility drugs; and (MAC) limits generic drugs. 351 drugs are listed on the
experimental drugs. Prior authorization required for: State-specific MAC list. Override requires “Brand
growth hormones; prescribed smoking deterrents; drugs Medically Necessary.”
used to treat ADHD; Procrit/Epogen; Neupogen;
OxyContin; Provigil; Rebetron; Vioxx; Celebrex; Bextra; Incentive Fee: None.
Enbrel; Botox; Mybloc; Synagis; and RespiGam.
Patient Cost Sharing: $1.00 copayment/Rx (includes
Coverage of Injectables: Injectable medicines refills) for generic prescriptions; $3.00 copayment/Rx for
reimbursable through the Prescription Drug Program brand name prescriptions.
when used in home health care and extended care facility,
and through both the Prescription Drug Program and Cognitive Services: Does not pay for cognitive services.
physician payment when used in physician offices.
NORTH DAKOTA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
North Dakota Department of Human Services. 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
D. PROVISIONS RELATING TO DRUGS authorized by the physician. One refill on proton pump
inhibitors.
Benefit Design
Monthly Quantity Limit: 34-day supply.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles used for insulin; Monthly Dollar Limits: None.
syringe combinations used for insulin; blood glucose test
strips; urine ketone test strips; and total parenteral
nutrition. Products not covered: cosmetics; fertility drugs; Drug Utilization Review
interdialytic parenteral nutrition; drugs used for hair
growth; prescription vitamins (except prenatal vitamins); PRODUR system implemented in July 1996.
and DESI drugs. Prior authorization required for: smoking
cessation (lifetime limits); nutritional supplements; and Pharmacy Payment and Patient Cost Sharing
orlistat.
Dispensing Fee: $5.10, effective 1/6/03.
Over-the-Counter Product Coverage: Products covered:
antacids; analgesics; iron supplements; artificial tears; and
Ingredient Reimbursement Basis: EAC = AWP-10%.
digestive products; and anti-ulcer medications. Products
covered with restriction: smoking deterrent products.
Prescription Charge Formula: Acquisition Cost plus a
Products not covered: allergy, asthma, and sinus products;
dispensing fee per prescription or the usual and customary
cough and cold preparations; and feminine products.
retail charge, whichever is lower. Acquisition Cost =
EAC or MAC.
Therapeutic Category Coverage: Categories covered:
anabolic steroids; analgecics, antipyretics and NSADDs;
Maximum Allowable Cost: State imposes Federal Upper
antibiotics; anticoagulants; anticouvulsants; anti-
Limits as well as State-specific limits on generic drugs.
depressants; antidiabetic agents; antihistamine drugs;
Override requires “Dispense As Written.”
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents;
Incentive Fee: None.
contraceptives; ENT anti-inflammatory agents; estrogens;
growth hormones; hypotensive agents, misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents. Prior Patient Cost Sharing: $3.00 (brand-name drugs)
authorization required: anoretics and prescribed smoking
deterrents (limited to nicotine patches, nicotine gum, and Cognitive Services: Does not pay for cognitive services
bupropion sustained release). Categories not covered:
prescribed cold medications. E. USE OF MANAGED CARE
Coverage of Injectables: Injectable medicines Over 400 Medicaid recipients were enrolled in managed
reimbursable through both the Prescription Drug Program care organizations in 2001. Recipients enrolled in MCO’s
and physician payment when used in physician offices, receive pharmacy benefits through the State.
home health care, and extended care facilities.
OHIO
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
OTC Coverage: Selected coverage for: allergy, asthma, Ingredient Reimbursement Basis: EAC = WAC+9% (eff.
and sinus products; analgesics; feminine products; 5/1/02).
smoking deterrent products; cough and cold preparations;
digestive products; topical products; laxatives; antacids; Prescription Reimbursement Formula: Reimbursement
and vitamins and minerals. for legend drugs and selected OTC products based on the
lowest of:
Therapeutic Category Coverage: Therapeutic categories 1. Provider’s submitted charge, which should reflect
covered: antibiotics; anticoagulants; anticonvulsants; anti- usual and customary charge to the general public;
depressants; antidiabetic agents; antilipemic agents; anti-
psychotics; anxiolytics, sedatives and hypnotics; 2. WAC+9% plus a dispensing fee.
chemotherapy agents; prescribed cold medications; 3. Federal- or state-established Maximum Allowable
contraceptives; ENT anti-inflammatory agents, estrogens; Cost (MAC), for specifically designated generically
sympathominetics (andrenergic); and thyroid agents. equivalent drugs plus a dispensing fee.
Therapeutic categories not covered: anorectics; innovator
multi-source drugs; certain antibiotics (last-line Non-legend drugs - reimbursement is based on WAC+9%
therapies); selected high-risk drugs (e.g., Accutane); and plus a dispensing fee, or MAC if applicable.
drugs used in special settings (e.g., outpatient hospital). Special reimbursement for Blood Factors 8 and 9.
Coverage of Injectables: Injectable medicines Maximum Allowable Cost: State imposes Federal Upper
reimbursable through the Prescription Drug Program Limits as well as State-specific limits on generic drugs.
when used in home health care and extended care Override requires prior authorization.
facilities, and through both the Prescription Drug Program
and physician payment when used in physicians offices. Incentive Fee: None.
Vaccines: Vaccines reimbursable as part of the Vaccines Patient Cost Sharing: No copayment.
for Children Program.
Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging not reimbursable.
E. USE OF MANAGED CARE
Approved Drug List (ADL)/Prior Authorization Approximately 300,000 Medicaid recipients were
enrolled in managed care in 2001. All received pharmacy
ADL: Closed ADL with approximately 28,000 NDC- services through managed care plans.
specific trade and generic drugs. Products excluded
include obesity, fertility, and experimental drugs. Managed Care Organizations
Prior Authorization: State currently has a formal prior Dayton Area Health Plan
authorization procedure. Prior authorization is needed for One South Main Street
certain individual drugs (see examples above) One Dayton Center
Dayton, OH 45402
937/224-3300
Family Health Plan
OKLAHOMA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
OREGON
1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
1 The State of Oregon did not respond to the 2002 NPC Survey. Using CMS data and other source materials, we have to the extent possible, updated the
Profile and the tables in other sections of the Compilation. Users should contact the Oregon Medicaid program to assess the accuracy and currency of the
information included.
Over-the-Counter Product Coverage: Products requiring 2) $3.80 (institutional/SNF: providers operating a True
prior authorization and physician prescription: allergy, or Modified Dose Delivery System).
asthma, and sinus products; analgesics; cough and cold
preparations; digestive products; topical products; and Ingredient Reimbursement Basis: EAC = AWP-13%.
smoking deterrent products.
Prescription Charge Formula: Estimated acquisition cost
Therapeutic Category Coverage: Therapeutic categories (EAC) defined as the lesser of: (1) AWP-13% (2) Federal
covered: Anabolic steroids; analgesics, antipyretics, and Upper Limits for multiple source drugs or (3) state MAC,
NSAIDs; anorectics; antibiotics; anticoagulants; or (4) the usual and customary charge plus a dispensing
anticonvulsants; anti-depressants; antidiabetic drugs; fee.
antilipemic agents; antipsychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; Maximum Allowable Cost: State imposes Federal Upper
prescribed cold medications; contraceptives; ENT anti- Limits as well as State-specific maximum allowable cost
inflammatory agents; estrogens; hypotensive agents; misc. (MAC) limits on generic drugs. Override requires
GI drugs; prescribed smoking deterrents; “Dispense as Written,” or “Brand Medically Necessary.”
sympathominetics (andrenergic); and thyroid agents.
Therapeutic categories requiring prior authorization: Incentive Fee: None.
antihistamine drugs; growth hormones; antifungals;
legend laxatives; oral nutrionals; topical antibiotics; Patient Cost Sharing: No copayment.
topical antivirals; weight reduction drugs; and any other
drug products for which the only indication is for a non- Cognitive Services: Does not pay for cognitive services.
funded condition. (The Oregon Health Plan coverages are
limited to conditions which appear on the HSC prioritized E. USE OF MANAGED CARE
list.)
Approximately 250,000 Medicaid Recipients were
enrolled in MCOs in FY 2001. Recipients enrolled in
Coverage of Injectables: Injectable medicines
MCOs receive pharmaceutical benefits through both State
reimbursable through physician payment when used in
and managed care plans.
physician offices, home health care, and extended care
facilities.
Care Oregon, Inc
522 SW Fifth Ave, Suite 200
Vaccines: Vaccines reimbursable by Medicaid as part of
Portland, OR 97204
the Vaccines for Children Program.
800/224-4840
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.
Sharon Leigh, Pharm.D. State has a Mail Order Pharmacy Program. All
Portland, OR beneficiaries are entitled to participate.
Physician-Administered Drug Program Contact
Robert Mendelson, M.D.
Portland, OR Isabel Bickel, R.N.
Office of Medical Assistance Programs
Clifford Singer, M.D. Department of Human Resources
Portland, OR 500 Summer Street, NE, E-35
Salem, OR 97301
James W. Winde, M.D. 503/945-6490
1212 Aspen Drive Office of Medical Assistance Officials
La Grande, OR 97850
Jean Thorne
Prescription Price Updating Director
Kathy Franklin Department of Human Services
Customer Support Department 500 Summer Street, NE, E-15
First Databank, Inc. Salem, OR 97301-1097
1111 Bayhill Drive NE T: 503/945-5944
San Bruno, CA 94066 F: 503/378-2897
T: 650/588-5454 E-mail: jean.i.thorne@state.org.us
F: 650/588-4003
E-mail: kathy_franklin@firstdatabank.com Lynn Read
Director
Medicaid Drug Rebate Contacts Office of Medical Assistance Programs
Department of Human Services
Becky Smith 500 Summer Street, NE
Rebate Analyst Salem, OR 97301
First Health Services Corp. T: 503/945-5772
565 Union St., NE, Suite 205 F: 503/373-7689
Salem, OR 97301 E-mail: lynn.read@state.or.us
T: 503/391-1981
F: 503/391-1979
E-mail: rssmith@fhsc.com
Claims Submission Contact
Mariellen Rich, R.Ph., 503/391-1980
PENNSYLVANIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2001.
RHODE ISLAND
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Coverage of Injectables: Injectable medicines Maximum Allowable Cost: State imposes Federal Upper
reimbursable under the Prescription Drug Program when Limits on generic drugs. Override requires “Brand
used in home health care and extended care facilities and Medically Necessary” with a documented medical reason
through physician payment when used in physician why a generic cannot be used.
offices.
Incentive Fee: None.
Vaccines: Limited coverage under the Vaccines for
Children Program. Patient Cost Sharing: No copayment.
Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.
Formulary/Prior Authorization
Formulary: State has a formulary. Prior authorization is
used to manage the formulary.
Technical: Helen Vaughn EDS, 401/784-3879 Rhode Island Society of Health-System Pharmacists
Policy: Paula Avarista, 401/462-6390 Richard Emery, President
DUR: Paula Avarista, 401/462-6390 2484 Warwick Avenue
Warwick, RI 02889
Claims Submission Contact
T: 401/737-4144
EDS, 401/784-3879 F: 401/737-0959
E-mail: remery@lifespan.org
Medicaid Managed Care Contact
Internet Address: www.rishp.org
Tricia Leddy, Administrator
Department of Human Services
600 New London Avenue
Cranston, RI 02920 State Board of Pharmacy
401/462-2127 Catherine A. Cordy
Mail Order Pharmacy Program Chief of The Board
3 Capitol Hill, Room 205
None
Providence, RI 02908-5097
Physician-Administered Drug Program Contact T: 401/277-2837
F: 401/222-2158
Paula Avarista, R.Ph., 401/462-6390
E-mail: dianet@doh.state.ri.us
Internet Address:
www.healthri.org//hsr/professions/pharmacy.htm
SOUTH CAROLINA
*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Source: CMS, MSIS Report, FY 2000, and CMS-64 Report FY 2001; South Carolina Medicaid Statistical Information System,
FY 2001.
Therapeutic Category Coverage: Therapeutic categories 1. Brand name products (excluding certain narrow,
covered: anabolic steroids; analgesics, antipyretics, therapeutic index drugs) for which there are A-
NSAIDs; antibiotics; anticoagulants; anticonvulsants; rated, therapeutically equivalent, less costly
antidepressants; antidiabetic agents; antihistamine drugs; generics available.
antilipemic agents; anti-psychotics; anxiolytics, sedatives, 2. COX-2 inhibitors for patients < age 60.
and hypnotics; cardiac drugs; chemotherapy agents; 3. Erectile dysfunction products.
prescribed cold medications; contraceptives; ENT anti- 4. OxyContin® (when maximum quantity
inflammatory agents; estrogens; growth hormones; limitation is exceeded).
hypotensive agents; misc. GI drugs; sympathominetics 5. Panretin®.
(adrenergic); and thyroid agents. Therapeutic categories 6. Proton pump inhibitors for patients > age 21.
not covered: anoretics and prescribed smoking deterrents. 7. Serostim®.
8. Targretin®.
Coverage of Injectables: Injectable medicines 9. Xenical®.
reimbursable through the Physician Services Program
when used in physicians’ offices. Injectables
reimbursable through the Prescription Drug Program Prescribing or Dispensing Limitations
when used at home, through home health care, or in long-
Prescription Refill Limit: The prescriber authorizes the
term care facilities.
number of refills.
Vaccines: Vaccines reimbursable based on CDC price as
Monthly Quantity Limit: Children (birth to age 21) are
part of the Vaccines for Children Program (age under 21).
allowed unlimited prescriptions per month. Beneficiaries
over the age of 21 are limited to a maximum of four
Unit Dose: Unit dose packaging reimbursable. prescriptions per month; however, pharmacists may
override the monthly prescription limit for adult Medicaid
Formulary/Prior Authorization beneficiaries if the prescription meets certain specified
Formulary: Open formulary; certain drug classifications override criteria.
excluded.
Quantity Limit per Prescription: 34 days’ supply per
General Exclusions: prescription.
1. Weight control products.
2. Investigational pharmaceuticals or products. Monthly Dollar Limit: None.
3. Immunizing agents. Drug Utilization Review
4. Pharmaceuticals determined by the FDA to be less
than effective and identical, related, or similar drugs. PRODUR system implemented November 2000. State
5. Injectable pharmaceuticals administered by the currently has a DUR Board with a monthly review.
practitioner in the office in a clinic, or in a mental
SOUTH DAKOTA
Physician Services +
Dental Services +
+ Renal Disease
**Total Other Expenditures/recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
Benefit Design Dispensing Fee: $4.75 to $5.55 (with unit dose fee
applied), effective 7/1/1991
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Ingredient Reimbursement Basis: EAC = AWP-10.5%.
combinations used for insulin; blood glucose test strips;
and urine ketone test strips. Products not covered: Prescription Charge Formula: Payment is the lower of:
cosmetics; DESI drugs; fertility drugs; experimental
drugs; total parental nutrition; drugs for impotence; and 1. FUL, state MAC plus a dispensing fee, or
interdialytic parenteral nutrition. 2. EAC plus a dispensing fee, or usual and customary
charge to the general public.
Over-the-Counter Product Coverage: Products not
covered: allergy, asthma and sinus products; analgesics; Maximum Allowable Cost: State imposes Federal Upper
cough and cold preparations; digestive products; feminine Limits as well as State-specific limits on generic drugs.
products; topical products; and smoking deterrents. Approximately 1,000 drugs are listed on the State-specific
MAC list. Override requires “Brand Medically
Therapeutic Category Coverage: Therapeutic categories Necessary.”
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; anoretics; antibiotics; anticoagulants; Incentive Fee: $110.00
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-psychotics; Patient Cost Sharing: Copayment is $2.00.
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti- Cognitive Services: Does not pay for cognitive services.
inflammatory agents; estrogens; hypotensive agents; misc.
GI drugs; sympathominetics (adrenergic); prescribed cold E. USE OF MANAGED CARE
medications and thyroid agents. Prior authorization
required for: growth hormones. Partial coverage for: Does not use MCOs to deliver pharmacy services to
prescribed smoking deterrents. Therapeutic categories not Medicaid recipients.
covered: nutritional supplements; clozapine.
Michelle Miller
McKennan Home Health
800 E. 21st Street
Sioux Falls, SD 57105-1016
A.A. Lampert, M.D.
Damian Prunty 13075 Bogus Jim Road
Program Administrator Rapid City, SD 57702-9720
Medical Services
TENNESSEE -- TennCare
On January 1, 1994, Tennessee made history by 1998. HCFA approved a waiver extension for three years
withdrawing from the Medicaid Program and beginning January 1, 1999 through December 31, 2001.
implementing an innovative new health care reform plan On July 1, 2002, Tennessee reached a new five-year
called TennCare. In order to implement TennCare, agreement with the federal government to continue
Tennessee was granted a Section 1115 demonstration TennCare.
waiver by the federal government. TennCare replaced the
existing Medicaid Program with a program of managed TennCare services are offered through managed care
health care. TennCare receives about 66 percent of its organizations (MCOs) and behavioral health
annual budget from the federal government. organizations (BHOs) under contract with the State.
Approximately one-third of the TennCare budget consists These MCOs, spread out over the twelve regions of
of state funds. TennCare required no new taxes and Tennessee, are paid a fixed amount. The MCOs and
extended health coverage not only to the nearly 800,000 BHOs negotiate payment rates with individual providers.
Tennesseans in the Medicaid population, but also to an Enrollees have a choice of MCOs (and their
approximately 400,000 uninsured or uninsurable persons corresponding BHO partner plan) from those available in
using a system of managed care. Enrollment was open in their geographic area. Effective January 1, 1997, all
1994 to eligible persons in the uninsured, uninsurable, and services are delivered within a strict "gatekeeper" model
Medicaid-eligible categories. system requiring primary care providers to manage
enrollees' health care.
On January 1, 1995, TennCare reached 90% of its target
enrollment and closed enrollment in the uninsured TennCare services, as determined medically necessary by
category. However, on April 1, 1997, enrollment in the the MCO, cover inpatient and outpatient hospital care,
uninsured category re-opened to children under the age of physician services, prescription drugs, lab and x-ray
18 who do not have access to health insurance through a services, medical supplies, home health care, hospice
parent or guardian. On May 21, 1997, TennCare care, and ambulance transportation. Excluded from
enrollment became available for eligible dislocated TennCare managed care services are long-term care
workers. Enrollment remains open to persons and their services and Medicare cross-over payments which are
dependents who have lost access to a COBRA insurance continuing as they were under the former Medicaid
plan and do not have access to other health insurance. In system.
an effort to expand coverage to more of Tennessee's
uninsured children, the Bureau of TennCare opened TennCare is financed by pooling current Federal, State
enrollment on January 1, 1998 to uninsured Tennesseans and local expenditures for indigent health care. Pooled
under the age of nineteen (19) with access to health resources totaled $5.5 billion in FY 2001. In the future,
insurance whose individual family incomes are below competition among managed care networks, combined
200% of the poverty level. Effective January 1, 1998, with the enrollment cap, should enable TennCare to grow
uninsured children under age nineteen (19) who meet the at a predictable rate not exceeding the annual rate of
TennCare criteria for uninsured are being allowed to growth in State spending.
enroll in TennCare indefinitely. The Bureau of TennCare
eliminated deductibles and limited co-payments to 2% for Source: TennCare Home Page on the World Wide Web,
these new eligibility populations and all uninsured last updated 01/09/03. http://www.state.tn.us/tenncare/
children under eighteen (18) years of age who enrolled in
TennCare during previous open enrollment periods.
ELIGIBILITY FOR TENNCARE COVERAGE
Enrollment remains open to persons who are Medicaid-
eligible or who are uninsurable as determined by an The current federal waiver separates TennCare into two
insurance company's denial (for medical reasons) of products: TennCare Medicaid and TennCare Standard.
health insurance to the individual. Current enrollment Tenncare Medicaid is a continuation of the basic
(2/26/02) is approximately 1.4 million of which 805,000 TennCare Medicaid program with a few minor changes in
are Medicaid eligibles and 618,000 are in the benefits and a three-tired co-payment structure that began
uninsured/uninsurable categories. on January 1, 2003. TennCare Medicaid adds a new
eligibility category: woman under 65 who have been
The State of Tennessee was granted approval by the screened by The Centers for Disease Control and are in
Health Care Financing Administration for a five-year need of treatment for breast or cervical cancer.
demonstration project under Section 1115 of the Social
Security Act. State rules were promulgated to assist in TennCare Standard is similar to a commercial HMO
administering the statewide program (TSOP). The initial package. People eligible for TennCare standard are adults
five-year demonstration project ended December 31, below the 100 percent of the federal poverty level,
TEXAS
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Formulary/Prior Authorization
C. ADMINISTRATION
Formulary: Open formulary; however, products must be
Texas Health and Human Services Commission. Vendor listed in the Texas Drug Code Index. General exclusions
drug program was implemented September 1, 1971. (diseases, drug categories, etc.) include: amphetamines,
appliances, durable medical equipment (bedpans, etc. -
D. PROVISIONS RELATING TO DRUGS either rental or purchase), elastic stockings, first aid
supplies, medical supplies, oxygen, supports and
Benefit Design suspensories, and trusses.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles (pen needles only) Prior Authorization: State currently has a prior
and syringe combinations used for insulin. Products not authorization procedure screening for drug classes and
covered: cosmetics; fertility drugs; experimental drugs; individual drugs.
total parenteral nutrition; and interdialytic parenteral Prescribing or Dispensing Limitations
nutrition; blood glucose test strips; urine ketone test
strips. Prescription Refill Limit: Five refills, but total amount
may not exceed 6-month supply.
Over-the-Counter Product Coverage: Products covered:
feminine products; topical products; allergy, asthma, and Monthly Quantity Limit: Prescribed quantity cannot
sinus products; analgesics; cough and cold preparations; exceed 6-month supply.
digestive products; smoking deterrent products. Certain
OTC drugs are covered on a prescription basis except as Monthly Prescription Limit: Limited to 3 per month
otherwise provided in the reimbursement formula and except for recipients under age 21 and nursing home
vendor payment to hospitals, nursing homes and recipients.
institutions.
Other Limit: Recipients in managed care pilots receive
Therapeutic Category Coverage: Therapeutic categories unlimited prescription coverage.
covered: anabolic steroids; antibiotics; analgesics, Drug Utilization Review
antipyretics, NSAIDs; anticoagulants; anticonvulsants;
anti-depressants; antidiabetic drugs; antihistamine drugs; PRODUR system implemented in February 1995. State
antilipemic agents; antipsychotics; anxiolytics, sedatives, currently has a DUR board with a quarterly review.
and hypnotics; cardiac drugs; chemotherapy agents; Pharmacy Payment and Patient Cost Sharing
contraceptives; prescribed cold medications; ENT anti-
inflammatory agents; estrogens; hypotensive agents; misc. Dispensing Fee: $5.27. The dispensing fee, including all
GI drugs; thyroid agents; prescribed smoking deterrents; costs of filling a prescription, was established by cost
and sympathominetics (adrenergic). Prior authorization accounting and service evaluation of the expenses
required for: growth hormones; dextroamphetamines (>21 involved in dispensing a prescription. Therefore, fees
years of age); xenical (hyperlipidemia only). Therapeutic paid to providers who experience different cost and
categories not covered: anorectics. service factors considered in arriving at the fee may
receive more or less than actual costs incurred in
Coverage of Injectables: Injectable medicines dispensing.
reimbursable through the Prescription Drug Program
when used in home health care, through physician Ingredient Reimbursement Basis: EAC = AWP-15% or
payment when used in physicians offices, and through WAC + 12%, whichever is lower, AAC for hospitals and
both the Prescription Drug Program and Physician public health providers.
payment in extended care facilities.
Prescription Charge Formula: Average dispensing
Vaccines: Vaccines reimbursable as part of EPSDT expense (ADE) formula for payment:
service, the Children’s Health Insurance Program, and the
Vaccines for Children Program. 1. (EAC + 5.27) divided by 0.980 = amount paid +
$0.15 delivery service.
Unit Dose: Unit dose packaging reimbursable if there is 2. DEAC only for Wyeth-Ayerst.
not an added expense for the packaging.
Insulin and approved non-legend drugs on prescription: Texas Health and Human Service Commission
pharmacists and dispensing physicians will be reimbursed 4900 N. Lamar Boulevard
on the basis of usual charges to the general public or cost Austin, TX 78751-2316
plus 50% of cost, whichever is lower; 50% of cost not to T: 512/424-6502
exceed assigned variable dispensing fee. F: 512/424-6587
E-mail: albert.hawkins@hhsc.state.tx.us
Maximum Allowable Cost: State imposes Federal Upper
Limits as well as State-specific limits on generic drugs. Jason Cooke
1,323 therapeutic classes and 8,580 NDC numbers are Medicaid Director
listed on the State-specific MAC list. Override requires Texas Health and Human Services Commission
“Brand Necessary” or “Brand Medically Necessary.” 4900 N. Lamar Boulevard
Austin, TX 78751-2316
Incentive Fee: None. T: 512/424-6517
F: 512/424-6587
Cognitive Services: Does not pay for cognitive services. E-mail: Medicaid@hhsc.state.tx.us
Prior Authorization Contact
Patient Cost Sharing: No copayment.
Don Valdes, R.Ph.
E. USE OF MANAGED CARE Pharmacist II
Vendor Drug Program
Approximately 502,000 Medicaid recipients are enrolled Texas Health and Human Services Commission
in MCOs (all of whom are AFDC/AFDC- related). 1100 W. 49th Street
Recipients in managed care receive pharmaceutical Austin, TX 78756-3174
benefits through the State. (Pharmacy program is “carved T: 512/338-6436
out.”) F: 512/794-5189
Managed Care Organizations E-mail: don.valds@hhsc.state.tx.us
Physician Corporation of America DUR Contact
8303 Mopac, Ste. 450
Austin, TX 78759-8370 Curtis Burch, R.Ph.
512/338-6922
Vista, Inc. DUR Board
9310 North Lomar
Austin, TX 78753 Leroy Knodel, Pharm.D., Vice Chairman
Drug Information Service
F. STATE CONTACTS Department of Pharmacology
The University of Texas Health Science Center
State Drug Program Administrator 7703 Floyd Curl Drive
Curtis Burch, R.Ph. San Antonio, TX 78284-7766
Director, Vendor Drug Program
Texas Health and Human Services Commission Thomas Lee Kurt, M.D., M.P.H.
1100 W. 49th Street 3645 Stratford Avenue
Austin, TX 78756-3174 Dallas, TX 75205
T: 512/338-6992
F: 512/794-5190 Mark S. Gittings, D.O., R.Ph.
E-mail: curtisburch@hhsc.state.tx.us 4327 Grants Glen
Internet address: Wichita Falls, TX 76309
www.hhsc.state.tx.us/hcf/vdp/vdpstart.html
UTAH
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
C. ADMINISTRATION
Therapeutic Category Coverage: Products covered:
Division of Health Care Financing, State Department of analgesics, and NSAIDs; antibiotics; anticoagulants;
Health. anticonvulsants; antidiabetic agents; antilipemic agents;
cardiac drugs; prescribed cold medications;
D. PROVISIONS RELATING TO DRUGS contraceptives; estrogens; hypotensive agents; misc. GI
drugs; sympathominetics (adrenergic); and thyroid agents.
Benefit Design Prior authorization required for: anoretics; anabolic
Drug Benefit Product Coverage: Prior authorization steroids (partial coverage); anti-deppresants;
required for: amphetamines; Ritalin/methylphenidate; antihistamines; anti-psychotics; chemotherapy agents;
darvocet; darvon; enbrel; relenza; human growth ENT anti-inflammatory agents; and growth hormones
hormones; lactulose syrup, lufyllin, oxandrin; panretin (partial coverage). Products not covered: prescribed
topiacal gel; prolastin; regranex retin-a-gel; tamiflu; smoking deterrents; diet medications.
zofran; aggrenox; cerezyme; adagen; xenical; lovenox;
prilosec; prevacid; aciphex; protonix, normiflo; fragmin; Coverage of Injectables: Injectable medicines
kytril; and anzemet. Products covered under DME: total reimbursable through physician payment when used in
parenteral nutrition and interdialytic parenteral nutrition. home health care and in physician offices.
Products not covered: cosmetics; fertility drugs;
experimental drugs; and hair growth products. Vaccines: Vaccines reimbursable at AWP minus 12%
plus a fee as part of the Vaccines for Children Program.
Over-the-Counter Product Coverage: OTC products that
are covered require a written prescription just like legend Unit Dose: Does not reimburse for unit dose packaging.
drugs in order for the pharmacy to fill them. Clients mus Formulary/Prior Authorization
present a Medicaid card and a prescription. Products
covered: Formulary: Open formulary.
− Acetone tests (e.g., Acetest, Chemstrip-K, Ketostix)
− Allergy, asthma and sinus products (generics only) Prior Authorization: Prior authorization procedure
− Analgesics (generics only) screening for individual drugs with fair hearing appeal
− Contraceptives process to DUR board.
− Cough and cold preparations (generics only) Prescribing or Dispensing Limitations
− Digestive products (generics only) Prescription Refill Limit: Limited to five.
− DSS, caps liquid and syrup
− DSS concentrate drops 5% Monthly Quantity Limit: In general, the quantity of
− Ferrous fumerate, All dosage forms medication shall be limited to a supply not to exceed 31
− Ferrous gluconate, All dosage forms days. Cumulative limit on specific drugs.
− Ferrous sulfate, All dosage forms
− Glucose blood tests (e.g., Chemstrip, BG, Dextrostix, Drug Utilization Review
Visidex) PRODUR system implemented in 1994.
− Glucose urine tests (e.g., Clinitest, Clinistix, Diatrix,
Tes Tape, Chemstrip G) Pharmacy Payment and Patient Cost Sharing
− Insulin Dispensing Fee: $3.90 for urban, $4.40 for rural, effective
− Insulin syringes/needles/disposable (100/month) 1993. $1.00 for OTCs.
− Kaolin w/pectin suspension (e.g., Kaopectate)
− Lactobacillus acidophilus (e.g., Bacid, Lactinex) Ingredient Reimbursement Basis: EAC = AWP-15%.
− Nutrients (all nutrients require prior approval)
− Pedialyte liquid Prescription Charge Formula: Lowest of:
− Prophylactics male
− Psyllium muciloid powder 1. EAC/MAC plus a dispensing fee, or
− Quinine, 5 gr. 2. Usual and customary charges to the private sector for
legend and generic legend drugs.
Products covered with restrictions: feminine products; Formula for OTCs is AWP minus 15% plus $1.00
topical products: Products not covered: vitamins (except dispensing fee.
for expectant mothers and children to age 5); smoking
deterrent products (special program for expectant Maximum Allowable Cost: State imposes Federal Upper
mothers); and topical products. Limits as well as State-specific limits on generic drugs.
Override requires “Brand Medically Necessary” and prior
For additional information or to obtain a list of covered authorization.
over-the-counter products, contact the Utah Medicaid
program at http://hlunix.hl.state.ut.us/Medicaid/. Incentive Fee: None.
VERMONT
1
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
1 The State of Vermont did not respond to either the 2001 or 2002 NPC Surveys. Using CMS data and other source materials, we have to the extent
possible, updated the Profile and the tables in other sections of the Compilation. Users should contact The Vermont Medicaid program to assess the
accuracy and currency of the information included.
VIRGINIA
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
C. ADMINISTRATION
Prescription Charge Formula: Based upon the lower of
Department of Medical Assistance Services. Eligibility FUL, VMAC or EAC plus a fee, or the usual and
determination by the Department of Social Services. customary charge minus a copayment of $1.00 for
generics and $2.00 for brand-name products, where
D. PROVISIONS RELATING TO DRUGS appropriate.
Benefit Design
Maximum Allowable Cost: State imposes Federal Upper
Drug Benefit Product Coverage: Products Covered: Limits as well as State-specific limits on generic drugs.
prescribed insulin and needles and syringe combinations Override requires “Brand Necessary.”
used for insulin. Products covered with restrictions: blood
glucose test strips (up to age 21 in FFS, otherwise under Incentive Fee: None.
DME) and total parenteral nutrition (special billing format
using HCVA 1500 form). Products not covered: Patient Cost Sharing: Copayment is $1.00/Rx for
cosmetics; fertility drugs; hair growth products; urine generics and $2.00/RX on brand-name products.
ketone drug test strips (paid under DME) interdialytic qualifying prescriptions. Exclusions include less than 21
parenteral nutrition; designated DESI drugs; experimental years old, pregnancy related, family planning, and nursing
drugs; non-legend drugs; and expired drugs. home patients.
Over-the-Counter Drug Coverage: A majority of OTC Cognitive Services: Does not pay for cognitive services at
drugs reimbursable when used in nursing homes and present.
certain classes in outpatient populations.
E. USE OF MANAGED CARE
Therapeutic Category Coverage: Prior authorization
required for: weight loss drugs. Approximately 503,950 beneficiaries enrolled in managed
care organizations in 2002. Recipients enrolled in
Coverage of Injectables: Injectable medicines managed care organizations receive pharmaceutical
reimbursable through the Prescription Drug Program benefits through managed care plans.
when used in home health care and extended care 1) Medallion - primary care physicians,
facilities, and through physician payment when used in 2) Options - optional enrollment for recipients into
physician offices. HMOs, and
3) Medallion II - mandatory HMOs
Vaccines: Vaccines reimbursable as part of the Vaccines
for Children Program. Managed Care Organizations
Unit Dose: Unit dose packaging reimbursable in nursing Virginia Premier Health Plan
homes. Trigon Health Keepers Plus
Sentara Family Care
Formulary/Prior Authorization Southern Health/CareNet
Formulary: Open Formulary UNICARE Health Plan of Virginia
Sally Rice
Manager, Provider Relations
DUR Board
Division of Program Operations
Robert O. Friedel, M.D. 804/786-9490
Matthew J. Goodman, M.D.
Fiscal Intermediary
Jason Lynam, M.D.
Thomas Moffatt, M.D. First Health Services
Elaine Ferrary, M.S.N. P.O. Box 6987
Jane Settle, N.P. Richmond, VA 23230
Geneva Briggs, Pharm.D.
Virginia Medicaid Pharmacy Liaison Committee
Sandra Johnson, R.Ph.
(PLC)
Kelly Goode, Pharm.D.
Mary Johnson, Pharm.D. Bill Hancock, R.Ph.
Lisa McClanahan, R.Ph. Long Term Care Pharmacy Coalition
Bill Rock, Pharm.D.
Alexander Maculey, R.Ph.
Prescription Price Updating
Virginia Association of Chain Drug Stores
David B. Shepherd, R.Ph., 804/786-8056
Michael Ayotte, R.Ph.
Medicaid Drug Rebate Contacts
Community Pharmacy Coalition
Policy: David B. Shepherd, R.Ph., 804/786-8056
Disputes: Lorraine Sumler, 804/965-7400 Rebecca Snead, R.Ph.
Virginia Association of Chain Drug Stores
Claims Submission Contact
MaryAnn McNeil, R.Ph. Jan Burrus
804/786-2196 Pharmaceutical Research and Manufacturers of America
Mail Order Pharmacy Program Executive Officers of State Medical and
Pharmaceutical Societies
None
Medical Society of Virginia
Medical Managed Care Contact Paul Kitchen
Mary Mitchell Executive Vice President
Supervisor 4205 Dover Road
Department of Medical Assistance Services Richmond, VA 23221-3267
600 East Broad Street, Ste. 1300 T: 804/353-2721
Richmond, VA 23219 F: 804/355-6189
T: 804/786-3594 E-mail: pkitchen@msv.org
F: 804/786-5799 Internet Address: www.msv.org
E-mail: mmitchell@dmas.state.va.us
Physician-Administered Drug Program Contact Virginia Pharmacists Association
Rebecca Snead
Sally Rice, 804/786-9490 Executive Director
Department of Medical Assistance Services 5501 Patterson Ave., Ste. 200
Officials Richmond, VA 23226
T: 804/285-4145
Patrick W. Finnerty F: 804/285-4227
Director E-mail: becky@vapharmacy.org
Department of Medical Assistance Services Internet Address: www.vapharmacy.org
600 East Broad Street, Ste. 1300
Richmond, VA 23219 State Board of Pharmacy
T: 804/786-4231 Elizabeth Scott Russell
F: 804/225-4512 Executive Director
E-mail: pfinnert@dmas.state.va.us 6603 W. Broad Street, 5th Floor
Richmond, VA 23230-1712
T: 804/662-9911
F: 804/662-9313
E-mail: pharmbd@dhp.state.va.us
Internet Address: www.dhp.state.va.us/pharmacy
WASHINGTON
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
WEST VIRGINIA
Source: West Virginia Medicaid Statistical Information System, FY 2001 and FY 2002.
WISCONSIN
*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
WYOMING
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Over-the-Counter Product Coverage: Products covered: Maximum Allowable Cost: State imposes Federal Upper
Analgesics; antacids; antidiarrheal; antihistimines; Limits as well as State-specific limits on generic drugs.
antitussive; contraceptives; food thickeners, insulin, Override requires “Brand Medically Necessary.”
Laxatives; nutrition products; pediatric and prenatal Currently, 6 drugs are included on the State’s MAC list.
vitamins; sodium chloride; supplements; topical
antibiotics, antifungals, antiparasitics; vaginal anti- Incentive Fee: None.
infectives; artificial tears; bronchodiolators; misc. topical
agents; and cough and cold products. Patient Cost Sharing: Copayment is $2.00. The
following recipients or products are exempt from the
Coverage of Injectables: Injectable medicines copayment:
reimbursable through physician payment when used in
home health care, extended care facilities and physician − Pregnant women
offices. − Foster care children
− Home and community based waiver recipients
Vaccines: Vaccines reimbursable at AWP plus a $7.00 − Eligible recipients under age 21
injection fee as part of the EPSDT services, the Children’s − Patients residing in nursing homes
Health Insurance Program and the Vaccines for Children − Family planning products
Program.
Cognitive Services: Does not pay for cognitive services.
Unit Dose: Unit dose packaging not reimbursable.
E. USE OF MANAGED CARE
Formulary/Prior Authorization Does not use MCOs to deliver services to Medicaid
recipients.
Formulary: Open formulary. General exclusions include
anorexants, except amphetamines and derivatives which
F. STATE CONTACTS
are used for narcolepsy and hyperkinetic states; products
to stimulate hair growth. Prior authorization implemented State Drug Program Administrator
10/1/02.
Roxanne Homar, R.Ph.
State Pharmacist
Prior Authorization: State currently has a formal prior
Community and Family Health Division
authorization procedure with review/appeal process.
Primary Case Services
Prescribing or Dispensing Limitations 2424 Pioneer Ave, Suite 100
Cheyenne, WY 82001
Monthly Quantity Limits: Quantity limits on some
T: 307/777-6032
medications as deemed clinically appropriate.
F: 307/777-6964
Drug Utilization Review Email: rhomar@state.wy.us
PRODUR system implemented in October 1995. State
currently has a DUR Board with 12 members that meets
bimonthly.
Appendix A:
State and Federal
Medicaid Contacts
ALABAMA CALIFORNIA
Louise F. Jones J. Kevin Gorospe, Pharm.D.
Pharmacy Program Manager Chief, Medi-Cal Pharmaceutical Section
Alabama Medicaid Agency California Department of Health Services
501 Dexter Avenue Medi-Cal Policy Division
P.O. Box 5624 714 P Street, Room 1540
Montgomery, AL 36103-5624 Sacramento, CA 95814
T: 334/242-5039 T: 916/657-4213
F: 334/353-7014 F: 916/654-0513
E-mail: lljones@Medicaid.state.al.us E-mail: kgorospe@dhs.ca.gov
Internet Address: www.medicaid.state.al.us Internet Address: www.dhs.ca.gov
ALASKA COLORADO
Dave Campana, R.Ph. Dima Ahram, Pharm.D.
Pharmacy Program Manager Department of Health Care Policy & Financing
Division of Medical Assistance 1575 Sherman Street, 5th Floor
4501 Business Park Blvd., Suite 24 Denver, CO 80203
Anchorage, AK 99503 T: 303/866-2468
T: 907/334-2425 F: 303/866-2573
F: 907/561-1684 E-mail: dima.ahram@state.co.us
E-mail: david_campana@health.state.ak.us
CONNECTICUT
ARIZONA Evelyn A. Dudley
Pharmacy Program Manager
Phyllis Biedess
Department of Social Services, Medical Operations
Director
25 Sigourney Street
Arizona Health Care Containment System
Hartford, CT 06106
801 E. Jefferson Street
T: 860/424-5654
Phoenix, AZ 85034
F: 860/424-5206
T: 602/417-4680
E-mail: evelyn.dudley@po.state.ct.us
F: 602/252-6536
Internet Address: ww.ctmedicalassistanceprogram.com
E-mail: PXBiedess@ahcccs.state.az.us
DELAWARE
ARKANSAS
Philip Soulé
Suzette Bridges, P.D., Administrator
Deputy Director/Medicaid
Prescription Drug Program
Department of Health and Social Services
Department of Human Services
1901 N. Dupont Highway
Division of Medical Services
New Castle, DE 19720
P.O. Box 1437, Slot 415
T: 302/255-9501
Little Rock, AR 72203
F: 302/255-4425
T: 501/683-4120
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us
KANSAS MARYLAND
Mary H. Obley, Pharmacist Frank Tetkoski
Health Care Policy Division Pharmacy Services Manager
Kansas Department of Social and Rehabilitation Division of Pharmacy and Clinic Services
Services 201 West Preston Street, Room 205
Docking State Office Building Baltimore, MD 21201
915 SW Harrison, Room 651-South T: 410/767-1455
Topeka, KS 66612-1570 F: 410/333-7049
T: 785/296-8406 E-mail: tetkoskif@dhmh.state.md.us
F: 785/296-4813 Internet Address: www.dhmh.state.md.us
E-mail: mho@srskansas.org
Internet Address: www.srskansas.org MASSACHUSETTS
Paul L. Jeffrey, Director of Pharmacy
KENTUCKY
Division of Medical Assistance
Troy Koch, Pharm.D., M.B.A. 600 Washington Street, 5th Floor
Pharmacy Director Boston, MA 02111
Department for Medicaid Services T: 617/210-5319
CHR Building, 6 W-A F: 617/210/5865
275 East Main Street E-mail: pjeffrey@nt.state.ma.us
Frankfort, KY 40621 Internet Address: www.state.ma.us/dma
T: 502/564-7940
F: 502/564-0509
E-mail: Troy.Koch@mail.state.ky.us MICHIGAN
James Kenyon, R.Ph.
Pharmacist Consultant
LOUISIANA MDCH/ Medical Services Administration
Mary J. Terrebonne, Pharm. D. 400 South Pine Street
Pharmacy Program Director Lansing, MI 48933
Department of Health and Hospitals T: 517/335-5265
1201 Capitol Access Road, 6th Floor F: 517/335-5294
P.O. Box 91030 E-mail: kenyonj@state.mi.us
Baton Rouge, LA 70821 Internet Address: www.Michigan.gov/mdch
T: 225/342-9768
F: 225/342-1980 MINNESOTA
E-mail: mterrebo@dhh.state.la.us
Internet Address: www.lamedicaid.com Cody Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager
Minnesota Department of Human Services
MAINE 444 Lafayette Road
Vacant St. Paul, MN 55155-3853
Director of Pharmacy T: 651/296-8515
Department of Human Services F: 651/282-6744
Bureau of Medical Services E-mail: cody.c.winberg@state.mn.us
442 Civic Center Drive Internet Address: www.dhs.mn.us
Augusta, ME 04333-0011
T: 207/287-4018
F: 207/287-8601
MISSISSIPPI NEVADA
Ricky R. Malloy, R.Ph. Dionne Coston, R.N.
Pharmacy Bureau Director Medicaid Services Specialist
Division of Medicaid Division of Health Care Financing and Policy
Robert E. Lee Building Pharmacy Program
239 North Lamar Street, Suite 801 1100 E. Williams Street
Jackson, MS 39201-1399 Carson City, NV 89701
T: 601/359-5253 T: 775/684-3775
F: 601/359-9555 F: 775/684-3762
E-mail: phrrm@medicaid.state.ms.us E-mail: dcpstpm@dhcfp.state.nv.us
Internet Address: www.dom.state.ms.us
NEW HAMPSHIRE
MISSOURI
Margaret A. Clifford
Susan McCann, R.Ph. Pharmacy Services Administrator
Pharmaceutical Consultant Office of Health Planning & Medicaid
Division of Medical Services 129 Pleasant Street, Annex
P.O. Box 6500 Concord, NH 03301-3857
Jefferson City, MO 65102-6500 T: 603/271-4210
T: 573/751-6963 F: 603/271-4376
F: 573/526-4650 E-mail: mclifford@dhhs.state.nh.us
E-mail: susanmccann@mail.medicaid.state.mo.us Internet Address: www.dhhs.state.nh.us
MONTANA
NEW JERSEY
Dan Peterson
Carl D. Tepper, R.Ph.
Pharmacy Program Officer
Chief, Pharmaceutical Services
Department of Public Health and Human Services
Department of Human Services
Medicaid Services Bureau
Division of Medical Assistance and Health Services
P.O. Box 202951
P.O. Box 712, Bldg. 11-A
1400 Broadway
Trenton, NJ 08625-0712
Helena, MT 59620-2951
T: 609/588-2744
T: 406/444-2738
F: 609/588-3889
F: 406/444-1861
E-mail: cdtepper@dhs.state.nj.us
E-mail: danpeterson@state.mt.gov
Internet Address: www.dphhs.state.mt.us
NEW MEXICO
NEBRASKA Neal Solomon, M.P.H., R.Ph.
Drug Program Administrator
Dyke Anderson, R.Ph.
Medicaid Assistance Division
Pharmaceutical Consultant
P. O. Box 2348
Department of Health and Human Services
Santa Fe, NM 87504-2348
Finance and Support, Medicaid Division
T: 505/827-3174
301 Centennial Mall South, 5th Floor - NSOB
F: 505/827-3185
P.O. Box 95026
E-mail: neal.solomon@state.nm.us
Lincoln, NE 68509-5026
T: 402/471-9379
F: 402/471-9092
E-mail: dyke.anderson@hhss.state.ne.us
Internet Address: www.hhs.state.ne.us
WEST VIRGINIA
Peggy A. King, R.Ph.
Director, Office of Pharmacy Services
WV Department of Human Services
350 Capitol St., Room 251
Charleston, WV 25301-3707
T: 304/558-1700
F: 304/558-1542
E-mail: pking@wvdhhr.org
Internet Address: www.wvhhhr.org/bms
WISCONSIN
Vacant
Division of Health Care Financing
Department of Health and Family Services
One West Wilson Street
P.O. Box 309
Madison, WI 53701-0309
T: 608/266-3753
F: 608/266-1096
E-mail: not available
Internet Address: www.dhfs.state.wi.us/medicaid
WYOMING
Roxanne Homar, R.Ph.
State Pharmacist
2424 Pioneer Avenue, Suite 100
Cheyenne, WY 82001
T: 307/777-6032
F: 307/777-6964
E-mail: rhomar@state.wy.us
State Contact
Vic Walker, R.Ph. B.C.P.P.
Senior Consulting Pharmacist
California Department of Health Services
CALIFORNIA Medi-Cal Policy Division
In-House DUR 714 P Street, Rm. 1540
Sacramento, CA 95814
T: 916/657-0785
F: 916/654-0513
E-mail: vwalker@dhs.ca.gov
State Contact
Dima Ahram, Pharm.D.
Deptartment of Health Care Policy and
Financing
COLORADO
1575 Sherman St., 5th Floor
In-House DUR
Denver, CO 80203
T: 303/866-2468
F: 303/866-2573
E-mail: dima.ahram@state.co.us
State Contact
Donna Bovell, R.Ph.
Pharmacy Consultant
Department of Health
DISTRICT OF Medical Assistance Administration
COLUMBIA 825 North Capitol Street, NE
In-House DUR Fifth Floor
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: donna.bovell@dcgov.org
State Contact
Jean Cox, R.Ph.
Drug Utilization/Prior Approval Coordinator
GA Dept. of Community Health
GEORGIA Division of Medical Assistance
In-House DUR 2 Peachtree St. NW, 37th Floor
Atlanta, GA 30303-3159
T: 404/657-7241
F: 404/656-8366
E-mail: jcox@dch.state.ga.us
State Contact
Kathleen Kang-Kaulupali
DUR Coordinator
HAWAII Med-Quest Division
In-House DUR P.O. Box 700190
Honolulu, HI 96709-0190
T: 808/692-8065
F: 808/692-8131
State Contact
Mary Beth Reinke, Pharm.D.
DUR Coordinator
Minnesota Dept. of Human Services
MINNESOTA
444 Lafayette Rd.
In-House DUR
St. Paul, MN 55155-3853
T: 651/215-1239
F: 651/282-6744
E-mail: mary.beth.reinke@state.mn.us
State Contact
Edward Vaccaro, R.Ph.
Assistant Director
Office of Utilization Management
Division of Medical Assistance and Health
NEW JERSEY Services
In-House DUR 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: ejvaccaro@dhs.state.nj.us
State Contact
Michael Zegarelli
DUR Manager
Office of Medicaid Management
NEW YORK NYS Dept. of Health
In-House DUR 99 Washington Ave, Suite 601
Albany, NY 12210
T: 518/474-6866
F: 518/473-5332
E-mail: maz03@health.state.ny.us
State Contact
Brendan K. Joyce, Pharm.D., R.Ph.
North Dakota Department of Human Services
NORTH DAKOTA 600 E. Boulevard Avenue, Dept. 325
In-House DUR Bismarck, ND 58505-0250
T: 701/328-4023
F: 701/328-1544
E-mail: sojoyb@state.nd.us
State Contact
Jan Lawson
DUR Administrator
OHIO
30 East Broad Street, 31st Floor
In-House DUR
Columbus, OH 43266-0423
T: 614/466-9698
F: 614/466-2866
State Contact
Michael Jockheck, R.Ph.
Pharmacy Consultant
SOUTH DAKOTA SD Department of Social Services
In-House DUR 700 Governors Drive
Pierre, SD 57501
605/773-6439
E-mail: mike.jockheck@state.sd.us
Contractor
State Contact Walter Fitzgerald
Jeffery G. Stockard, D.Ph. Professor of Pharmacy
Associate Pharmacy Director University of Tennessee College of
Bureau of TennCare Pharmacy
TENNESSEE 729 Church Street 26 South Dunlap, Suite 202
Nashville, TN 37247-6501 Memphis, TN 38163
Contracted DUR
T: 615/532-3107 T: 901/448-2351
F: 615/253-5481 F: 901/448-3701
E-mail: jeff.stockard@state.tn.us E-mail: wfitzgerald@utmem.edu
Within Federal and State guidelines, individual managed care and pharmacy benefit
management organizations make formulary/drug decisions.
State Contact
Curtis Burch, R. Ph.
Director, Vendor Drug Program
Texas Health and Human Services
TEXAS Commision
In-House DUR 1100 West 49th Street
Austin, TX 78756-3174
T: 512/338-6922
F: 512/338-6910
E-mail: curtis.burch@hhsc.state.tx.us
State Contact
Duane Parke
DUR Director
Division of Health Care Financing
UTAH Department of Health
In-House DUR P.O. Box 143102
Salt Lake City, UT 84114-3102
T: 801/538-6452
F: 801/538-6099
E-mail: dpark@utah.gov
State Contact
MaryAnn McNeil, R.Ph.
Pharmacy Manager
Deparment of Medical Asistance Services
VIRGINIA
600 East Broad Street, Suite 1300
In-House DUR
Richmond, VA 23219
T: 804/783-2196
F: 804/786-0973
E-mail: mmcneil@dmas.state.va.us
State Contact
Nicole N. Nguyen, Pharm.D.
Clinical Pharmacist
Medical Assistance Administration, DSHS
WASHINGTON 805 Plum Street, SE
In-House DUR P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1757
F: 360/586-2262
E-mail: nguyen@dshs.wa.gov
ALABAMA COLORADO
Keith Hollis, Account Manager ACS, Inc.
EDS 600 17th Street
301 Technacenter Dr. Suite 600 North
Montgomery, AL 36117 Denver CO 80202
334/215-0111 T: 800/237-0757
F: 303/534-0439
ALASKA
CONNECTICUT
Linda Walsh
Systems Administrator Kevin Walsh
Division of Medical Assistance EDS
4501 Business Park Blvd., Suite 24 100 Stanley Street
Anchorage, AK 99503 New Britain, CT 06053
T: 907/334-2441 860/832-5858
F: 901/561-1684
E-mail: linda_walsh@health.state.ak.us DELAWARE
Robert Cornutt
ARIZONA
System Manager
AHCCCS/DBF/CLMS EDS
Lori Petre, Claims Administrator 248 Chapman Rd
701 E. Jefferson Newark, DE 19702
Phoenix, AZ 85034 T: 302/453-8453
602/417-4547 F: 302/454-7603
KANSAS
GEORGIA
EDS
Dustin Gruhlke
3600 SW Topeka Boulevard
Account Manager
Suite 204
Express Scripts, Inc.
Topeka, KS 66611
6625 W. 78th St., BL-0420
785/274-5939
Bloomington, MN 55439
T: 952/837-7741
F: 952/837-7741 KENTUCKY
E-mail: dustin.gruhlke@express-scripts.com Unisys Provider Services
P.O. Box 2100
HAWAII Frankfort, KY 40602
T: 502/226-1140
ACS
F: 502/226-1860
P.O. Box 1220
Honolulu, HI 96807-1220
808/952-5570 LOUISIANA
Doug Hasty
IDAHO Project Manager
Unisys
EDS
8591 United Plaza Blvd., Ste. 300
P.O. Box 23
Baotn Rouge, LA 70809
Boise, ID 83707
T: 225/237-3391
T: 208/395-2000
F: 225/237-3334
F: 208/395-2030
E-mail: doug.hasty@unisys.com
ILLINOIS
MAINE
Illinois Dept. of Public Aid
Marcia Pykare
1001 North Walnut Street
Data Processing Manager
Springfield, IL 62702
Goold Health Systems
T: 217/782-5565
P.O. Box 1090
F: 217524-7194
Augusta, ME 04332
E-mail: dpa_webmaster@state.il.us
T: 207/622-7153
F: 207/623-5125
INDIANA
ACS MARYLAND
E-mail: david.george@acs-inc.com
James Demery
Manager, Pharmacy Services
IOWA First Health Services Corporation
Mindy Ruby Division of Claims Processing
Claims Manager 201 W. Preston St.
ACS Baltimore, MD 21201
P.O. Box 14422 T: 401/767-6028
Des Moines, IA 50306-3422 F: 410/333-7186
T: 515/327-0950 x1108 E-mail: DemeryJ@dhmh.state.md.us
F: 515/327-0945
NEBRASKA
MASSACHUSETTS Glenn Sharp
ACS State Health Care Account Representative
365 Northridge Road First Health Services Corp.
Atlanta, GA 30350 4300 Cox Rd.
800/358-2381 Glen Allen, VA 23060
T: 804/527-3013
F: 804/290-4831
MICHIGAN
First Health Services Corp. NEVADA
4300 Cox Rd.
Glen Allen, VA 23060 First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
MINNESOTA 800/884-3238
Dwaine Voas
MMIS Unit Supervisor NEW HAMPHSHIRE
Minnesota Dept. of Human Services
800 Minnehaha Avenue Farah Jiwa
St. Paul, MN 51555 Account Manager
First Health Services Corp
17 Chenell Drive
MISSISSIPPI Concord, NH 03301
Terry Childress 603/224-2083
Director of Systems Management E-mail: JiwaFa@fhsc.com
Division of Medicaid
Robert E. Lee Building NEW JERSEY
239 North Lamar St.
Jackson, MS 39201-1399 Peter Ringel, Deputy Project Director
T: 601/359-6075 Unisys
F: 601/359-6048 3705 Quakerbridge Rd., Suite 101
E-mail: pptcc@medicaid.state.ms.us Trenton, NJ 08619
T: 609/588-6000
F: 609/584-8270
MISSOURI E-mail: Ringel@njpo1.him.unisys.com
Jim Judge
Claims Process Administrator NEW MEXICO
Verzion
905 Weathered Rock Rd. ACS, Inc.
Jefferson City, MO 65101 365 Northridge Road
573/635-2434 Northridge Center One, Suite 400
Atlanta, GA 30350-2348
T: 770/352-8592
MONTANA F: 770/730-5198
Kevin Quinn
Executive Account Manager NEW YORK
ACS, Inc.
34 N. Last Chance Gulch, Suite 200 eMed NY
Helena, MT 59601 Computer Sciences Corporation
T: 406/449-7693 One CSC Way
F: 406/442-2819 Rensselaer, NY 12144
E-mail: kevin.quinn@acs-inc.com T: 800/343-9000
E-mail: general@emedny.org
WEST VIRGINIA
TEXAS
Becky Garrigan
Laura Bagheri
PBM Account Manager
Manager, Pharmacy Resolutions
ACS, Inc.
Vendor Drug Program
365 Northridge Road
Texas Health and Human Services Commission
Northridge Center One, Suite 400
1100 West 49th Street
Atlanta, GA 30350
Austin, TX 78756-3174
T: 770/352/8592
T: 512/338-6909
F: 770/730-5198
F: 512/794-6190
E-mail: becky.garrigan@acs-inc.com
E-mail: laura.bagheri@hhsc.state.tx.us
WISCONSIN
UTAH
Mark Gajewski
Brenda Bryant, Manager
Account Director
Bureau of Medicaid
EDS
Division of Health Care Financing
6406 Bridge Road
Department of Health
Madison, WI 53784-0014
P.O. Box 143102
T: 608/221-4746
Salt Lake City, UT 84114-3102
F: 608/221-4567
T: 801/538-6136
F: 801-538-6099
E-mail : bbryant@utah.gov WYOMING
ACS
VERMONT Northridge Center, Suite 400
365 Northridge Road
EDS
Atlanta, GA 30350
312 Hurricane Lane, Ste 101
T: 866/322-5960
Williston, VT 05495
F: 888/335-8459
T: 802/879-4450
F: 802/878-3440
VIRGINIA
MaryAnn McNeil, R.Ph.
Pharmacy Manager
Department of Medical Assistance
600 East Broad Street, Suite 1300
Richmond, VA 23219
T: 804/783-2196
F: 804/786-0973
E-mail: mmcneil@dmas.state.va.us
WASHINGTON
Chris Johnson
Claims Processing Manager
Medical Assistance Administrator-DSHS
P.O. Box 45506
Olympia, WA 98504-5506
T: 360/725-1067
F: 360/586-4994
E-mail: johnsc2@dshs.wa.gov
ALABAMA COLORADO
Beverly R. Churchwell, Administrator First DataBank
Alabama Medicaid Agency 1111 Bayhill Drive, Suite 350
501 Dexter Avenue San Bruno, CA 94066
P.O. Box 5624 T: 650/588-5454
Montgomery, AL 36103-5624 F: 650/827-4578
T: 334/242-5034
F: 334/353-7014 CONNECTICUT
E-mail: bchurchwell@medicaid.state.al.us
Ellen Arce
EDS Federal Corp
ALASKA
100 Stanley Drive
Dave Campana, R.Ph New Britain, CT 06053
Pharmacy Program Manager 860/832-5885
Division of Medical Assistance
4501 Business Park Blvd., Suite 24 DELAWARE
Anchorage, AK 99503
T: 907/273-3224 Cynthia Denemark
F: 907/561-1684 Pharmacy Manager
E-mail: david_campana@health.state.ak.us EDS
248 Chapman Road, Suite 200
Newark, DE 197029720
ARIZONA
T: 302/453-8453
Joan Terry F: 302/454-7603
DBF/CLMS/AHCCCS E-mail: cynthia.denemark@eds.com
701 E. Jefferson
Phoenix, AZ 85034 DISTRICT OF COLUMBIA
602/417-7927
First DataBank
1111 Bayhill Drive, Suite 350
ARKANSAS
San Bruno, CA 94066
First DataBank T: 650/588-5454
1111 Bayhill Drive, Suite 350 F: 650/827-4578
San Bruno, CA 94066
650/588-5454 FLORIDA
First DataBank
CALIFORNIA
1111 Bayhill Drive, Suite 350
EDS Federal Corporation San Bruno, CA 94066
P.O. Box 31029 T: 650/588-5454
Sacramento, CA 95813-4029 F: 650/827-4578
916/636-1000
KANSAS
GEORGIA
Mary H. Obley
Andrew Shim, Pharm.D.
Pharmacist
Clinical Program Manager
Health Care Policy Division
Express Scripts, Inc.
Kansas Department of Social and Rehabilitation
6625 W 78th Street, BL0420
Services
Bloomington, MN 55439
Docking State Office Building
T: 952-837-5326
915 SW Harrison, Room 651-South
F: 952-837-7184
Topeka, KS 66612-1570
E-mail: andrew.shim@express-scripts.com
T: 785/296-3981
F: 785/296-4813
HAWAII E-mail: mho@srskansas.org
First DataBank
1111 Bayhill Drive, Suite 350 KENTUCKY
San Bruno, CA 94066
Unisys Provider Services
800/633-3453
P.O. Box 2100
Frankfort, KY 40602
IDAHO T: 502/226-1140
Kaydeen Burkett, R. Ph. F: 502/226-1860
Pharmacy Services Specialist
Department of Health and Welfare LOUISIANA
Division of Medicaid
Maggie Vick
Bureau of Care Management
Unisys
3380 Americana Terrace, Suite 140
8591 United Plaza Blvd., Ste. 300
Boise, ID 87320-0036
Baton Rouge, LA 70809
208/364-1826
T: 225/237-3251
E-mail: burkettk@idhw.state.id.us
F: 225/237-3334
E-mail: margaret.vick@unisys.com
ILLINOIS
First DataBank MAINE
1111 Bayhill Drive, Suite 350
Medispan
San Bruno, CA 94066
650/588-5454
MARYLAND
INDIANA First DataBank
1111 Bayhill Drive, Suite 350
First DataBank
San Bruno, CA 94066
1111 Bayhill Drive, Suite 350
T: 415/588-5454
San Bruno, CA 94066
F: 415/827-4578
650/588-5454
MASSACHUSETTS
IOWA
First DataBank
Sherey Swanson
1111 Bayhill Drive, Suite 350
Deputy Account Manager
San Bruno, CA 94066
ACS, Inc.
T: 650/588-5454
P.O. Box 14422
F: 650/827-4578
Des Moines, IA 50306-3422
T: 515/327-0950 x1107
F: 515/327-0945
MICHIGAN NEVADA
First DataBank First DataBank
1111 Bayhill Drive, Suite 350 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 San Bruno, CA 94066
T: 650/588-5454 T: 650/588-5454
F: 650/588-4003 F: 650/827-4578
Rickey R. Mallory
NEW JERSEY
Pharmacy Bureau Director
Division of Medicaid First DataBank, Inc.
Robert E. Lee Building 1111 Bayhill Drive, Suite 350
239 North Lamar St., Suite. 801 San Bruno, CA 94066
Jackson, MS 39201-1399 T: 650/588-5454
T: 601/359-6296 F: 650/827-4578
F: 601/369-4185
E-mail: phrrm@medicaid.tate.ms.us NEW MEXICO
Neal Solomon, M.P.H, R.Ph.
MISSOURI
Drug Program Administrator
First DataBank Medicaid Assistance Division
1111 Bayhill Drive, Suite 350 P. O. Box 2348
San Bruno, CA 94066 Santa Fe, NM 87504-2348
T: 650/588-5454 T: 505/827-3174
F: 650/827-4578 F: 505/827-3185
E-mail: neal.solomon@state.nm.us
MONTANA
First DataBank NEW YORK
1111 Bayhill Drive, Suite 350 Carl Cioppa, Pharm. D.
San Bruno, CA 94066 Pharmacy Operations Manager
T: 650/588-5454 Pharmacy Policy and Operations
F: 650/827-4578 Office of Medicaid Management
NYS Dept. of Health
NEBRASKA 99 Washington Ave., Suite 606
Albany, NY 12210
First DataBank T: 518/486-3209
1111 Bayhill Drive, Suite 350 F: 518/473-5508
San Bruno, CA 94066 E-mail: ctc02@health.state.ny.us
T: 650/588-5454
F: 650/827-4578
PENNSYLVANIA
NORTH CAROLINA
First DataBank, Inc.
Sharon Greeson, R.Ph.
1111 Bayhill Drive, Suite 350
Pharmacy Programs Manager
San Bruno, CA 94066
EDS
800/633-3453
4905 Waters Edge Drive
Raleigh, NC 27606
T: 919/816-4475 RHODE ISLAND
F: 919/816-4399 Paula J. Avarista, R.Ph.
E-mail: sharon.greeson@eds.com Chief of Pharmacy
Department of Human Services
NORTH DAKOTA 600 New London Avenue
Cranston, RI 02920
Brendan K. Joyce, Pharm.D., R. Ph.
T: 401/462-6390
North Dakota Department of Human Services
F: 401/462-6336
600 East Boulevard Ave.
E-mail: pavarist@gw.dhs.state.ri.us
Dept. 325
Bismark, ND 58505-0250
T: 701/328-4023 SOUTH CAROLINA
F: 701/328-1544 First DataBank
E-mail: sojoyb.@state.nd.us 1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
OHIO T: 650/588-5454
F: 650/588-4003
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066 SOUTH DAKOTA
T: 650/588-5454 Mark Petersen, R.Ph.
F: 650/827-4578 Pharmacy Consultant
Department of Social Services
OKLAHOMA 700 Governors Drive
Pierre, SD 57501
First DataBank
T: 605/773-3495
1111 Bayhill Drive, Suite 350
F: 605/773-5246
San Bruno, CA 94066
E-mail: markp@state.sd.us
800/633-3453
TENNESSEE
OREGON
First DataBank
Kathy Frankiln
1111 Bayhill Drive, Suite 350
Customer Support Department
San Bruno, CA 94066
First DataBank
T: 650/588-5454
1111 Bayhill Drive, Suite 350
F: 650/588/6867
San Bruno, CA 94066
T 650/588-5454
F: 650/588-4003
E-mail: kathy_franklin@firstdatabank.com
TEXAS WASHINGTON
Martha McNeill, R.Ph. Tom Zuchlewski
Director, Product and Prescriber Management Medical Assistance Administration, DSHS
Texas Health and Human Services Commission P.O. Box 45510
1100 West 49th Street Olympia, WA 98504-5510
Austin, TX 78756-3174 T: 360/725-1837
T: 512/338-6965 F: 360/753-9152
F: 512/338-6462 E-mail: zuchltm@dshs.wa.gov
E-mail: martha.mcneill@hhsc.state.tx.us
WEST VIRGINIA
UTAH
Becky Garrigan
RaeDell Ashley, R.Ph. PBM Account Manager
Pharmacy Director ACS, Inc.
Division of Health Care Financing 365 Northridge Road
Department of Health Northridge Center, Suite 400
P.O. Box 143102 Atlanta, GA 30350
Salt Lake City, UT 84114-3102 T: 770/352-8592
T: 801/538-6495 F: 770/730-5198
F: 801/538-6099 E-mail: Becky.Garrigan@acs-inc.com
E-mail: rashley@doh.state.ut.us
WISCONSIN
VERMONT
First DataBank
Christine Dapkiewicz 1111 Bayhill Drive, Suite 350
Drug Rebate Coordinator San Bruno, CA 94066
EDS T: 800/633-3453
312 Hurricane Lane, Suite 101 F: 650/827-4578
Williston, VT 05495
T: 802/879-4450
WYOMING
F: 802/878-3440
First DataBank
1111 Bayhill Drive, Suite 350
VIRGINIA
San Bruno, CA 94066
David B. Shepherd, R.Ph. 800/633-3453
Pharmacy Consultant
Department of Medical Asisstance Services
600 East Broad Street, Suite 1300
Richmond, VA 23112
T: 804/786-8056
F: 804/786-0414
E-mail: dsheper@dmas.state.va.us
ALABAMA CALIFORNIA
Gladys Gray, Associate Director Craig Miller
Alabama Medicaid Agency Chief, Medi-Cal Rebate and Vision Section
501 Dexter Avenue Medi-Cal Policy Division
P.O. 5624 714 P Street, Room 1540
Montgomery, AL 36103-5624 Sacramento, CA 95814
334/242-2323 T: 916/654-0532
E-mail: ggray@medicaid.state.al.us F: 916/654-0513
E-mail: cmiller2@dhs.ca.gov
ALASKA
COLORADO
Peter Yan
Accountant Vince Sherry
Division of Medical Assistance Drug Rebate Manager
4501 Business Park Blvd., Ste. 24 Department of Health Care Policy and Financing
Anchorage, AK 99503 1575 Sherman St., 5th Floor
T: 907/334-2409 Denver, CO 80203
F: 907/561-1684 T: 303/866-5408
E-mail: peter_yan@health.state.ak.us F: 303/866-2573
ARIZONA CONNECTICUT
AHCCCS/DBF/CLMS Mark Heuschkel
Lori Petre, Claims Administrator Lead Planning Analyst - Pharmacy
701 E. Jefferson Department of Social Services
Phoenix, AZ 85034 Medical Operations
602/417-4547 25 Sigourney Street
Hartford, CT 06106
ARKANSAS T: 860/424-5347
F: 860/424-5206
Suzette Bridges, P.D., Administrator E-mail: mark.heuschkel@po.state.ct.us
Prescription Drug Program
Department of Human Services
DELAWARE
Division of Medical Services
Pharmacy Program Lynessa Reynoso
P.O. Box 1437, Slot 415 Rebate Analyst
Little Rock, AR 72203 EDS
T: 501/683-4120 248 Chapman Road
F: 501/683-4124 Newark, DE 19702
E-mail: suzette.bridges@medicaid.state.ar.us T: 302/454-7622
F: 302/454-7603
KENTUCKY MASSACHUSETTS
Betsy Scott Martha Kessenich
Department for Medicaid Services Rebate Analyst
CHR Building, 6 E-B ACS State Health Care
275 E. Main St. 365 North Ridge Road
Frankfort, KY 40621 Atlanta, GA 30350
T: 502/564-5472 800/358-2381
F: 502/564-0223
E-mail: Betsy.Scott@mail.state.ky.us MICHIGAN
James Kenyon, R.Ph.
LOUISIANA
Pharmacist Consultant
Mary J. Terrebonne, Pharm.D MDCH/Medical Services Administration
Pharmacy Program Director 400 S. Pine St.
Department of Health and Hospitals Lansing, MI 48933
1201 Capitol Access Road, 6th Floor T: 517/335-5265
P.O. Box 91030 F: 517/335-5294
Baton Rouge, LA 70821 E-mail: kenyonj@state.mi.us
T: 225/342-9768
F: 225/342-1980 MINNESOTA
E-mail: mterrebo@dhh.state.la.us Jarvis P. Jackson, R.Ph.
Drug Rebate Coordinator
MAINE Dept. of Human Services
444 Lafayette Rd.
Rossi Rowe
St. Paul, MN 55155-3849
TPL Manager
T: 651/282-5881
DHS/Bureau of Medical Services
F: 651/282-6744
11 State House Station
E-mail: jarvisp.jackson@state.mn.us
Augusta, ME 04333-0011
T: 207/287-1838
MISSISSIPPI
F: 207/287-1788
E-mail: rossi.rowe@state.me.us Glenda Grant
Division of Medicaid
Robert E. Lee Building
MARYLAND
239 North Lamar St., Suite 801
Kenneth Smoot Jackson, MS 39201
Deputy Director 601/359-6050
Office of Management and Finance E-mail: acgag@medicaid.state.ms.us
201 W. Preston St.
Baltimore, MD 21201
T: 401/767-5186
F: 410/333-5409
WYOMING
Governor
Honorable Dave Freudenthal
State Capitol, Room 124
Cheyenne, WY 82002-0010
T: 307/777-7434
F: 307/632-3909
E-mail:
governor@missc.state.wy.us
Internet address: www.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: iolesk@state.wy.us
Internet address: wdhfs.state.wy.us
Appendix B:
Medicaid Program Statistics --
CMS MSIS Tables
Historically, States summarized and reported the data processed through their
Medicaid claims processing and payment operations unless they opted to
participate in the Medicaid Statistical Information System (MSIS) project. Prior
to Federal fiscal year 1999, MSIS was a voluntary program and those States
participating in the MSIS project provide data tapes from their claims processing
systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with
the Balanced Budget Act of 1997, all claims processed on or after January 1,
1999, must be submitted electronically in the MSIS format.
The MSIS Report is the primary CMS source on recipients’ use of services and
the associated payments for these services. However, the new reporting
requirements have resulted in a lag in the timely release of MSIS summary
tables. The most recent MSIS service utilization information available from
CMS for all states is for FY 2000, too old for inclusion in the main body of this
year’s Compilation. Hence in many sections of this year’s Compilation, we have
used data from other, more current sources. MSIS data for FY 2001 have been
released for some states, and partial data are included in this Appendix where
appropriate. Please note these data are preliminary and subject to change.
*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these national
totals.
**New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting.
***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals.
*Percentages may not add to 100% due to rounding. Puerto Rico and the U.S. Territories are not included in these national totals.
**New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting.
***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals.
State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of Total
National Total* $168,307,231,426 $20,013,770,558 42,763,233 20,516,882 11.9%
Alabama $2,391,194,897 $331,574,388 619,480 438,529 13.9%
Alaska $470,249,823 $51,196,685 96,432 60,273 10.9%
Arizona $2,111,769,849 $1,952,231 681,258 7,034 0.1%
Arkansas $1,510,079,842 $209,933,612 489,325 290,749 13.9%
California $17,060,494,184 $2,316,135,493 7,915,450 2,487,875 13.6%
Colorado $1,808,569,210 $152,478,786 380,964 160,264 8.4%
Connecticut $2,839,310,317 $264,641,409 419,890 113,089 9.3%
Delaware $528,339,689 $66,263,771 115,267 78,167 12.5%
District of Columbia $792,584,432 $55,092,178 138,677 38,129 7.0%
Florida $7,350,363,024 $1,366,193,807 2,360,417 1,072,082 18.6%
Georgia $3,577,903,288 $580,612,920 1,289,795 847,730 16.2%
Hawaii** $535,162,729 $44,849,664 203,763 35,687 8.4%
Idaho $593,750,993 $83,525,730 131,077 92,776 14.1%
Illinois $7,807,447,335 $847,001,431 1,516,082 1,013,254 10.8%
Indiana $2,976,177,145 $464,982,829 704,624 420,041 15.6%
Iowa $1,476,340,040 $193,832,443 313,648 212,178 13.1%
Kansas $1,226,210,559 $167,216,488 262,557 158,334 13.6%
Kentucky $2,912,792,289 $465,178,958 770,536 427,514 16.0%
Louisiana $2,630,563,430 $476,400,908 761,248 581,356 18.1%
Maine $1,306,809,473 $175,938,952 191,624 148,049 13.5%
Maryland $3,585,781,047 $374,121,433 664,576 409,511 10.4%
Massachusetts $5,397,153,356 $682,519,910 1,047,440 666,627 12.6%
Michigan $4,880,769,009 $374,334,359 1,351,650 435,654 7.7%
Minnesota $3,277,014,103 $221,682,000 559,463 180,104 6.8%
Mississippi $1,807,391,891 $370,355,016 605,077 415,925 20.5%
Missouri $3,270,152,458 $600,484,118 890,318 447,062 18.4%
Montana $433,207,577 $58,634,278 103,821 58,899 13.5%
Nebraska $958,490,235 $135,355,734 229,038 165,891 14.1%
Nevada $515,444,377 $51,682,326 138,069 51,169 10.0%
New Hampshire $650,594,289 $80,562,181 96,935 73,313 12.4%
New Jersey $4,706,928,703 $584,533,211 822,369 298,450 12.4%
New Mexico $1,248,764,305 $57,502,713 375,585 67,238 4.6%
New York $26,147,613,087 $2,366,900,006 3,419,893 2,173,791 9.1%
North Carolina $4,830,025,832 $794,550,074 1,208,789 827,039 16.5%
North Dakota $356,184,829 $38,076,519 60,864 38,957 10.7%
Ohio $7,090,395,763 $882,579,749 1,304,886 777,632 12.4%
Oklahoma $1,603,788,998 $178,254,361 507,059 221,984 11.1%
Oregon $1,700,408,573 $163,263,562 542,392 191,901 9.6%
Pennsylvania $6,365,806,031 $533,527,373 1,492,352 416,498 8.4%
Rhode Island $1,069,994,225 $89,482,143 178,859 49,809 8.4%
South Carolina $2,672,145,530 $334,740,332 685,104 474,465 12.5%
South Dakota $401,175,221 $44,650,518 101,951 53,666 11.1%
Tennessee $3,490,956,581 $0 1,568,318 0 0.0%
Texas $9,075,305,586 $1,125,238,856 2,602,616 1,852,801 12.4%
Utah $959,100,396 $100,794,076 224,268 133,164 10.5%
Vermont $479,258,616 $91,724,918 138,862 103,228 19.1%
Virginia $2,483,930,711 $382,471,744 627,214 347,251 15.4%
Washington $2,432,050,117 $387,877,281 895,279 339,440 15.9%
West Virginia $1,391,731,163 $216,077,217 335,014 261,544 15.5%
Wisconsin $2,905,598,526 $349,558,072 576,636 267,417 12.0%
Wyoming $213,957,743 $27,233,795 46,422 33,342 12.7%
* Puerto Rico and the U.S. Territories are not included in the national totals.
** Hawaii data is for FY1999
State Total Payments Drug Payments Total Recipients Drug Recipients Drugs as a % of Total
National Total
Alabama
Alaska $557,398,672 $64,923,574 105,464 65,278 11.6%
Arizona $2,453,184,175 $4,254,191 763,422 9,761 0.2%
Arkansas $1,684,717,766 $248,392,084 531,533 321,920 14.7%
California $19,824,989,448 $2,808,298,437 8,596,862 2,486,910 14.2%
Colorado $1,952,708,545 $177,115,553 393,195 143,169 9.1%
Connecticut $2,962,088,094 $304,470,534 684,717 116,755 10.3%
Delaware $601,182,212 $81,623,058 122,948 85,351 13.6%
District of Columbia $830,258,078 $62,292,004 140,720 35,324 7.5%
Florida $8,398,159,525 $1,487,935,645 2,458,609 1,159,155 17.7%
Georgia $3,815,267,274 $655,515,772 1,256,990 856,797 17.2%
Hawaii
Idaho $713,433,025 $105,473,425 157,121 112,357 14.8%
Illinois $14,838,487,574 $975,308,665 1,655,837 1,068,512 6.6%
Indiana $3,355,995,714 $562,120,344 771,785 464,879 16.7%
Iowa $1,660,864,098 $230,430,967 319,741 221,691 13.9%
Kansas $1,370,248,183 $189,290,260 272,783 158,515 13.8%
Kentucky $3,235,072,953 $598,093,343 807,435 475,365 18.5%
Louisiana $2,779,206,115 $547,731,897 740,730 594,364 19.7%
Maine
Maryland $3,855,002,531 $417,080,496 634,273 413,755 10.8%
Massachusetts $5,765,107,723 $795,309,302 1,039,979 664,891 13.8%
Michigan $5,316,248,739 $604,759,491 1,352,418 551,593 11.4%
Minnesota $3,766,604,923 $265,240,353 609,314 188,566 7.0%
Mississippi $2,180,662,071 $494,805,247 707,899 478,404 22.7%
Missouri $3,626,212,602 $680,574,899 978,546 472,624 18.8%
Montana $482,543,436 $69,552,397 107,708 63,338 14.4%
Nebraska $1,089,787,848 $161,577,499 242,901 178,365 14.8%
Nevada $565,299,853 $62,849,319 133,103 55,580 11.1%
New Hampshire $691,195,787 $90,927,579 97,062 73,489 13.2%
New Jersey $5,011,794,888 $649,274,352 898,685 307,798 13.0%
New Mexico $1,476,537,827 $70,147,344 379,207 75,669 4.8%
New York $27,497,918,486 $2,779,026,904 3,039,436 2,283,293 10.1%
North Carolina $5,499,093,501 $971,066,103 1,304,684 907,413 17.7%
North Dakota
Ohio $7,772,738,205 $1,087,552,923 1,413,925 904,380 14.0%
Oklahoma $2,004,799,211 $215,717,760 570,671 249,678 10.8%
Oregon
Pennsylvania
Rhode Island
South Carolina $3,096,853,528 $438,498,935 760,797 542,764 14.2%
South Dakota $426,633,598 $52,608,524 109,461 58,203 12.3%
Tennessee $4,059,332,053 $0 1,602,027 - 0.0%
Texas $9,644,600,358 $1,327,222,456 2,659,682 1,917,351 13.8%
Utah $1,059,729,740 $117,101,302 232,520 136,682 11.1%
Vermont $541,283,084 $105,673,417 149,262 109,328 19.5%
Virginia $2,715,962,318 $419,133,293 618,395 333,880 15.4%
Washington
West Virginia $1,565,008,585 $256,395,319 349,229 269,174 16.4%
Wisconsin $3,029,722,940 $389,373,521 633,463 262,238 12.9%
Wyoming $241,187,030 $31,881,860 51,068 36,704 13.2%
*2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
*Puerto Rico and the U.S. Territories are not included in the national totals.
** Hawaii data is for FY1999
*2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
* Puerto Rico and the U.S. Trust Territories are not included in the national totals.
** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000.
CMS included their FY 1999 data in the FY 2000 MSIS Report.
*** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting.
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
** Puerto Rico and the U.S. Trust Territories are not included in the national totals.
** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000. CMS
included their FY 1999 data in the FY 2000 MSIS Report.
*** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting.
*Puerto Rico and the U.S. Territories are not included in the national totals.
**Hawaii data is for FY 1999.
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
Source: CMS, HCFA-2082 Reports, FY 1996-FY 1998 and MSIS Reports, FY 1999-2001.
Source: U.S. Department of Commerce, Bureau of the Census, State Population Estimates; CMS, MSIS, FY 2001.
Appendix C:
Medicaid Rebate Law
(1) In general
In order for payment to be available under section 1396b(a) of this title for covered outpatient drugs of a
manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in
subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a
State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph
(5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after
November 4,1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991,
shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered into on
January 1,1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an
agreement, subsequently entered into, shall become effective as of the date on which the agreement is entered into
or, at State option, on any date thereafter on or before the first day of the calendar quarter that begins more than
60 days after the date of the agreement is entered into.
(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.
*This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States
Code.
(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.
(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) 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.
(A) In general
Each manufacturer with an agreement in effect under this section shall report to the Secretary - (i) not
later than 30 days after the last day of each rebate period under the agreement (beginning on or after
January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and,
(for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in
subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the
agreement, and (ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 for
each of the manufacturer’s covered outpatient drugs.
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).
(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.
(1) Basic rebate for single source drugs and innovator multiple
source drugs
(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate
period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a
single source drug or an innovator multiple source drug shall be equal to the product of -
(i) the total number of units of each dosage form and strength paid for under the State plan in the rebate
period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined in
subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer
price, for the rebate period.
(II) any prices charged under the Federal Supply Schedule of the General Services Administration;
(III) any prices used under a State pharmaceutical assistance program; and
(IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of
the Federal Government.
(ii) Special rules
The term “best price” -
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement,
volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form
or product or package; and
(III) shall not take into account prices that are merely nominal in amount.
(2) Additional rebate for single source and innovator multiple source drugs
(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount
equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for
which payment was made under the State plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar quarter
beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an
entity, including a division or subsidiary of the manufacturer, after the first day of such quarter),
increased by the percentage by which the consumer price index for all urban consumers (United States
city average) for the month before the month in which the rebate period begins exceeds such index for
September 1990
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1,
1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter
after the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and
“the month prior to the first month of the first full calendar quarter after the day on which the drug was
first marketed” for “September 1990”.
(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.
(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).
(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.
(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other
appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s
drug use review board established under subsection (g)(3) of this section).
(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any
manufacturer which has entered into and complies with an agreement under subsection (a) of this section
(other than any drug excluded from coverage or otherwise restricted under paragraph (2)).
(C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or
condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a
drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate
compendia described in subsection (k)(6) of this section), the excluded drug does not have a significant,
clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such
treatment for such population over other drugs included in the formulary and there is a written
explanation (available to the public) of the basis for the exclusion.
(D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excluded
from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that
is consistent with paragraph (5).
(E) The formulary meets such other requirements as the Secretary may impose in order to achieve
program savings consistent with protecting the health of program beneficiaries. A prior authorization
program established by a State under paragraph (5) is not a formulary subject to the requirements of this
paragraph.
(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).
(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).
(1) In general
(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by not
later than January 1, 1993, for a drug use review program described in paragraph (2) for covered
outpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and
(iii) are not likely to result in adverse medical results. The program shall be designed to educate
physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross
overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients, or
associated with specific drugs or groups of drugs, as well as potential and actual severe adverse reactions
to drugs including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug
interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical
abuse/misuse.
(B) The program shall assess data on drug use against predetermined standards, consistent with the
following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information;
(III) the DRUGDex information System;
(IV) American Medical Association Drug Evaluations; and
(ii) the peer-reviewed medical literature.
(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each State
an amount equal to 75 per centum of so much of the sums expended by the State plan during calendar
years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug
use review program which conforms to the requirements of this subsection.
(D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to
residents of nursing facilities which are in compliance with the drug regimen review procedures
prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title,
currently at section 483.60 of title 42, Code of Federal Regulations.
(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.
(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the
“DUR Board”) either directly or through a contract with a private organization.
(B) Membership
The membership of the DUR Board shall include health care professionals who have recognized
knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed
and actively practicing physicians and at least 1/3 licensed and actively practicing pharmacists.
(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section.
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems or
individuals identified in the course of retrospective drug use reviews performed under this subsection.
Intervention programs shall include, in appropriate instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists
in the State of information concerning its duties, powers, and basis for its standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both)
information and suggested changes in prescribing or dispensing practices, communicated in a manner
designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in rational drug
therapy and selected prescribers and pharmacists who have been targeted for educational intervention,
including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up
face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluate
interventions after an appropriate period of time to determine if the intervention improved the quality
of drug therapy, to evaluate the success of the interventions and make modifications as necessary.
(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.
(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the
Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the
Senate and the House of Representatives a report on the operation of this section in the preceding fiscal year.
(2) Details
Each report shall include information on –
(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and
nonprescription covered outpatient drugs;
(B) the total value of rebates received and number of manufacturers providing such rebates;
(C) how the size of such rebates compare with the size of rebates offered to other purchasers of covered
outpatient drugs;
(D) the effect of inflation on the value of rebates required under this section;
(E) trends in prices paid under this subchapter for covered outpatient drugs; and
(F) Federal and State administrative costs associated with compliance with the provisions of this
subchapter.
(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 -
(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title,
a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) of
such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is
identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal
Regulations) to such a drug, and (II) which has not been the subject of a final determination by the
Secretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or
304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21
U.S.C. 352(f), 355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the
Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or
related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such
a drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under
section 505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the
Secretary to withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use prescribed,
recommended, or suggested in its labeling; and
(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356).
(C) Dental services, except that drugs for which the State plan authorizes direct reimbursement to the
dispensing dentist are covered outpatient drugs.
(F) Nursing facility services and services provided by an intermediate care facility for the mentally
retarded.
(5) Manufacturer
The term “manufacturer” means any entity which is engaged in -
(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.
(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug
(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not
including any drug described in paragraph (5)) for which there are 2 or more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent
publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as
defined in subparagraph (C) and as determined by the Food and Drug Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source
drug that was originally marketed under an original new drug application approved by the Food and Drug
Administration.
(iii) Noninnovator multiple source drug
The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator
multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or distributed under an
original new drug application approved by the Food and Drug Administration, including a drug product
marketed by any cross-licensed producers or distributers operating under the new drug application.
(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the
requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug
products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C).
(C) Definitions
For purposes of this paragraph -
(i) drug products are pharmaceutically equivalent if the products contain identical amounts of the same
active drug ingredient in the same dosage form and meet compendial or other applicable standards of
strength, quality, purity, and identity;
So in original. Probably should be “pharmaceutically”.
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if they
do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a published national
listing of average wholesale prices selected by the Secretary, provided that the listed product is generally
available to the public through retail pharmacies in that State.
Appendix D:
Federal Upper Limits for
Multiple Source Products
The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of the
Social Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL)
listing has been accomplished by computer. Payments for multiple source drugs identified and listed in the
accompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drug
entity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount based
on the limit per unit which CMS has determined to be equal to a 150 percent applied to the lowest price listed (in
package sizes of 100 units, unless otherwise noted) in any of the published compendia of cost information of
drugs. Issued by CMS on November 20, 2001 the initial listing was based on data current as of April 2001 from
the First Data Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional
changes (i.e., additions, deletions, pricing changes) through May 11, 2003. The list does not reference the
commonly known brand names. However, the brand names are included in the FUL listing provided to the State
agencies in electronic media format. The FUL price list is in Microsoft Word format at
http://www.cms.hhs.gov/Medicaid/drugs/drug10.asp.
In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL
listing for which the Food and Drug Administration (FDA) has issued a notice of an opportunity for a hearing as
a result of the Drug Efficacy Study and Implementation (DESI) program and which has been found to be less
than effective or is identical, related, or similar (IRS) to the DESI drug. The DESI drug is identified by the FDA
or reported by the drug manufacturer for purposes of the Medicaid drug rebate program.
The November 20, 2001 list has been amended with all changes to be implemented no later than May 11, 2003.
Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B
Acetazolamide
250 mg, Tablet, Oral 100 0.2454 R
Acetylcysteine
10%, Solution, Inhalation; Oral 10 ml 0.7634 B
20%, Solution, Inhalation; Oral 10 ml 0.9285 B
Acyclovir
200 mg, Capsule, Oral 100 0.3525 B
400 mg, Tablet, Oral 100 0.7048 R
800 mg, Tablet, Oral 100 1.2160 B
Albuterol
0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B
Albuterol Sulfate
Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B
Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B
Allopurinol
100 mg, Tablet, Oral 100 0.0784 B
300 mg, Tablet, Oral 100 0.1671 B
Alprazolam
0.25 mg, Tablet, Oral 100 0.0614 R
0.5 mg, Tablet, Oral 100 0.0698 B
1 mg, Tablet, Oral 100 0.0885 B
2 mg, Tablet, Oral 100 0.1745 R
Amantadine Hydrochloride
50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M
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
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
Amoxapine
50 mg, Tablet, Oral 100 0.5425 R
Amoxicillin
250 mg, Capsule, Oral 100 0.0636 B
500 mg, Capsule, Oral 100 0.1272 B
125 mg/5 ml, Powder for reconstitution, Oral 150 0.0201 B
250 mg, Tablet, Chewable, Oral 100 0.1595 B
Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral, 100 0.1295 R
500 mg, Capsule, Oral, 100 0.2171 B
Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.3522 B
Atenolol
25 mg, Tablet, Oral 100 0.1595 B
50 mg, Tablet, Oral 100 0.0885 B
100 mg, Tablet, Oral 100 0.1650 B
Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.1762 B
100 mg; 25 mg, Tablet, Oral 100 0.2549 B
Benzonatate
100 mg, Capsule, Oral 100 0.4387 B
Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.1227 B
1 mg, Tablet, Oral 100 0.1502 B
2 mg, Tablet, Oral 100 0.1930 B
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
Bumetanide
0.5 mg, Tablet, Oral 100 0.1743 B
1 mg, Tablet, Oral 100 0.2814 B
2 mg, Tablet, Oral 100 0.4708 B
Buspirone Hydrochloride
5 mg, Tablet, Oral 100 0.2964 B
10 mg, Tablet, Oral 100 0.3942 B
15 mg, Tablet, Oral 60 0.4470 B
Captopril
12.5 mg, Tablet, Oral 100 0.0398 B
100 mg, Tablet, Oral 100 0.1867 B
Captopril; Hydrochlorothiazide
25 mg; 15 mg, Tablet, Oral 100 0.2359 B
25 mg; 25 mg, Tablet, Oral 100 0.2360 B
50 mg; 15 mg, Tablet, Oral 100 0.3702 B
50 mg; 25 mg, Tablet, Oral 100 0.3702 B
Carbamazepine
200 mg, Tablet, Oral 100 0.1388 R
Carbidopa; Levodopa
10 mg; 100 mg, Tablet, Oral 100 0.3644 B
25 mg; 100 mg, Tablet, Oral 100 0.3915 B
25 mg; 250 mg, Tablet, Oral 100 0.4657 B
Carisoprodol
350 mg, Tablet, Oral 100 0.3743 B
Carteolol Hydrochloride
1%, Solution/Drops, Ophthalmic 10 ml 3.6775 R
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 0.1661 B
Eq 250 mg base/5 ml,
Powder for reconstitution, Oral 150 0.2995 B
Eq 375 mg base/5 ml,
Powder for reconstitution, Oral 100 0.4492 B
Cefadroxil/Cefadroxil Hemihydrate
Eq 500 mg base, Capsule, Oral 50 2.4837 B
Cephalexin
Eq 250 mg base, Capsule, Oral 100 0.2513 B
Eq 500 mg base, Capsule, Oral 100 0.4446 B
Chlordiazepoxide Hydrochloride
5 mg, Capsule, Oral 100 0.1140 B
10 mg, Capsule, Oral 100 0.0877 B
Chlorhexidine Gluconate
0.12%, Solution, Dental 480 ml 0.0146 B
Chlorpheniramine Maleate
4 mg, Tablet, Oral 100 0.0171 M
Chlorpropamide
100 mg, Tablet, Oral 100 0.1837 B
250 mg, Tablet, Oral 100 0.3885 B
Chlorthalidone
25 mg, Tablet, Oral 100 0.0509 B
50 mg, Tablet, Oral 100 0.0558 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
Cimetidine Hydrochloride
Eq 300 mg bases/ 5 ml solution, Oral 240 ml 0.1139 B
Clindamycin Hydrochloride
Eq 150 mg base, Capsule, Oral 100 0.9180 R
Clindamycin Phosphate
Eq 1% base, Solution, Topical 60 ml 0.2060 R
Clobetasol Propionate
0.05%, Cream, Topical 30 gm 0.8315 B
Clomipramine Hydrochloride
25 mg, Capsule, Oral 100 0.3322 R
50 mg, Capsule, Oral 100 0.5138 B
75 mg, Capsule, Oral 100 0.5772 B
Clonazepam
0.5 mg, Tablet, Oral 100 0.2455 B
1 mg, Tablet, Oral 100 0.2852 B
2 mg, Tablet, Oral 100 0.3903 B
Clonidine Hydrochloride
0.1 mg, Tablet, Oral 100 0.0968 B
0.2 mg, Tablet, Oral 100 0.1350 B
0.3 mg, Tablet, Oral 100 0.1794 B
Clorazepate Dipotassium
3.75 mg, Tablet, Oral 100 0.8350 B
7.5 mg, Tablet, Oral 100 1.0388 B
15 mg, Tablet, Oral 100 1.4094 B
Cromolyn Sodium
4%, Solution/ Drops, Ophthalmic 10 ml 3.3750 B
Cyclobenzaprine Hydrochloride
10 mg, Tablet, Oral 100 0.2728 B
Desonide
0.05%, Ointment, Topical 60 gm 0.4077 B
Desoximetasone
0.25%, Cream, Topical 60 gm 0.6180 B
Dexamethasone
0.5 mg/5 ml, Elixir, Oral 240 ml 0.0625 B
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
Diclofenac Potassiuim
50 mg, Tablet, Oral 100 0.8625 B
Diclofenac Sodium
50 mg, Tablet, Delayed Release, Oral 100 0.4748 R
75 mg, Tablet, Delayed Release, Oral 100 0.5850 R
Dicyclomine Hydrochloride
10 mg, Capsule, Oral 100 0.1222 B
20 mg, Tablet, Oral 100 0.1185 B
Diflunisal
500 mg, Tablet, Oral 60 1.0000 B
Diltiazem Hydrochloride
30 mg, Tablet, Oral 100 0.1019 B
60 mg, Tablet, Oral 100 0.1114 B
90 mg, Tablet, Oral 100 0.2312 B
120 mg, Tablet, Oral 100 0.2331 B
Diphenhydramine Hydrochloride
12.5 mg/5 ml, Elixir, Oral 120 ml 0.0137 B
Dipivefrin Hydrochloride
0.1%, Solution/Drops, Ophthalmic 5 ml 0.8700 B
Doxazosin Mesylate
1 mg, Tablet, Oral 100 0.5918 B
2 mg, Tablet, Oral 100 0.5918 B
4 mg, Tablet, Oral 100 0.6210 B
8 mg, Tablet, Oral 100 0.6518 B
Doxepin Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.0891 R
Eq 25 mg base, Capsule, Oral 100 0.1822 B
Eq 50 mg base, Capsule, Oral 100 0.1447 R
Eq 75 mg base, Capsule, Oral 100 0.2052 R
Eq 100 mg base, Capsule, Oral 100 0.4174 B
Eq 10 mg base/ml, Concentrate, Oral 120 ml 0.1145 R
Doxycycline Hyclate
Eq 50 mg base, Capsule, Oral 50 0.0915 B
Eq 100 mg base, Capsule, Oral 50 0.1050 B
Eq 100 mg base, Tablet, Oral 50 0.1287 B
Erythromycin
250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1889 B
2%, Solution, Topical 60 ml 0.0687 B
Estazolam
1 mg, Tablet, Oral 100 0.5925 R
2 mg, Tablet, Oral 100 0.6449 R
Estradiol
0.5 mg, Tablet, Oral 100 0.1791 B
1 mg, Tablet, Oral 100 0.1932 B
2 mg, Tablet, Oral 100 0.3060 B
Estropipate
0.75 mg, Tablet, Oral 100 0.2754 B
1.5 mg, Tablet, Oral 100 0.3450 B
3 mg, Tablet, Oral 100 0.8622 B
Etodolac
200 mg, Capsule, Oral 100 0.4800 B
400 mg, Tablet, Oral 100 0.3600 R
500 mg, Tablet, Oral 100 1.0032 R
Famotidine
20 mg, Tablet, Oral 100 0.6210 B
40 mg, Tablet, Oral 100 1.2000 B
Fenoprofen Calcium
Eq 600 mg base, Tablet, Oral 100 0.2400 R
Fluocinolone Acetonide
0.01%, Solution, Topical 60 ml 0.1172 B
Fluocinonide
0.05%, Cream, Topical 60 gm 0.1789 B
0.05%, Gel, Topical 60 gm 0.4965 R
0.05%, Solution, Topical 60 ml 0.2483 R
Fluorometholone
0.1%, Suspension/Drops, Ophthalmic 5 ml 1.6590 B
Fluoxetine Hydrochloride
10 mg, Capsule, Oral 100 0.5850 B
20 mg, Capsule, Oral 100 0.6000 B
40 mg Capsule, Oral 30 4.0125 B
20 mg/5ml, Solution, Oral 120 ml 0.7500 R
10 mg, Tablets, Oral 30 0.6000 B
Fluphenazine Hydrochloride
1 mg, Tablet, Oral 100 0.2273 B
2.5 mg, Tablet, Oral 100 0.2775 B
5 mg, Tablet, Oral 100 0.3546 B
10 mg, Tablet, Oral 100 0.5099 R
Flurazepam Hydrochloride
15 mg, Capsule, Oral 100 0.0750 R
30 mg, Capsule, Oral 100 0.0922 R
Flurbiprofen
100 mg, Tablet, Oral 100 0.3600 B
Flurbiprofen Sodium
0.03%, Solution/Drops, Ophthalmic 2ml 4.0679 B
Folic Acid
1 mg, Tablet, Oral 100 0.0456 B
Furosemide
10 mg/ml, Solution, Oral 60 ml 0.1300 B
20 mg, Tablet, Oral 100 0.0563 B
40 mg, Tablet, Oral 100 0.0599 B
80 mg, Tablet, Oral 100 0.1043 B
Gemfibrozil
600 mg, Tablet, Oral 500 0.3058 B
Gentamicin Sulfate
Eq 0.3% Base, Solution/Drops, Ophthalmic 5 ml 0.6540 B
Glipizide
5 mg, Tablet, Oral 100 0.0699 B
10 mg, Tablet, Oral 100 0.0944 B
Glyburide
1.25 mg, Tablet, Oral, 100 0.1244 B
1.5 mg, Tablet, Oral 100 0.2549 R
2.5 mg, Tablet, Oral, 100 0.1893 B
3 mg, Tablet, Oral 100 0.3202 R
5 mg, Tablet, Oral, 100 0.2831 B
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
Hydralazine Hydrochloride
10 mg, Tablet, Oral 100 0.0354 B
25 mg, Tablet, Oral 100 0.0450 B
Hydrochlorothiazide; Spironolactone
25 mg; 25 mg, Tablet, Oral 100 0.3463 B
Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 0.3177 B
25 mg; 37.5 mg, Tablet, Oral 100 0.1932 B
50 mg; 75 mg, Tablet, Oral 100 0.0488 B
Hydrocortisone
0.5%, Cream, Topical, 30 gm 0.0375 B
1%, Cream, Topical 30 gm 0.0585 B
2.5%, Cream, Topical 30 gm 0.1820 B
1%, Lotion, Topical 120 ml 0.0572 B
2.5%, Lotion, Topical 59 ml 0.6814 B
Hydroxychloroquine Sulfate
200 mg, Tablet, Oral 100 0.8535 B
Hydroxyzine Hydrochloride
10 mg/5 ml, Syrup, Oral 480 ml 0.0307 B
Hydroxyzine Pamoate
Eq 25 mg HCL, Capsule, Oral 100 0.0892 B
Eq 50 mg HCL, Capsule, Oral 100 0.1013 B
Ibuprofen
400 mg, Tablet, Oral 100 0.0493 B
600 mg, Tablet, Oral 100 0.0573 B
800 mg, Tablet, Oral 100 0.1065 B
Imipramine Hydrochloride
10 mg, Tablet, Oral 100 0.3210 B
25 mg, Tablet, Oral 100 0.4275 R
50 mg, Tablet, Oral 100 0.5615 B
Indapamide
1.25 mg, Tablet, Oral 100 0.1035 B
2.5 mg, Tablet, Oral 100 0.1125 B
Isoniazid
300 mg, Tablet, Oral 100 0.0890 B
Isosorbide Dinitrate
10 mg, Tablet, Oral 100 0.0281 R
20 mg, Tablet, Oral 100 0.0291 B
2.5 mg, Tablet, Sublingual 100 0.0488 B
5 mg, Tablet, Sublingual 100 0.0456 B
Isosorbide Mononitrate
10 mg, Tablet, Oral 100 0.6110 R
20 mg, Tablet, Oral 100 0.4950 B
60 mg, Tablet, Extended Release, Oral 100 0.7492 B
Ketoconazole
200 mg, Tablet, Oral 100 2.7750 B
Ketoprofen
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
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
0.5 mg, Tablet, Oral 100 0.4350 B
1 mg, Tablet, Oral 100 0.5718 B
2 mg, Tablet, Oral 100 0.5698 B
Lovastatin
10 mg, Tablet, Oral 60 0.7487 B
20 mg, Tablet, Oral 60 1.2488 B
40 mg, Tablet, Oral 60 2.2738 B
Meclizine Hydrochloride
12.5 mg, Tablet, Oral 100 0.0599 B
25 mg, Tablet, Oral 100 0.0717 B
Medroxyprogesterone Acetate
2.5 mg, Tablet, Oral 100 0.2025 B
5 mg, Tablet, Oral 100 0.3061 B
10 mg, Tablet, Oral 100 0.2488 B
Megestrol Acetate
20 mg, Tablet, Oral 100 0.3489 B
40 mg, Tablet, Oral 100 0.6755 B
Meperidine Hydrochloride
50 mg, Tablet, Oral 100 0.5370 B
100 mg, Tablet, Oral 100 1.0347 B
Methazolamide
25 mg, Tablet, Oral 100 0.3150 R
50 mg, Tablet, Oral 100 0.4650 R
Methenamine Mandelate
1 gm, Tablet, Oral 100 0.2923 B
Methocarbamol
500 mg, Tablet, Oral 100 0.1943 B
Methotrexate Sodium
Eq 2.5 mg base, Tablet, Oral 100 1.2637 B
Methylphenidate Hydrochloride
5 mg, Tablet, Oral 100 0.3020 B
10 mg, Tablet, Oral 100 0.4224 B
20 mg, Tablet, Oral 100 0.6180 B
Methylprednisolone
4 mg, Tablet, Oral 100 0.2849 B
Metoclopramide
10 mg, Tablet, Oral 100 0.1095 B
Metoclopramide Hydrochloride
Eq 5 mg base/5 ml, Solution, Oral 480 ml 0.0155 B
Eq 5 mg base, Tablet, Oral 100 0.1842 B
Eq 10 mg base, Tablet, Oral 100 0.1089 B
Metoprolol Tartrate
50 mg, Tablet, Oral 100 0.0703 B
100 mg, Tablet, Oral 100 0.0914 B
Metronidazole
250 mg, Tablet, Oral 100 0.0849 B
500 mg, Tablet, Oral 100 0.2184 B
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
20 mg, Tablet, Oral 100 0.4650 B
40 mg, Tablet, Oral 100 0.4289 B
80 mg, Tablet, Oral 100 0.8025 B
Naltrexone Sodium
50 mg, Tablet, Oral 100 4.0400 B
Naphazoline Hydrochloride
0.1%, Solution/Drops, Ophthalmic 15 ml 0.3140 R
Naproxen
250 mg, Tablet, Oral 100 0.1044 R
375 mg, Tablet, Oral 100 0.1383 R
500 mg, Tablet, Oral 100 0.1805 B
375 mg, Tablet, Delayed Release, Oral 100 0.6750 B
Niacin
500 mg, Tablet, Oral 100 0.0390 B
Nicardipine Hydrochloride
20 mg, Capsule, Oral 100 0.3375 B
30 mg, Capsule, Oral 100 0.4050 B
Nifedipine
10 mg, Capsule, Oral 100 0.1237 B
Nizatidine
150 mg, Capsule, Oral, 60 1.8307 B
300 mg, Capsule, Oral, 30 3.6615 B
Nortriptyline Hydrochloride
Eq 10 mg base, Capsule, Oral 100 0.1019 B
Eq 25 mg base, Capsule, Oral 100 0.1406 B
Eq 50 mg base, Capsule, Oral 100 0.1722 B
Eq 75 mg base, Capsule, Oral 100 0.2203 B
Nystatin
100,000 units/gm, Cream, Topical 30 gm 0.0755 B
100,000 units/gm, Ointment, Topical 15 gm 0.1019 B
100,000 units/ml, Suspension, Oral 60 ml 0.1757 B
Orphenadrine Citrate
100 mg, Tablet, Extended Release, Oral 100 1.8225 B
Oxaprozin
620 mg, Tablet, Oral 100 0.6758 B
Oxazepam
10 mg, Capsule, Oral 100 0.5363 B
15 mg, Capsule, Oral 100 0.7624 B
30 mg, Capsule, Oral 100 1.2337 R
Oxybutynin Chloride
5 mg, Tablet, Oral 100 0.1260 R
Penicillin V Potassium
Eq 250 mg base/5 ml, Powder for reconstitution, Oral 200 ml 0.0165 B
Pentoxifylline
400 mg, Tablet, Extended Release, Oral 100 0.3147 B
Perphenazine
2 mg, Tablet, Oral 100 0.2801 R
4 mg, Tablet, Oral 100 0.3448 B
16 mg, Tablet, Oral 100 0.6377 R
Pindolol
5 mg, Tablet, Oral 100 0.1537 B
10 mg, Tablet, Oral 100 0.1973 B
Piroxicam
10 mg, Capsule, Oral 100 0.0891 B
20 mg, Capsule, Oral 100 0.1131 B
Potassium Chloride
8 mEq, Tablet, Extended Release, Oral 100 0.0772 B
Prednisolone
15 mg/5 ml, Syrup, Oral 480 ml 0.2081 B
Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 10 ml 1.6950 B
Prednisone
5 mg, Tablet, Oral 100 0.0330 B
10 mg, Tablet, Oral 100 0.0548 B
20 mg, Tablet, Oral 100 0.0758 B
Primidone
250 mg, Tablet, Oral 100 0.6405 B
Probenecid
500 mg, Tablet, Oral 100 0.7059 B
Prochlorperazine Maleate
Eq 5 mg base, Tablet, Oral 100 0.3986 B
Eq 10 mg base, Tablet, Oral 100 0.5766 B
Promethazine Hydrochloride
6.25 mg/5 ml, Syrup, Oral 120 ml 0.0264 B
Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0585 B
20 mg, Tablet, Oral 100 0.0705 B
40 mg, Tablet, Oral 100 0.0848 B
80 mg, Tablet, Oral 100 0.1140 B
Quinidine Gluconate
324 mg, Tablet, Extended Release, Oral 100 0.4500 B
Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B
Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.7658 R
Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B
Spironolactone
25 mg, Tablet, Oral 100 0.3000 B
Sucralfate
1 gm, Tablet, Oral 100 0.3690 B
Sulfacetamide Sodium
10%, Solution/Drops, Opthalmic 15 ml 0.1530 B
Sulfamethoxazole; Trimethoprim
400 mg; 80 mg, Tablet, Oral 100 0.1325 B
800 mg; 160 mg, Tablet, Oral 100 0.1590 B
Sulfasalazine
500 mg, Tablet, Oral 100 0.1757 B
Sulindac
150 mg, Tablet, Oral 100 0.3317 B
200 mg, Tablet, Oral 100 0.4289 B
Temazepam
15 mg, Capsule, Oral 100 0.1365 B
30 mg, Capsule, Oral 100 0.1748 B
Terazosin Hydrochloride
Eq 1 mg base, Capsule, Oral 100 1.5413 B
Eq 2 mg base, Capsule, Oral 100 1.5413 B
Eq 5 mg base, Capsule, Oral 100 1.5413 B
Eq 10 mg base, Capsule, Oral 100 1.5413 B
Tetracycline Hydrochloride
500 mg, Capsule, Oral 100 0.0975 B
Theophylline
100 mg, Tablet, Extended Release, Oral 100 0.1184 B
200 mg, Tablet, Extended Release, Oral 100 0.1607 B
300 mg, Tablet, Extended Release, Oral 100 0.1593 B
Thioridazine Hydrochloride
10 mg, Tablet, Oral 100 0.2190 B
25 mg, Tablet, Oral 100 0.3030 B
50 mg, Tablet, Oral 100 0.3885 R
100 mg, Tablet, Oral 100 0.5025 B
Thiothixene
1 mg, Capsule, Oral 100 0.1388 B
2 mg, Capsule, Oral 100 0.1860 B
5 mg, Capsule, Oral 100 0.2963 B
10 mg, Capsule, Oral 100 0.4065 B
Ticlopidine Hydrochloride
250 mg, Tablet, Oral 60 1.5119 B
Timolol Maleate
Eq 0.25% base, Solution/Drops, Ophthalmic 10 ml 0.6975 B
Eq 0.5% base, Solution/Drops, Ophthalmic 15 ml 0.9000 B
Tizanidine Hydrochloride
2 mg, Tablet, Oral, 150 0.8071 B
4 mg, Tablet, Oral, 150 0.9560 B
Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 1.1850 M
Tolazamide
250 mg, Tablet, Oral 100 0.4005 B
Tramadol Hydrochloride
50 mg, Tablet, Oral, 100 0.3068 B
Trazodone Hydrochloride
50 mg, Tablet, Oral 100 0.0684 R
100 mg, Tablet, Oral 100 0.0952 B
150 mg, Tablet, Oral 100 0.3113 B
Triamcinolone Acetonide
0.025%, Cream, Topical 80 gm 0.0364 B
0.1%, Cream, Topical 80 gm 0.0448 B
0.5%, Cream, Topical 15 gm 0.1889 B
0.1%, Lotion, Topical 60 ml 0.1215 B
0.1%, Ointment, Topical 80 gm 0.0502 B
0.1%, Paste, Dental 5 gm 0.8280 B
Triazolam
0.125 mg, Tablet, Oral 100 0.4041 B
Trifluoperazine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.2433 B
Eq 2 mg base, Tablet, Oral 100 0.3552 B
Eq 5 mg base, Tablet, Oral 100 0.4271 B
Eq 10 mg base, Tablet, Oral 100 0.5403 B
Trihexyphenidyl Hydrochloride
2 mg, Tablet, Oral 100 0.1275 B
5 mg, Tablet, Oral 100 0.2580 B
Tropicamide
0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B
Valproic Acid
250 mg, Capsule, Oral 100 0.3488 B
250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M
Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
180 mg, Capsule, Extended Release, Oral 100 0.8700 B
240 mg, Capsule, Extended Release, Oral 100 0.4350 B
40 mg, Tablet, Oral 100 0.1963 R
80 mg, Tablet, Oral 100 0.0735 B
120 mg, Tablet, Oral 100 0.1110 B
180 mg, Tablet, Extended Release, Oral 100 0.4350 B
240 mg, Tablet, Extended Release, Oral 100 0.3683 B
Appendix E:
Glossary
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.”
Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO, for
services such as claims processing, billing and enrollment, and overhead
costs. Administrative costs can be expressed as a percentage of premiums or
on a per member per month basis. Additional costs that are often expressed as
administrative include those related to utilization review, insurance marketing,
medical underwriting, agents’ commissions, premium collection, claims
processing, insurer profit, quality assurance activities, medical libraries and
risk management.
Administrative Services Only (ASO) An insurance arrangement requiring the employer to be at risk for the cost of
health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.
Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of benefits,
thereby driving up costs and increasing financial risk.
Term Definition
Aged For purposes of Medicare enrollment, persons 65 years of age or over are
considered to be aged. Medicaid eligibility is determined on the basis of
financial need for people who meet Supplemental Security Income (SSI)
eligibility criteria (aged, blind, or disabled individuals) and Temporary
Assistance for Needy Families (TANF) criteria (adults and children).
Eligibility determinations are made for an entire economic unit or “case”
(sometimes a family) based on whether or not one member of a case meets the
criteria. For example, an “aged” case could consist of a 66 year old male and
his 63 year old wife. In contrast, a disabled enrollee could be over 65 years of
age. May also be defined as “Elderly.”
Agency for Healthcare Research and A Federal agency under Health and Human Services (HHS) whose purpose is
Quality (AHRQ) to enhance the quality and effectiveness of healthcare by funding healthcare
services research, conducting health technology assessments and outcomes
studies, and developing and disseminating clinical practice guidelines.
Aid to Families with Dependent A State-based Federal cash assistance program for low-income families. In all
Children (AFDC) States, AFDC recipiency may be used to establish Medicaid eligibility. Now
known as Temporary Assistance 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 A nonprofit organization that coordinates the development of voluntary
(ANSI) national standards in both the public and private sectors.
Ancillary Charge (1) The fee associated with additional service performed prior to and/or
secondary to a significant procedure. (2) Also referred to as hospital “extras”
or miscellaneous hospital charges. They are supplementary to a hospital’s
daily room and board charge. They include such items as charges for drugs,
medicines and dressings, lab services, x-ray examinations, and use of the
operating room.
Term Definition
Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.
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.
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.
Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.
Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs during
a benefit period.
Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.
Term Definition
Best Price For purposes of Medicaid rebate calculations, lowest price paid for a product
by any purchaser other than Federal agencies and State pharmaceutical
assistance programs.
Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured by
blood levels, urine levels, etc.
Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand name
and generic drugs are listed by product, manufacturer, National Drug or
Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.
Brand Name Name identifying a drug as the product of a specific pharmaceutical company.
Also known as proprietary trademark name.
Cafeteria Plan An employee benefit plan under which all participants are permitted to choose
among two or more benefit options according to their needs and/or ability to
pay. Also called a flexible benefit plan of “flex plan.”
Capitation 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.”
Term Definition
Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize healthcare resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that assists
the patient in determining the most appropriate and cost-effective treatment
plan. It is used for patients who have prolonged expensive or chronic
conditions, helps determine the treatment location (hospital, or other
institution, or home), and authorizes payment for such care if it is not covered
under the patient’s benefit agreement.
Case Manager An experienced professional (e.g., nurse, doctor or social worker) who works
with patients, providers and insurers to coordinate all services deemed
necessary to provide the patient with a plan of medically necessary and
appropriate health care.
Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for TANF, Supplemental Security Income, or an optional State
supplement.
Centers for Medicare and Medicaid The government agency within the Department of Health and Human Services
Services (CMS) 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.
Term Definition
Claims Administration A carrier function involving the review of health insurance claims submitted
for payment, by individual claim or in the aggregate. Claims administration,
as it relates to professional review programs, is an identification procedure,
screening treatment or charge pattern, for subsequent peer review and
adjudication.
Claims Clearinghouse System A system which allows electronic claims submission through a single source.
Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be sure
the cost of the service is not excessive.
Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.
Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.
Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.
Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.
Closed-Panel HMO Generally offers the services of a relatively limited number of healthcare
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.
CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic source
of state-reported eligibility and claims data on the Medicaid population, their
characteristics, utilization, and payments. Through FY 1998, the HCFA-2082
was an annual State submitted report designed to collect aggregate statistical
data on Medicaid eligibles, recipients, services, and expenditures during each
federal fiscal year. States summarized and reported the data processed through
their own Medicaid claims processing and payment systems unless they opted
to participate in The Medicaid Statistical Information System (MSIS) where
the 2082 Report was produced by CMS. State-by-State national summary
tables were developed based on the 2082 Reports. As a result of legislation
enacted by The Balanced Budget Act of 1997, States, beginning in FY 1999,
are required to submit all of their eligibility and claims data on a quarterly
basis through MSIS. The State requirement for completing the HCFA-2082
Report has been eliminated.
CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system. It
is a statement of expenditures for The Medicaid program that states submit to
CMS 30 days after each quarter. The Report is an accounting statement of
actual expenditures made by the States for which they are entitled to receive
federal reimbursement under Title XIX for that quarter. Along with The CMS
MSIS Report, it is one of the primary sources for Medicaid statistical data.
Coinsurance The portion of covered healthcare costs for which the covered person has a
financial responsibility, usually according to a fixed percentage. Often
coinsurance applies after first meeting a deductible requirement.
Term Definition
Commercial Managed Care A health maintenance organization with a contract §1876 or a Medicare +
Organization (Comp-MCO) 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.
Comprehensive Benefits Plan A variation of the major medical plan which carries copayment requirements,
usually 10-20 percent of all health expenses and deductibles ranging from
$100 to $1,000.
Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.
Consolidated Omnibus Reconciliation A Federal law that, among other things, requires employers to offer continued
Act (COBRA) health insurance coverage to certain employees and their beneficiaries whose
group health insurance coverage has been terminated.
Consumer Price Index (CPI) A price index constructed monthly by the U.S. Department of Labor using
retail prices of goods and services sold in large cities across the country.
Continuous Quality Improvement A formal process of constantly seeking better ways to achieve stated goals.
(CQI)
Continuum of Care A range of clinical services provided to an individual or group, which may
reflect treatment rendered during a single inpatient hospitalization, or care for
multiple conditions over a lifetime. The continuum provides a basis for
analyzing quality, cost and utilization over the long term.
Contract Pharmacy System Pharmaceutical benefit delivery arrangement in which an HMO contracts with
community pharmacies (chain or selected independents) to provide
medications to members. Reimbursement may be by fee-for-service,
capitation, or some other arrangement.
Contributory Program A method of payment for group coverage in which part of the premium is paid
by the employee and part is paid by the employer or union.
Term Definition
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.
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.
Customary Charge The charge a physician or supplier usually bills his patients for furnishing a
particular service or supply is called the customary charge.
Term Definition
Customary, Prevailing, and Reasonable Method of reimbursement which limits payment to the lowest of the
Charges following: physician’s actual charge, physician’s median charge in a recent
prior period (customary), or the 75th percentile of charges in the same time
period (prevailing).
Day Supply Maximum The maximum amount of medication a person may receive at one time,
usually the amount needed for 30 (acute) or 90 (maintenance) days of therapy,
as defined by the drug benefit.
Deductible An amount the insured person must pay before payments for covered services
begin. For example, an insurance plan might require the insured to pay the
first $250 of covered expenses during a calendar year before the insurance
company will begin payment.
Demand The amount of care a population seeks to obtain through the health delivery
system.
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 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.
Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand-name drug ordered.
Dispensing, Fill or Professional Fee The amount paid to a pharmacy for each prescription, in addition to the
negotiated formula for reimbursing ingredient cost.
Term Definition
Disproportionate Share Hospital (DSH) A disproportionate share hospital (DSH) is a hospital that serves a
disproportionate number of low-income patients with special needs and
receives a payment adjustment for providing such services. In addition to
certain requirements for the provision of obstetrical services to individuals
entitled to medical assistance, a hospital is deemed to be a disproportionate
share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at least
one standard deviation above the mean Medicaid inpatient utilization rate for
hospitals receiving Medicaid payments in the state, or 2) the hospital’s low-
income utilization rate exceeds 25 percent.
Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.
Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to covered
persons. This list is subject to periodic review and modification by the health
plan. A plan that has adopted an “open or voluntary” formulary allows
coverage for both formulary and non-formulary medications. A plan that has
adopted a “closed, select or mandatory” formulary limits coverage to those
drugs in the formulary.
Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine the
appropriateness of drug therapy. There are three forms of DUE: prospective
(before or at the time of prescription dispensing), concurrent (during the
course of drug therapy), and retrospective (after the therapy has been
completed). Same as “Drug Utilization Review.”
Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over-utilization.
Early and Periodic Screening, The EPSDT program covers screening and diagnostic services to determine
Diagnosis, and Treatment (EPSDT) physical or mental defects in recipients under age 21, as well as health care
and other measures to correct or ameliorate any defects and chronic
conditions discovered.
Electronic Data Interchange (EDI) The computer-to-computer exchange of business or other information. The
data may be in either a standardized or priority format.
Employee Benefits Program Health insurance and other benefits, beyond salaries, offered to employees at
their place of work. The employer typically picks up all or part of the cost of
these benefits.
Employee Retirement Income Security A Federal act passed in 1974, that established new standards and
Act of 1974, Public Law 93-406 reporting/disclosure requirements for employer-funded pension and health
(ERISA) benefit programs. To date, self-funded health benefit plans operating under
ERISA have been held to be exempt from State insurance laws.
Enrollment The total number of covered persons in a health plan. Also refers to the
process by which a health plan signs up groups and individuals for
membership, or the number of enrollees who sign up in any one group.
Term Definition
Estimated Acquisition Cost (EAC) An estimate of the price generally, and currently, paid by providers for a drug
marketed or sold by a particular manufacturer or labeler in the package size
most frequently purchased by providers.
Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider organization.
Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.
Experimental, Investigational or Medical, surgical, psychiatric, substance abuse or other healthcare services,
Unproven Procedures supplies, treatments, procedures, drug therapies or devices that are determined
by the health plan (at the time it makes a determination regarding coverage in
a particular case) to be either: not generally accepted by informed healthcare
professionals in the U.S. as effective in treating the condition, illness or
diagnosis for which their use is proposed; or not proven by scientific evidence
to be effective in treating the condition, illness or diagnosis for which their
use is proposed.
Extended Care Long-term care, ranging from routine assistance for daily activities to
sophisticated medical and nursing care for those needing it. The care, covered
under certain insurance policies, can be provided in homes, day-care centers
or other facilities.
Family Planning Services Any medically approved means, including diagnosis, treatment, drugs,
supplies and devices, and related counseling which are furnished or prescribed
by or under the supervision of a physician for individuals of childbearing age
for purposes of enabling such individuals freely to determine the number or
spacing of their children.
Favorable Selection A tendency for utilization of health services in a population group to be lower
than expected or estimated.
Federal Upper Limits (FUL) The upper limit amount that Medicaid can reimburse for a drug product if
there are three or more generic versions of the product rated therapeutically
equivalent and at least three suppliers listed in the current editions of
published national compendia. These limits are intended to assure that the
Federal government acts as a prudent buyer of drugs. The upper limits
program seeks to achieve savings by taking advantage of current market
prices.
Term Definition
Federally Qualified Health Center Federally Qualified Health Centers are facilities or programs more commonly
(FQHC) known as Community Health Centers, Migrant Health Centers, and Health
Care for The Homeless. These centers may qualify as Medicaid providers of
services if: 1) The facility receives a grant under sections 329, 330, or 340 of
The Public Health Services Act; 2) HRSA recommends, and the HHS
Secretary determines, that the facility meets the requirements of the grant; or
3) The Secretary determines that a facility may qualify through waivers of the
requirements (such a waiver cannot exceed two years) .
Federally Qualified HMOs HMOs that meet certain federally stipulated provisions aimed at protecting
consumers: e.g., providing a broad range of basic health services, assuring
financial solvency, and monitoring the quality of care. HMOs must apply to
the Federal government for qualification. The Office of Prepaid Health Care
of CMS administers the process.
Fee Maximum The maximum amount a participating provider may be paid for a specific
healthcare service provided to a covered person under a specific contract.
Sometimes called “fee max.”
Fee Schedule A listing of codes and related services with pre-established payment amounts
that could be percentages of billed charges, flat rates or maximum allowable
amounts.
Fee-for-Service Reimbursement The traditional healthcare payment system, under which physicians and other
providers receive a payment that does not exceed their billed charge for each
unit of service provided. Fees are paid as care is rendered.
First-Dollar Coverage Health policies that pay all or a portion of medical expenses upon enrollment,
without a deductible charge.
Fiscal Agent A contractor that processes or pays vendor claims on behalf of a Medicaid
agency.
Fiscal Intermediary The agent that has contracted with providers of service to process claims for
reimbursement under health care coverage. In addition to handling financial
matters, it may perform other functions such as providing consultative
services or serving as a center for communication with providers and making
audits of providers’ records.
Fiscal Year Any predetermined set of 12 months for which annual accounts are kept. The
Federal Government’s fiscal year extends from Oct. 1 to the following Sept.
30.
Fixed Fee An established “fee” schedule for pharmacy services allowed by certain
government and private third-party programs in lieu of cost-of-doing business
markups.
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).
Term Definition
Generic Drug A chemically equivalent copy of a brand name drug whose patent has expired.
Drug formulations must be of identical composition with respect to the active
ingredient (i.e., meet official standards of identity, purity, and quality of active
ingredient). Also called generic equivalent or non-innovator multiple source
drug.
Global Target A financing method identical to a global budget except that no enforcement
mechanism is used to keep providers and hospitals within budget (i.e.,
providers and hospitals will receive additional funding if their costs exceed
their budgeted payments).
HCFA 1500 A universal form developed by the government agency previously known as
the Health Care Financing Administration (HCFA, now CMS), for providers
of services to bill professional fees to health carriers.
HCFA Common Procedural Coding A listing of services, procedures and supplies offered by physicians and other
System (HCPCS) providers. HCPCS includes current procedural terminology (CPT) codes,
national alphanumeric codes and local alphanumeric codes. The national
codes are developed by 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 See “Centers for Medicare and Medicaid Services.”
(HCFA)
Health Care Prepayment Plan (HCPP) A cost contract with the CMS that prepays a health plan a flat amount per
month to provide Medicare-eligible Part B medical services to enrolled
members. Members pay premiums to cover the Medicare coinsurance,
deductibles and copayments, plus any additional non-Medicare covered
services that the plan provides. The HCPP does not arrange for Part A
services.
Health Insurance
Financial protection against the medical care costs arising from disease or
accidental bodily injury. Such insurance usually covers all or part of the
medical costs of treating the disease or injury. Insurance may be obtained on
either an individual or a group basis.
Health Insuring Organization (HIO) An entity that provides for or arranges for the provision of care and contracts
on a prepaid capitated risk basis to provide a comprehensive set of services.
Term Definition
Health Maintenance Organizations (1) An entity that provides, offers or arranges for coverage of designated
(HMO’s) health services needed by plan members for a fixed, prepaid premium. There
are four basic models of HMOs: staff model, group model, network model
and individual practice association; (2) Under the Federal HMO Act, an entity
must have three characteristics to call itself an HMO: (a) An organized system
for providing healthcare or otherwise assuring healthcare delivery in a
geographic area, (b) An agreed upon set of basic and supplemental health
maintenance and treatment services, and (c) A voluntary enrolled group of
people.
Health Plan An organization that provides a defined set of benefits; this term usually refers
to an HMO-like entity, as opposed to an indemnity insurer.
Health Plan Employer Data and A core set of performance measures to assist employers and other health
Information Set (HEDIS) purchasers in understanding the value of healthcare purchases and evaluating
health plan performance. HEDIS 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 A healthcare model that contracts with physicians and other community
(IPA) healthcare providers, to provide services in return for a negotiated fee.
Physicians continue in their existing individual or group practices and are
compensated on a per capita, fee schedule, or fee-for-service basis.
HMO - Network Model An HMO type in which the HMO contracts with more than one physician
group, and may contract with single- and multi-specialty groups. The
physician works out of his/her own office. The physician may share in
utilization savings, but does not necessarily provide care exclusively for HMO
members.
HMO - Staff Model A healthcare model that employs physicians to provide healthcare to its
members. All premiums and other revenues accrue to the HMO, which
compensates physicians by salary and incentive programs.
Home Health Agency (HHA) A facility or program licensed, certified or otherwise authorized pursuant to
State and Federal laws to provide healthcare services in the home.
Home Health Services Services and items furnished to an individual who is under the care of a
physician by a home health agency or by others under arrangements made by
such agency. Services are furnished under a plan established and periodically
reviewed by a physician. They are provided on a visiting basis in an
individual’s home and include: nursing, physical therapy, dietary, counseling,
and social services; part-time or intermittent skilled nursing care; physical,
occupational, or speech therapy; medical social services, medical supplies and
appliances (other than drugs and biologicals); home health aide services; and
services of interns and residents.
Term Definition
Hospice A program that provides palliative and supportive care for terminally ill
patients and their families, either directly or on a consulting basis with the
patient's physician or another community agency. Originally a medieval name
for a way station for crusaders where they could be replenished, refreshed,
and cared for, hospice is used here for an organized program of care for
people going through life's "last station." The whole family is considered the
unit of care, and care extends through their period of mourning.
Indemnity Insurance An insurance program in which the insured person is reimbursed or the
provider is paid for covered expenses after services are rendered.
Innovator Multiple-Source Drug An innovator multiple-source drug is a multiple source drug that was
originally marketed under an original new drug application approved by the
FDA.
Inpatient Hospital Services Items and services furnished to a resident patient of a hospital by the hospital.
May include such items as: bed and board; nursing and related services;
diagnostic and therapeutic services; and medical or surgical services.
Integrated Behavioral Health A carve-out benefit plan that combines independent managed care services
into what is designed as a seamless delivery system for behavioral health
concerns. Components could include employee assistance services, a
telephone counseling triage, utilization management, behavioral health
treatment networks, claims payment, and data management.
Integrated Delivery System A generic term referring to a joint effort of physician/hospital integration for a
variety of purposes. Some models of integration include physician-hospital
organization, group practice without walls, integrated provider organization
and medical foundation.
Intensive Care Skilled nursing services, usually in a hospital, prescribed by a physician for
individuals with serious medical conditions and delivered with the guidance of
a registered nurse.
Intermediate Care Facility (ICF) An institution that is licensed under State law to provide on a regular basis,
health-related care and services to individuals who do not require the degree
of care or treatment which a hospital or skilled nursing facility is designed to
provide. Public institutions for care of the mentally retarded or people with
related conditions are also included in the definition. The distinction between
"health-related care and services" and "room and board" has often proven
difficult to make but is important because ICFs are subject to quite different
regulations and coverage requirements than institutions which do not provide
health-related care and services.
International Classification of Diseases, A listing of diagnoses and identifying codes used by physicians for reporting
9th Edition (Clinical Modification) diagnoses of health plan enrollees. The coding and terminology provide a
(ICD-9-CM) uniform language that can accurately designate primary and secondary
diagnoses and provide for reliable, consistent communications on claim
forms.
Investigational Treatments Medical treatments, including drugs waiting for FDA approval, that are
considered experimental and, therefore, may not be covered by insurance
plans. The definition of experimental currently varies from plan to plan.
Term Definition
Laboratory and Radiological Services Professional and technical laboratory and radiological services ordered by a
licensed practitioner, provided in an office or similar facility (other than a
hospital outpatient department or clinic) or by a qualified lab.
Legend Drug A drug that, by law, can be obtained only by prescription and bears the label,
“Caution: Federal law prohibits dispensing without a prescription.” See
“Prescription Medication.”
Lifetime Maximum Benefit A limitation on financial coverage for healthcare for an individual stated by an
insurer. This amount serves as a cap on contractual liability and can be
exceeded only in rare and unusual circumstances.
Long Term Care A set of health care, personal care and social services required by persons
who have lost, or never acquired, some degree of functional capacity (e.g., the
chronically ill, aged, disabled, or retarded) in an institution or at home, on a
long-term basis. The term is often used more narrowly to refer only to long-
term institutional care such as that provided in nursing homes, homes for the
retarded and mental hospitals. Ambulatory services such home health care,
which can also be provided on a long-term basis, are seen as alternatives to
long-term institutional care.
Magnetic Resonance Imaging State-of-the-art machine used as a diagnostic tool, using magnetic fields to
produce comprehensive pictures of the anatomy.
Managed Care (1) A system of healthcare delivery that influences utilization and cost of
services and measures performance. The goal is a system that delivers value
by giving people access to high quality, cost-effective healthcare; (2) A
systemized approach which seeks to ensure the provision of the right
healthcare at the right time, place and cost.
Managed Care Organization (MCO) Broad term that encompasses various types of health plans, including Health
Maintenance Organizations (HMOs), Preferred Provider Organizations
(PPOs), Point-of-Service plans (POSs) and Provider-Sponsored Organizations
(PSOs). Often used to refer to a health plan that is similar to an HMO but
which does not have an HMO license and serves only Medicaid beneficiaries.
Mandated Benefits Those benefits which health plans are required by State or Federal law to
provide to policyholders and eligible dependents.
Maximum Allowable Cost, or A maximum cost is fixed for which the pharmacist can be reimbursed for
“Reasonable Cost Range” selected products, as identified in a “formulary.”
Maximum Out-of-Pocket Costs The limit on total member copayments, deductibles and coinsurance under a
benefit contract.
Term Definition
Medicaid Buy-In A provision in certain health reform proposals whereby the uninsured would
be allowed to purchase Medicaid coverage by paying premiums on a sliding
scale based on income.
Medicaid Management Information Federally developed guidelines for a computer system designed to achieve
System (MMIS) national standardization of Medicaid claims processing, payment, review and
reporting for all health care claims.
Medicaid-only Managed Care An MCO that provides comprehensive services to Medicaid beneficiaries but
Organization (Mcaid-MCO) not commercial or Medicare enrollees.
Medicaid Statistical Information The information system developed by CMS to collect detailed data on
System (MSIS) 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 Payment Advisory A Federal commission established under the Balanced Budget Act of 1997 to
Commission (MedPAC) advise and assist Congress and the Department of Health and Human Services
in maintaining and updating the Medicare prospective payment system.
MedPAC replaces and assumes the responsibilities of the Physician Payment
Review Commission (PPRC) and the Prospective Payment Assessment
Commission (ProPAC).
Medicare Supplemental Insurance A policy guaranteeing that a health plan will pay a policyholder’s coinsurance,
deductible and copayments and will provide additional health plan or non-
Medicare coverage for services up to a predefined benefit limit. In essence,
the product pays for the portion of the cost of services not covered by
Medicare. Also called “Medigap” or “Medicare wrap.”
Term Definition
Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain
fee maximums for each procedure.
Most Favored Nations Discount or A contractual agreement that stipulates that a vendor must provide to a
Clause particular payor the lowest prices that would be available to any purchaser.
The Federal government often invokes most favored nation clauses for
healthcare contracts.
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 A national organization founded in 1979 composed of 14 directors
Assurance (NCQA) representing consumers, purchasers, and providers of managed health care. It
accredits quality assurance programs in prepaid managed health care
organizations, and develops and coordinates programs for assessing the
quality of care and service in the managed care industry, including the HEDIS
quality measures.
National Drug Code (NDC) A national classification system for identification of drugs. Similar to the
Universal Product Code (UPC).
Nurse-Midwife Services Nurse-midwife services are those concerned with the management of care of
mothers and newborns throughout the maternity cycle. OBRA 1980 required
that payment be made for providing nurse-midwife services to categorically
needy recipients to the extent that the nurse-midwife is authorized to practice
under State law or regulation. States are also required to offer direct
reimbursement to nurse-midwives as one of the payment options. Nurse-
midwives must be registered nurses who are either certified by an
organization recognized by the Secretary of HHS or who have completed a
program of study and clinical experience that has been approved by the
Secretary.
Network Plan A phrase that generally refers to arrangements where providers contract with
payers or a managed care plan to provide services for patients enrolled in the
managed care plan. See “Managed Care.”
Other Practitioners’ Services Health care services of licensed practitioners other than physicians and
dentists.
Out-of-Pocket Costs/Expenses (OOPs) The portion of payments for health services required to be paid by the
enrollee, including copayments, coinsurance and deductibles.
Term Definition
Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance - as
defined per the contract. Once this limit is reached, benefits will increase to
100% for health services received during the rest of that calendar year. Some
out-of-pocket costs (e.g., mental health, penalties for non-precertification,
etc.) are not eligible for out-of-pocket limits.
Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health status.
Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.
Outpatient Services Outpatient services are medical and other services provided on a non-resident
basis (patients are not admitted to the facility) by a hospital or other qualified
facility, such as a mental health clinic, rural health clinic, mobile X-ray unit,
or freestanding dialysis unit. Such services include outpatient physical therapy
services, diagnostic X-ray and laboratory tests, and X-ray and other radiation
therapy.
Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State law.
Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy, other
facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.
Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with regard
to a specific condition (e.g., an arthritic patient’s ability to make a fist or an
asthmatic patient’s ability to climb a flight of stairs).
Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).
Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.
Peer Review The evaluation of quality of total healthcare provided, by medical staff with
equivalent training.
Term Definition
Peer Review Organization (PRO) An entity established by the Tax Equity and Fiscal Responsibility Act of 1982
(TERFA) to review quality of care and appropriateness of admissions,
readmissions and discharges for Medicare and Medicaid. These organizations
are held responsible for maintaining and lowering admission rates, and
reducing lengths of stay while insuring against inadequate treatment. Also
known as “Professional Standards Review Organization.”
Personal Support Services Personal support services consist of a variety of services including personal
care, targeted case management, home and community-based care for
functionally disabled elderly, rehabilitative services, hospice services, and
nurse-midwife, nurse practitioner, and private duty nursing services.
Pharmacy And Therapeutics (P&T) An organized panel of physicians and pharmacists from varying practice
Committee specialties, who function as an advisory panel to the plan regarding the safe
and effective use of prescription medications. Often compromises the official
organizational line of communication between the medical and pharmacy
components of the health plan. A major function of such a committee is to
develop, manage and administer a drug formulary.
Physician Any doctor of medicine (M.D.) or doctor of osteopathy (D.O.) who is duly
licensed and qualified under the law of jurisdiction in which treatment is
received.
Physician-Hospital Organization A legal entity formed by a hospital and a group of physicians to further mutual
(PHO) interests and to achieve market objectives. A PHO generally combines
physicians and a hospital into a single organization for the purpose of
obtaining payer contracts. Doctors maintain ownership of their practices and
agree to accept managed care patients according to the terms of a professional
service agreement with the PHO. The PHO serves as a collective negotiating
and contracting unit. It is typically owned and governed jointly by a hospital
and shareholder physicians.
Point-Of-Service (POS) Plan A health plan allowing the covered person to choose to receive a service from
a participating or non-participating provider, with different benefit levels
associated with the use of participating providers. POS can be provided in
several ways: an HMO may allow members to obtain limited services from
non-participating providers; an HMO may provide non-participating benefits
through a supplemental major medical policy; a PPO may be used to provide
both participating and non-participating levels of coverage and access; or
various combinations of the above may be used.
Portability Requirement that health plans guarantee continuous coverage without waiting
periods for persons moving between plans.
Term Definition
Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specified
period immediately preceding the covered person’s effective date of coverage
under the master group contract.
Preferred Provider Organization A program in which contracts are established with providers of medical care.
(PPO) Providers under such contracts are referred to as preferred providers. Usually,
the benefit contract provides significantly better benefits (fewer copayments)
for services received from preferred providers, thus encouraging covered
persons to use these providers. Covered persons are generally allowed
benefits for non-participating providers’ services, usually on an indemnity
basis with significantly higher copayments. A PPO arrangement can be
insured or self-funded. Providers may be, but are not necessarily, paid on a
discounted fee-for-service basis.
Prepaid Group Practice Plans Organized medical groups of essentially full-time physicians in appropriate
specialties, as well as other professional and subprofessional personnel, who,
for regular compensation, undertake to provide comprehensive care to an
enrolled population for premium payments that are made in advance by the
consumer and/or their employers.
Prepaid Health Plan (PHP) An entity that provides a non-comprehensive set of services on either
capitated risk or non-risk basis or the entity provides comprehensive services
on a non-risk basis.
Prescribed Drugs Prescribed drugs are drugs dispensed by a licensed pharmacist on the
prescription of a practitioner licensed by law to administer such drugs, and
drugs dispensed by a licensed practitioner to his own patients. This item does
not include a practitioner’s drug charges that are not separable from his other
charges, or drugs covered by a hospital bill.
Prescription Medication A drug which has been approved by the Food and Drug Administration and
which can, under Federal and State law, be dispensed only pursuant to a
prescription order from a duly licensed prescriber, usually a physician.
Preventive Care Comprehensive care emphasizing priorities for prevention, early detection and
early treatment of conditions, generally including routine physical
examinations, immunization and well person care.
Primary Care Case Management Managed care arrangements where primary care providers receive a per capita
(PCCM) management fee to coordinate a patient's care in addition to reimbursement
(fee-for-service or capitation) for the medical services they provide.
Term Definition
Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations who
determines whether the presenting patient needs to see a specialist or requires
other non-routine services. See Care Coordinator.
Prior Authorization The process of obtaining prior approval as to the appropriateness of a service
or medication. Prior authorization does not guarantee coverage.
Prospective Financing Financing for health care services based on prices or budgets determined prior
to the delivery of service. Payments can be per unit of service, per member, or
per time period. In all its forms prospective financing differs from cost-based
reimbursement, under which a provider is paid for costs incurred.
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 A formal set of activities to review and affect the quality of services provided.
Improvement (QI) Quality assurance includes assessment and corrective actions to remedy any
deficiencies identified in the quality of direct patient, administrative and
support services.
Rate Setting A form of financing under which hospitals or nursing homes are paid prices
that are prospectively determined, generally by a State agency. Prospectively
determined prices may be paid by all payers for all covered services, as in all
payer systems, or by only some payers. The unit of payment can be service,
patient, or time period. See “Prospective Financing.”
Rational Drug Therapy Prescribing the right drug for the right patient, at the right time, in the right
amount, and with due consideration of relative cost.
Reasonable Charge In processing claims for Supplementary Medical Insurance benefits, carriers
use CMS guidelines to establish the reasonable charge for services rendered.
The reasonable charge is the lowest of: the actual charge billed by the
physician or supplier; the charge the physician or supplier customarily bills
his patients for the same services, and the prevailing charge which most
physicians or suppliers in that locality bill for the same service. Increases in
the physicians’ prevailing charge levels are recognized only to the extent
justified by an index reflecting changes in the costs of practice and in general
earnings.
Reasonable Cost In processing claims for Health Insurance benefits, intermediaries use CMS
guidelines to determine the reasonable cost incurred by the individual
providers in furnishing covered services to enrollees. The reasonable cost is
based on the actual cost of providing such services, including direct and
indirect costs of providers, excluding any costs that are unnecessary in the
efficient delivery of services covered by the insurance program.
Term Definition
Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care providers
authorize a referral for coverage of specialty services.
Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”
Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.
Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.
Risk Contract (1) An agreement between a State Medicaid program and an HMO or
competitive medical plan requiring the HMO to furnish at a minimum all
Medicaid covered services to Medicaid eligible enrollees for an annually
determined, fixed monthly payment rate from the state government. The
HMO is then liable for services regardless of their extent, expense or degree.
(2) An agreement between a provider and payer, or intermediary, on behalf of
a payer, that requires the provider to furnish all specified services for a
specified enrollee for a set fee, usually prepaid, and for a set period of time
(usually one year). The provider is then liable for services regardless of their
extent, expense or degree. Such stated limitations for such liability are stated
in advance and may be subject to reinsurance.
Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physician and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that is
not urbanized as defined by the Census Bureau and that is designated by the
Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an agreement
with the Secretary not to charge any individual or other person for items or
services for which such individual is entitled to have payment made by
Medicare, except for the amount of any deductible or coinsurance amount
applicable.
Secondary Care Services provided by medical specialists, such as cardiologists, urologists and
dermatologists, who generally do not have first contact with patients. See also
“Primary Care.”
Term Definition
Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid for
the purpose of conducting pilot, experimental or demonstration projects.
Section 1115 demonstration waivers allow States to change provisions of their
Medicaid programs, including: eligibility requirements, the scope of services
available, the freedom to choose a provider, a provider’s choice to participate
in a plan, the method of reimbursing providers, and the statewide application
of the program. Projects typically run three to five years.
Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section
1915(b) freedom-of-choice waivers allowed States to require Medicaid
recipients to enroll in HMOs or other managed care plans in an effort to
control costs. The waivers allowed States to: implement a primary care case-
management system; require Medicaid recipients to choose from a number of
competing health plans; provide additional benefits in exchange for savings
resulting from recipients’ use of cost-effective providers; and limit the
providers from which beneficiaries can receive non-emergency treatment.
Under the BBA, States can enroll recipients into managed care without
applying for 1915(b) waivers.
Sin Taxes Taxes imposed on items considered harmful to public health interests, such as
tobacco and alcohol.
Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients in
need of rehabilitation and medical care that is of a lesser intensity than that
received in a hospital.
Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified
skilled nursing facility that meets standards set by Secretary of DHHS.
State Buy-In The term given to the process by which a State may provide Supplementary
Medical Insurance coverage for its needy eligible persons through an
agreement with the Federal government under which the State pays the
premiums for them.
State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health
services (e.g., in vitro fertilization) or services provided by certain health care
providers (e.g., audiologists). Self-insureds are exempt from these
requirements. There are over 800 mandates nationwide.
Term Definition
State 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.
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 The Federal law which created the current risk and cost contract provisions
Act of 1982 (TEFRA) under which health plans contract with CMS and which defined the primary
and secondary coverage responsibilities of the Medicare program.
Temporary Assistance to Needy Federal-State welfare program which replaces Aid to Families with
Families (TANF) Dependent Children. Authorized by the 1996 Welfare Reform Act. States
may use TANF to establish Medicaid eligibility.
Therapeutic Alternatives Drug products containing different chemical entities but which should provide
similar treatment effects, the same pharmacological action or chemical effect
when administered to patients in therapeutically equivalent doses.
Therapeutic Substitution Dispensing by a pharmacist of a product different from that which was
prescribed, but which is deemed to be therapeutically equivalent. In most
States such a practice requires the prescribing physician’s authorization before
the substitution may occur. A pharmacy and therapeutics committee (P&T)
most often approves the rationale for therapeutic equivalency prior to such
practice.
Third-Party Administrator (TPA) An independent person or corporate entity (third party) that administers group
benefits, claims and administration for a self-insured company/group. A TPA
does not underwrite the risk.
Third-Party Liability Under Medicaid, third-party liability exists if there is any entity (i.e., other
government programs or insurance) which is or may be liable to pay all or
part of the medical cost or injury, disease, or disability of an applicant or
recipient of Medicaid.
Universal Access The availability of affordable public or private insurance coverage for every
United States citizen or legal resident. There is no guarantee, however, that all
individuals will actually choose to purchase or have the funds to purchase
coverage. See “Universal Coverage.”
Term Definition
Universal Coverage The guaranteed provision of at least basic health care services to every United
States citizen or legal resident. See “Universal Access.”
Usual, Customary and Reasonable A term used to refer to the commonly charged or prevailing fees for health
Charges services within a geographic area. A fee is considered to be reasonable if it
falls within the parameters of the average or commonly charged fee for the
particular service within that specific community.
Utilization The extent to which the members of a covered group use a program or obtain
a particular service, or category of procedures, over a given period of time.
Usually expressed as the number of services used per year or per 100 or 1,000
persons eligible for the service.
Utilization Management (UM) A process of integrating review and case management of services in a
cooperative effort with other parties, including patients, providers, and payers.
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.
Withhold “At-risk” portion of a claim deducted and withheld by the health plan before
payment is made to a participating physician as an incentive for appropriate
utilization and quality of care. This amount – for example, 20% of the claim
– remains within the plan and is credited to the doctor’s account. Can be used
where the plan needs additional funds to pay for claims. The withhold may be
returned to the physician in varying levels which are determined based on
analysis of his/her performance or productivity compared against his/her
peers. Also called “physician contingency reserve (PCR).”
ACRONYMS