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Pharmaceutical Benefits

Under State Medical


Assistance Programs

2002

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

©2003 by the National Pharmaceutical Council


This compilation of data on State Medical Assistance Programs (Title XIX)
presents a general overview of the characteristics of State programs, together
with detailed information on the pharmaceutical benefits provided. The data
collection effort covers all States with Medicaid programs and the District of
Columbia.

Information for this compilation was acquired from multiple sources, including a
survey of Medicaid prescription drug programs administered for the National
Pharmaceutical Council by Muse & Associates, Washington, DC with assistance
from Compensation Solutions, LLC and StateScape. While we have checked all
secondary data in the book for consistency relative to the original source, we
have not validated the original data reported by the Centers for Medicare and
Medicaid Services (CMS) and other organizations.

The data were compiled and the book prepared for publication by Donald Muse,
Ph.D., David Goldenberg, Ph.D., Anne Marie Hummel, Steven Heath, M.P.A.,
Stanley Weintraub, C.P.A, Daniel B. Gurley, M.P.A., Errica Philpott, Liz Segall,
and Tiffany Crawford of Muse & Associates. Paul Gavejian and Philip Farber
of Compensation Solutions prepared and conducted the 2001 survey. James
Elliott at StateScape supervised the compilation of information on State officials,
State professional associations, and expanded drug programs for elderly and
disabled beneficiaries. Gary Persinger and Kimberly Dietrich of the National
Pharmaceutical Council provided valuable input and support, including the
conceptualization of the methodology used in Section 1.
Pharmaceutical Benefits 2002

INTRODUCTION

The year 2002 edition of Pharmaceutical Benefits under State Medical


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

The data used to create each edition of the Compilation are assembled from
many sources. The “Medicaid Compilation” incorporates information on each
State pharmacy program from an annual NPC survey of State Medicaid program
administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal
agencies and other organizations. Each year, finding and compiling current,
relevant information for inclusion in the Compilation presents a challenge.
Updating the data for the 2002 Compilation was no exception.

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

This new requirement resulted in major difficulties in the submission of data to


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

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

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

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Pharmaceutical Benefits 2002

State characteristics, especially their Medicaid programs. For example, on


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

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

In order to give a better understanding of the content of the “Medicaid


Compilation,” the information contained in this version of the book is
summarized below by section:

• Section 1: Reports on a methodology for identification of Medicaid chronic


illness propulations for case and disease management programs.

• Section 2: Contains an overview of the Medicaid program, details about


Medicaid managed care enrollment, including a breakdown by plan type and
enrollment by plan type and a synopsis of 1915(b) waivers and 1115
demonstrations.

• Section 3: Consists of sociodemographic statistics, by age, race, insurance,


income, and employment, for the fifty States and the District of Columbia
for calendar year 2001. Additionally, a description of the Medicaid certified
facilities in each State, including the number of hospitals, skilled nursing
facilities, and intermediate care facilities for the mentally retarded (ICFs-
MR), home health agencies, and rural health clinics are presented.

• Section 4: Provides Medicaid pharmacy program characteristics, drawn


largely from the 2002 NPC annual survey of State pharmacy program
administrators. In addition, this section provides Medicaid eligibility
statistics from CMS for fiscal year 2000 and program expenditure data for
fiscal years 2000 and 2001. Medicaid pharmacy programs are characterized
by estimates of total expenditures, drug payments, drug benefit design, and
pharmacy payment and patient cost sharing.

• Section 5: Contains detailed profiles of the States’ Medicaid pharmacy


programs. This section contains a description of medical assistance benefits
and eligibles, drug payments and recipients, benefit design, pharmacy
payment and patient cost sharing, use of managed care, and State contacts.

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• Section 6: Profiles the “expanded” drug programs in States that are


providing pharmaceutical coverage or discounts to the elderly and/or
disabled persons.

The book also contains a series of appendices. Appendix A features a list of


State contacts, CMS regional offices and Medicaid program personnel.
Appendix B provides a national level summary on total Medicaid program
recipients by type of service for FY 1999 and FY 2000 and data on total number
of drug recipients for each State and the nation as a whole for the period 1996-
2000. Appendix C provides the current Medicaid drug rebate law. Appendix D
contains the list of CMS upper limits on multiple source products. Appendix E
is a glossary and list of acronyms.

NPC gratefully acknowledges the cooperation and assistance of the many State
and Federal program officials and their staffs. With their cooperation, we were
able to achieve an 82 percent response rate to the 2002 Survey. Unfortunately,
not all States were able to submit revised/updated information. In such
instances, we have incorporated the most recently available data from other
sources. However, for these States, much of the information may reflect data
that have been presented in previous versions of the Compilation.

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

Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council

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

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BACKGROUND AND PURPOSE

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

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

SPENDING TRENDS

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

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

$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

POPULATION SIZE, DEMOGRAPHICS, AND GROWTH RATE

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

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Figure 1-2: Population vs. Expenditures* 8

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

Women, Children and Others Aged or Disabled

* 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.

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

$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

PRESCRIPTION DRUG USE IN THE MEDICAID POPULATION

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

TABLE 1-1: Prescription Drug Therapy


State X – 2000-2001 Prescription Drug
Expenditures
Fee-for-Service in Millions of Dollars

Group Dollars Percent


Aged $ 291 34.1%
Blind/Disabled $ 434 50.7%
Children $ 92 10.7%
Other Adults $ 38 4.5%
Total $ 855

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

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

aged blind/disabled adult child

30%
25%
20%
15%
10%
5%
0%
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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.

CHRONIC DISEASES IN THE MEDICAID FEE-FOR-SERVICE POPULATION

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

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DATA AND METHODOLOGY

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

The Selection of State X


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

Table 1-2: State X Compared to National Program

Comparison of National and State X Medicaid Programs


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

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

Analytic File Development


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

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Limitations of the Data


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

ANALYSIS

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

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

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

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

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

A METHODOLOGY FOR IDENTIFING HIGH IMPACT MEDICAID RECIPIENT GROUPS


POTENTIALLY AMENABLE TO CASE AND DISEASE MANAGEMENT PROGRAMS

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

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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

> 1 year eligibility


457,055 Dual eligibles
$4.9 B 81,860
Cost/patient/yr: $5,849 $2.6 B
Cost/patient/yr: $16,836
Not amenable to C & DM:
Not amenable to C & DM: 75+,LTC, MR
75+,LTC, MR
Medicaid only 45,457, $2.1 B
7,887, $525 M 386,253
$2.3 B Amenable to C&DM efforts (w/ waiver):
Cost/patient/yr: $3,465
< 75 years, not in LTC, not mentally retarded
36,403, $500 M, Cost/patient/yr: $7,187
Amenable to C&DM efforts:
< 75 years, not in LTC, not mentally retarded Patients with 9+ Rx in 180 Days
378,366, $1.8 B, Cost/patient/yr: $2,730 42,632,Cost/patient/yr: $9,956
See Table 1-4

Patients with Selected Patients with 20+ Rx in 180 Days


Chronic Diseases 8,914, Cost/patient/yr: $20,093
95,794 See Table 1-3 See Table 1-5

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

Step 1: Removed all Medicaid recipients enrolled in managed care.


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

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

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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

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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

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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.

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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.

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Section 2:
The Medicaid Program

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MEDICAID PROGRAM OVERVIEW

Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State


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

Medicaid Eligibility: Medicaid is a “means tested program for low income


individuals.” To qualify, a Medicaid recipient must not have “income” or
“resources” that exceed the applicable limits prescribed in the law and
regulations.

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

Mandatory Categorically Needy: There are numerous and detailed categories


under which the “categorically needy” may qualify for Medicaid benefits. The
principal categories of the mandatory categorically needy are:

• Low-income families with children;

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

• Individuals qualified for adoption assistance agreements or foster care


maintenance payments under Title IV-E of the Social Security Act;

• Qualified pregnant women;

• Newborn children of Medicaid-eligible women;

• Various categories of low-income children; and

• Certain low-income Medicare beneficiaries.

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

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

Special Categories: The Medicaid statute also authorizes limited Medicaid


benefits to special categories of individuals. In general, these are individuals
whose income and resources would otherwise be too high to qualify for full
Medicaid benefits under the regular provisions.

For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who


qualifies for Medicare Part A, whose income does not exceed 100 percent of the
Federally poverty level, and whose resources do not exceed twice the SSI
resource-eligibility standard. Medicaid coverage of QMBs is limited to payment
of their Medicare cost-sharing charges, such as the Medicare premiums,
coinsurance, and co-payment amounts.

Non-Eligibles: A State can include in its Medicaid program individuals who do


not meet the statutory eligibility criteria. However, the State must pay the full
costs for these individuals. There are no Federal matching payments.

MEDICAID SERVICES

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

• Inpatient and outpatient hospital services;


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

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

• Prenatal care and delivery services for pregnant women;


• Ambulatory services to individuals under age 18 and individuals entitled to
institutional services;
• Home health services to individuals entitled to nursing facility services; and
• If the State Plan includes services either in institutions for mental diseases or
in intermediate care facilities for the mentally retarded (ICFs/MR), it must
offer medically needy groups certain specified services provided to the
categorically needy.
States may also receive Federal funding if they elect to provide other
optional services. The most commonly covered optional services under the
Medicaid program include:

• Clinic services;
• Services of ICFs/MR;
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
• TB-related services for TB infected persons;
• Prosthetic devices; and
• Dental services.
States may provide home and community-based care waiver services to certain
individuals who are eligible for Medicaid. The services to be provided to these
persons may include case management, personal care services, respite care
services, adult day health services, homemaker/home health aide, habilitation,
and other services requested by the State and approved by CMS.

CHARACTERISTICS OF BENEFITS PROVIDED

Inpatient Hospital Services

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

• The facility must be licensed or formally approved as a hospital by an


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

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• The facility must have in effect an approved utilization review plan,


applicable to all Medicaid patients, unless a waiver has been granted by the
Secretary of Health and Human Services because the State’s own utilization
review procedures are adequate.
• A peer review organization (PRO) may satisfy these requirements.
In addition to the Federal limitations, each State may impose further limitations
on inpatient hospital services.

Outpatient Hospital Services

Outpatient hospital services refer to preventive, diagnostic, therapeutic,


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

• The services must be provided under the direction of a physician or dentist;


• The facility must be licensed or formally approved as a hospital by an
officially designated authority for State standard setting; and
• The facility must meet the requirements for participation in Medicare as a
hospital.

Rural Health Clinic Services

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

Services in RHCs must be provided by a physician or by a PA, NP, nurse-


midwife, or other specialized nurse practitioner. Services and supplies are
furnished as an incident to the professional services of such a practitioner are
also covered. Part-time or intermittent visiting nurse services and related
medical supplies are provided if the RHC is located in an area which HHS has
determined has a shortage of home health agencies, the services are furnished by
nurses employed by the RHC, and the services are furnished to a homebound
recipient under a written plan of treatment.

Other Laboratory and X-Ray Services

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

• Ordered and provided by or under the direction of a physician or other


licensed practitioner of the healing arts within the scope of his or her
practice, as defined by State law, or ordered and billed by a physician but
provided by an independent laboratory;
• Provided in an office or similar facility other than a hospital inpatient or
outpatient department or clinic; and

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• Provided by a laboratory that meets the requirements for participation in


Medicare.
• In addition, the States can place limitations on “other laboratory and X-ray
services.”

Nursing Facility Services

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

• Provided by a facility or a distinct part of a facility that is certified to meet


the requirements for participation in the Medicaid program as a NF; and
• Ordered by and furnished under the direction of a physician.

Early and Periodic Screening, Diagnosis and Treatment

Early and periodic screening, diagnosis and treatment (EPSDT) refers to


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

Screening:
• Comprehensive health and developmental history screening;
• Comprehensive unclothed physical examination;
• Appropriate vision testing;
• Appropriate hearing testing;
• Appropriate laboratory tests;
• Dental screening services furnished by direct referral to a dentist for children
beginning at 3 years of age.
Diagnosis and Treatment:
In addition to any diagnostic and treatment services included in the State
Medicaid Plan, the State must provide to eligible EPSDT recipients the
following services, the need for which is indicated by screening, even if the
services are not included in the Plan:
• Diagnosis of and treatment for defects in vision and hearing, including
eyeglasses and hearing aids;
• Dental care, at as early an age as necessary, needed for relief of pain and
infections, restoration of teeth and maintenance of dental health; and
• Appropriate immunizations. (If it is determined at the time of screening that
immunization is needed and appropriate to administer at the time of
screening, then immunization treatment must be provided at that time.)

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

Family Planning Services

Federal Requirements: States are required to provide family planning services


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

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

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

Federal Matching Payments: Federal Financial Participation (FFP) is available


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

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

FFP at the 90 percent rate is not available for the cost of a hysterectomy nor for
the costs related to other procedures performed for medical reasons, such as
removal of an intrauterine device due to infection. Only items and procedures
clearly provided or performed for family planning purposes may be matched at
the 90 percent rate. Transportation to a family planning service is not eligible
for the 90 percent match. Transportation must be claimed as either an

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administrative cost or a State Plan service, in accordance with the State’s


approved Medicaid State Plan.

Abortions: Abortions may not be claimed as a family planning service. For


more than 20 years, Congressional restrictions have been placed on appropriated
funds for HHS programs that fund abortions. FFP is available only in
expenditures for an abortion when a physician has found, and so certified in
writing to the Medicaid agency, that on the basis of his/her professional
judgment, the life of the mother would be endangered if the fetus were carried to
term. The certification must contain the name and address of the patient.
Congress has prohibited the use of Federal funds for victims of rape or incest.

Voluntary Sterilizations: FFP is available in expenditures for the sterilization of


an individual only if she is at least age 21, has voluntarily given informed
consent in accordance with Medicaid regulations, and is not a mentally
incompetent individual.

Physicians’ Services

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

Prescribed Drugs

Prescribed drugs are simple or compound substances or mixtures of substances


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

Home Health Services

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

• Part-Time Nursing: Nursing that is provided on a part-time or intermittent


basis by a home health agency. If there is no home health agency in the area,
services may be provided by a registered nurse who is currently licensed to
practice in the State, receives written orders from the patient’s physician,
documents the care and services provided, and has had orientation to

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acceptable clinical and administrative record keeping from a health


department nurse.
• Home Health Aide: Home health aide services provided by a home health
agency.
• Medical Supplies and Equipment: Medical supplies, equipment, and
appliances that are suitable for use in the home.
• Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and
Audiology Services: PT, OT, speech and hearing services provided by a
home health agency or a facility licensed by the State to provide medical
rehabilitation.
• Home health services are provided to categorically needy recipients age 21
and over and to those under 21 only if the State Plan provides SNF services
for them.

Personal Support Services

Personal support services consist of a variety of services including personal care,


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

1. Personal Care Services: Services provided to an individual who is not an


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

Nurse-Midwife Services

Nurse-midwife services are those concerned with management of the care of


mothers and newborns throughout the maternity cycle. The Omnibus Budget
Reconciliation Act of 1980 required that payment be made providing for nurse-
midwife services to categorically needy recipients (42 CFR 440.165). These
provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or
regulation. The statute also requires that States offer direct reimbursement to

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nurse-midwives as one of the payment options. Nurse-midwives must be


registered nurses who are either certified by an organization recognized by the
Secretary of HHS or who have completed a program of study and clinical
experience that has been approved by the Secretary.

Pediatric Nurse Practitioner and Family Nurse Practitioner


Services

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

CPNP and CFNP certification requirements include a current license to practice


as a registered nurse in the State, meet the applicable state requirements for
qualification of pediatric nurse practitioners or family nurse practitioners, and be
currently certified by the American Nurses’ Association as a pediatric nurse
practitioner or a family nurse practitioner.

Federally Qualified Health Center and other Ambulatory


Services

Medicaid programs must offer Federally Qualified Health Center (FQHC)


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

FQHCs are facilities or programs more commonly known as Community Health


Centers, Migrant Health Centers, and Health Care for the Homeless. These
centers may qualify as providers of service under Medicaid, under the following
conditions:

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

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AMOUNT AND DURATION OF SERVICES

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

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

MEDICAID PAYMENT FOR SERVICES

The Medicaid program operates on the basis of a division of responsibilities


between the Federal government and the States with the Federal government
paying States for a portion of State medical expenditures and administrative
costs. Funding for the program is shared between the two bodies, with the
Federal government matching State health care provider reimbursements at an
authorized rate of between 50% and 76.62%, depending on the State’s per capita
income (see the Federal Medical Assistance Percentage (FMAP) table, page 2-
17).

The FMAP is based upon the State’s per capita income; if a State’s per capita
income is equal to or greater than the national average, the Federal share is 50%.
If a State’s per capita income is below the national average, the Federal share is
increased, up to a maximum of 76.62%.

The percentages apply to State expenditures for assistance payments and medical
services. Federal statute provides separate Federal matching amounts for
administrative costs. Cost sharing for administrative expenditures vary with the
services, i.e., 75% for training, 90% for designing, developing or installing
mechanized claims processing and information retrieval, etc. (Federal Medicaid
Law (Section 1903(a)(2) et seq.)).

In 2000, the Medicaid program enrolled 44.3 million eligible individuals with
vendor payments for medical care services totaling $168.3 billion. The vendor
payments reported in the 2000 MSIS Report do not include Disproportionate
Share Hospital (DSH), Medicare premium payments made by State Medicaid
programs, and other Medicaid program expenditures. The CMS-64 Report,

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which does include such expenditures, shows total net expenditures for 2000 of
$195.2 billion. When administrative costs are added to total net expenditures,
total Medicaid program expenditures in 2000 were $205.7 billion.

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Total Medicaid Eligibles by Basis of Eligibility, 20001, 2


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

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

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Total Medicaid Eligibles


Per 1000 Population, 20001
Total State Total Eligibles per
State Population Eligibles* 1000 Populations
National Total 281,421,906 44,297,288 157.4
Alabama 4,447,100 665,767 149.7
Alaska 626,932 109,457 174.6
Arizona 5,130,632 683,224 133.2
Arkansas 2,673,400 504,297 188.6
California 33,871,648 8,063,644 238.1
Colorado 4,301,261 377,670 87.8
Connecticut 3,405,565 417,682 122.6
Delaware 783,600 124,327 158.7
District of Columbia 572,059 150,802 263.6
Florida 15,982,378 2,237,610 140.0
Georgia 8,186,453 1,238,794 151.3
Hawaii 1,211,537 202,912 167.5
Idaho 1,293,953 150,817 116.6
Illinois 12,419,293 1,736,185 139.8
Indiana 6,080,485 756,195 124.4
Iowa 2,926,324 316,425 108.1
Kansas 2,688,418 267,812 99.6
Kentucky 4,041,769 724,478 179.2
Louisiana 4,468,976 827,413 185.1
Maine 1,274,923 214,093 167.9
Maryland 5,296,486 721,762 136.3
Massachusetts 6,349,097 1,103,724 173.8
Michigan 9,938,444 1,360,726 136.9
Minnesota 4,919,479 596,726 121.3
Mississippi 2,844,658 595,824 209.5
Missouri 5,595,211 991,428 177.2
Montana 902,195 97,136 107.7
Nebraska 1,711,263 238,054 139.1
Nevada 1,998,257 158,526 79.3
New Hampshire 1,235,786 110,155 89.1
New Jersey 8,414,350 855,745 101.7
New Mexico 1,819,046 398,498 219.1
New York 18,976,457 3,401,448 179.2
North Carolina 8,049,313 1,228,105 152.6
North Dakota 642,200 62,235 96.9
Ohio 11,353,140 1,420,386 125.1
Oklahoma 3,450,654 584,620 169.4
Oregon 3,421,399 560,734 163.9
Pennsylvania 12,281,054 1,767,817 143.9
Rhode Island 1,048,319 182,149 173.8
South Carolina 4,012,012 775,428 193.3
South Dakota 754,844 98,740 130.8
Tennessee 5,689,283 1,535,121 269.8
Texas 20,851,820 2,706,974 129.8
Utah 2,233,169 203,751 91.2
Vermont 608,827 147,817 242.8
Virginia 7,078,515 681,292 96.2
Washington 5,894,121 916,838 155.6
West Virginia 1,808,344 354,326 195.9
Wisconsin 5,363,675 619,129 115.4
Wyoming 493,782 52,470 106.3

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

2-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Total Net U.S. Medical Assistance Expenditures


by Type of Service

Percent Percent Percent


Service FY 2001 of Total FY 2000 of Total Change
Nursing Facility $43,317,811,704 20.1% $39,607,169,035 20.3% +9.4%
Inpatient Acute Care Hospital $39,586,413,122 18.3% $36,650,532,554 18.8% +8.0%
Pharmaceuticals $24,656,812,921 11.4% $20,551,215,451 10.5% +20.0%
HCBS Waivers $14,864,788,473 6.9% $12,628,550,113 6.5% +17.7%
ICF-Mentally Retarded $10,686,809,919 5.0% $10,184,590,576 5.2% +4.9%
Hospital Outpatient $7,709,540,429 3.6% $7,055,207,899 3.6% +9.3%
Inpatient Mental Health Hospital $6,862,423,184 3.2% $7,331,896,067 3.8% -6.4%
Clinic* $6,689,968,278 3.1% $5,863,580,557 3.0% +14.1%
Physicians $6,670,379,109 3.1% $5,892,807,109 3.0% +13.2%
Personal Care Services $5,251,140,806 2.4% $4,566,864,434 2.3% +15.0%
Home Health Care $2,613,356,673 1.2% $2,311,780,853 1.2% +13.0%
Dental $2,193,475,415 1.0% $1,795,228,321 0.9% +22.2%
Other Practitioners $1,141,272,064 0.5% $1,030,135,204 0.5% +10.8%
EPSDT $935,836,328 0.4% $829,205,382 0.4% +12.9%
Lab/X-ray $660,398,684 0.3% $612,378,794 0.3% +7.8%
Other** $41,969,472,522 19.4% $38,245,755,438 19.6% +9.7%
Total Expenditures $215,809,899,631 100.0%‡ $195,156,897,787 100%‡ +10.6%
‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands excluded.
* Clinic includes clinics, FQHCs, and rural health clinics.
** Other includes hospice, other care services, payments to managed care organizations, etc..
Source: CMS, HCFA-64 Report, FY 2001 and FY 2000

National Pharmaceutical Council 2-17


Pharmaceutical Benefits 2002

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


State 2002 FMAP 2003 FMAP 2003 FMAP (Q3&Q4)* 2003 Enhanced FMAP**
Alabama 70.45% 70.60% 73.55% 79.42%
Alaska 57.38% 58.27% 61.22% 70.79%
Arizona 64.98% 67.25% 70.20% 77.08%
Arkansas 72.64% 74.28% 77.23% 82.00%
California 51.40% 50.00% 54.35% 65.00%
Colorado 50.00% 50.00% 52.95% 65.00%
Connecticut 50.00% 50.00% 52.95% 65.00%
Delaware 50.00% 50.00% 52.95% 65.00%
District of Columbia** 70.00% 70.00% 72.95% 79.00%
Florida 56.43% 58.83% 61.78% 71.18%
Georgia 59.00% 59.60% 62.55% 71.72%
Hawaii 56.34% 58.77% 61.72% 71.14%
Idaho 71.02% 70.96% 73.97% 79.67%
Illinois 50.00% 50.00% 52.95% 65.00%
Indiana 62.04% 61.97% 64.99% 73.38%
Iowa 62.86% 63.50% 66.45% 74.45%
Kansas 60.20% 60.15% 63.15% 72.11%
Kentucky 69.94% 69.89% 72.89% 78.92%
Louisiana 70.30% 71.28% 74.23% 79.90%
Maine 66.58% 66.22% 69.53% 76.35%
Maryland 50.00% 50.00% 52.95% 65.00%
Massachusetts 50.00% 50.00% 52.95% 65.00%
Michigan 56.36% 55.42% 59.31% 68.79%
Minnesota 50.00% 50.00% 52.95% 65.00%
Mississippi 76.09% 76.62% 79.57% 83.63%
Missouri 61.06% 61.23% 64.18% 72.86%
Montana 72.83% 72.96% 75.91% 81.07%
Nebraska 59.55% 59.52% 62.50% 71.66%
Nevada 50.00% 52.39% 55.34% 66.67%
New Hampshire 50.00% 50.00% 52.95% 65.00%
New Jersey 50.00% 50.00% 52.95% 65.00%
New Mexico 73.04% 74.56% 77.51% 82.19%
New York 50.00% 50.00% 52.95% 65.00%
North Carolina 61.46% 62.56% 65.51% 73.79%
North Dakota 69.87% 68.36% 72.82% 77.85%
Ohio 58.78% 58.83% 61.78% 71.18%
Oklahoma 70.43% 70.56% 73.51% 79.39%
Oregon 59.20% 60.16% 63.11% 72.11%
Pennsylvania 54.65% 54.69% 57.64% 68.28%
Rhode Island 52.45% 55.40% 58.35% 68.78%
South Carolina 69.34% 69.81% 72.76% 78.87%
South Dakota 65.93% 65.29% 68.88% 75.70%
Tennessee 63.64% 64.59% 67.54% 75.21%
Texas 60.17% 59.99% 63.12% 71.99%
Utah 70.00% 71.24% 74.19% 79.87%
Vermont 63.06% 62.41% 66.01% 73.69%
Virginia 51.45% 50.53% 54.40% 65.37%
Washington 50.37% 50.00% 53.32% 65.00%
West Virginia 75.27% 75.04% 78.22% 82.53%
Wisconsin 58.57% 58.43% 61.52% 70.90%
Wyoming 61.97% 61.32% 64.92% 72.92%
* The Tax Relief and Reconciliation Act of 2003 (May 28, 2003) provides for a temporary increase in the FMAP with regard to certain expenditures.
This increase is only available for the last two quarters of FY 2003 and the first three quarters of FY 2004. More information is available at:
http://cms.hhs.gov/states/letters/smd61303.pdf.
** The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or
all of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
*** The values for the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH allotments under
those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for the District of Columbia is 50.00%.
Source: Federal Register, November 17, 2000, Vol. 65, No. 223, pages 69560-69561 and Federal Register, November 30, 2001, Vol. 66, No. 231, pages
59790-59793.

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Pharmaceutical Benefits 2002

Medicaid Total Net Expenditures and Eligibles, 20001


Total Net Medical Total Average
State Assistance Expenditures Eligibles Per Eligible
National Total $195,156,897,787 44,297,288 $4,406
Alabama $2,696,375,751 665,767 $4,050
Alaska $481,281,298 109,457 $4,397
Arizona $2,225,044,559 683,224 $3,257
Arkansas $1,579,670,038 504,297 $3,132
California $21,150,591,241 8,063,644 $2,623
Colorado $1,944,315,136 377,670 $5,148
Connecticut $3,141,982,373 417,682 $7,522
Delaware $523,748,320 124,327 $4,213
District of Columbia $827,804,186 150,802 $5,489
Florida $7,525,260,503 2,237,610 $3,363
Georgia $4,321,247,201 1,238,794 $3,488
Hawaii $641,774,557 202,912 $3,163
Idaho $577,303,622 150,817 $3,828
Illinois $7,487,650,546 1,736,185 $4,313
Indiana $3,469,954,218 756,195 $4,589
Iowa $1,637,949,106 316,425 $5,176
Kansas $1,410,784,891 267,812 $5,268
Kentucky $3,034,651,254 724,478 $4,189
Louisiana $3,443,268,554 827,413 $4,161
Maine $1,184,602,684 214,093 $5,533
Maryland $3,029,230,799 721,762 $4,197
Massachusetts $6,345,106,895 1,103,724 $5,749
Michigan $6,740,820,182 1,360,726 $4,954
Minnesota $3,322,271,106 596,726 $5,567
Mississippi $1,978,270,095 595,824 $3,320
Missouri $3,939,465,005 991,428 $3,974
Montana $450,228,083 97,136 $4,635
Nebraska $1,046,569,334 238,054 $4,396
Nevada $598,188,701 158,526 $3,773
New Hampshire $791,841,232 110,155 $7,188
New Jersey $6,069,845,736 855,745 $7,093
New Mexico $1,222,368,395 398,498 $3,067
New York $30,186,294,675 3,401,448 $8,875
North Carolina $5,464,863,059 1,228,105 $4,450
North Dakota $428,657,394 62,235 $6,888
Ohio $7,479,847,366 1,420,386 $5,266
Oklahoma $1,613,315,267 584,620 $2,760
Oregon $2,110,836,095 560,734 $3,764
Pennsylvania $10,387,923,145 1,767,817 $5,876
Rhode Island $1,151,540,265 182,149 $6,322
South Carolina $2,664,608,648 775,428 $3,436
South Dakota $395,665,682 98,740 $4,007
Tennessee $4,941,572,835 1,535,121 $3,219
Texas $10,609,803,586 2,706,974 $3,919
Utah $810,160,698 203,751 $3,976
Vermont $516,874,481 147,817 $3,497
Virginia $2,728,848,408 681,292 $4,005
Washington $3,962,522,212 916,838 $4,322
West Virginia $1,378,345,915 354,326 $3,890
Wisconsin $3,266,901,080 619,129 $5,277
Wyoming $218,851,375 52,470 $4,171
1. FY 2001 data have not been released for all states. Partial data are available in Appendix B.
Source: CMS, CMS-64 Report, FY 2000 and CMS-MSIS Report, 2000.

National Pharmaceutical Council 2-19


Pharmaceutical Benefits 2002

Total Medicaid Program Expenditures, 2001


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

Source: CMS, CMS-64 Report, 2001.

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Pharmaceutical Benefits 2002

Total SCHIP Expenditures, 2001


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

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

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Pharmaceutical Benefits 2002

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Pharmaceutical Benefits 2002

MEDICAID MANAGED CARE ENROLLMENT

Since 1981, when Congress authorized States to implement Section


1915(b) and Section 1115 Medicaid waivers to increase access to
managed care and test innovative health care financing and delivery
options, enrollment in Medicaid managed care has grown considerably,
although the trend appears to be leveling off. Over the past nine years,
managed care enrollment as a percentage of total Medicaid enrollment
has increased by 300 percent (i.e., from 14.4% to 57.6%). In 2001, more
than half of all Medicaid beneficiaries were enrolled in some type of
managed care program. As of June 30, 2002, all but three States (Alaska,
Mississippi, and Wyoming) were enrolling Medicaid beneficiaries in
some type of managed care plan.

Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment

100%

80% 46.4% 44.4% 44.2% 43.2% 42.4%


52.2%
59.9%
76.8% 70.6%
60% 85.6%

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

Managed Care Fee for Service

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for
Medicaid & State Operations. *Approximated numbers for 1995. Total Medicaid population was provided by the
Office of the Actuary, which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The managed
care population differs from the 11,619,929 reported in the 1995 report as the number represented enrollment of some
beneficiaries in more than one plan.

TYPES OF MEDICAID MANAGED CARE PLANS

Medicaid managed care beneficiaries can be enrolled in one of five basic


Medicaid managed care plans:

• Health Insuring Organization (HIO): an entity that provides for or


arranges for the provision of care and contracts on a prepaid capitated
risk basis to provide a comprehensive set of services.

National Pharmaceutical Council 2-23


Pharmaceutical Benefits 2002

• Commercial Managed Care Organization (Com-MCO): a Com-


MCO is a health maintenance organization with a contract under §1876
or a Medicare+Choice organization, a provider sponsored organization
or any other private or public organization, which meets the
requirements of §1902(w). They provide comprehensive services to
commercial and/or Medicare enrollees, as well as Medicaid enrollees.

• Medicaid-only Managed Care Organization (Mcaid-MCO): a MCO


that provides comprehensive services to Medicaid beneficiaries, but not
commercial or Medicare enrollees.

• Prepaid Health Plan (PHP): an entity that provides less than


comprehensive services on an at-risk basis or one that provides any
benefit package on a non-risk basis.

• Primary Care Case Management (PCCM): a provider (usually a


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

• “Other” Managed Care Arrangement: An entity where the plan is not


considered a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO,
or HIO.

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

Table 2-1: Medicaid Managed Care Plans

Number of Plans Number of Enrollees


Health Insuring Organization (HIO) 5 511,353
Commercial Managed Care Organization (COM-MCO) 188 9,734,395
Medicaid-only Managed Care Organization (Mcaid-MCO) 120 5,722,554
Primary Care Case Management (PCCM) 38 5,614,541
Prepaid Health Plan (PHP) 159 10,166,056
Other 25 199,299
Total 535 31,948,198*

* 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.

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Pharmaceutical Benefits 2002

Medicaid Managed Care Enrollment, As of June 30, 2002


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

National Pharmaceutical Council 2-25


Pharmaceutical Benefits 2002

Pharmaceutical Benefits Under Managed Care Plans


Where do managed care recipients receive Special requirements
pharmacy benefits? for pharmacy benefits
State (State, Managed Care Plan, Both) in managed care?
Alabama N/A N/A
Alaska - -
Arizona* - -
Arkansas State None
California Both Statutes, regulations, contractual
Colorado Managed Care Plan Contractual
Connecticut Managed Care Plan Statutes, regulations, contractual
Delaware State N/A
District of Columbia Both None
Florida Managed Care Plan Contractual
Georgia N/A N/A
Hawaii Both Guidelines
Idaho N/A N/A
Illinois Managed Care Plan Contractual
Indiana Managed Care Plan None
Iowa State None
Kansas Managed Care Plan Guidelines, contractual
Kentucky Both Contractual
Louisiana State N/A
Maine State None
Maryland Both Regulations
Massachusetts Managed Care Plan Contractual
Michigan Both Contractual
Minnesota Managed Care Plan Contractual
Mississippi - -
Missouri Managed Care Plan Contractual
Montana State None
Nebraska State None
Nevada Managed Care Plan None
New Hampshire State None
New Jersey Managed Care Plan Guidelines
New Mexico Managed Care Plan Regulations, contractual
New York State Statutes, FFS program
North Carolina State None
North Dakota State None
Ohio Managed Care Plan Statutes
Oklahoma Both Contractual
Oregon Both Contractual
Pennsylvania Managed Care Plan Contractual
Rhode Island Managed Care Plan Regulations
South Carolina Managed Care Plan Contractual
South Dakota N/A N/A
Tennessee* Managed Care Plan -
Texas State N/A
Utah State N/A
Vermont State None
Virginia Managed Care Plan Contractual
Washington Both Contractual
West Virginia State N/A
Wisconsin Both Contractual
Wyoming - -

*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.

2-26 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Managed Care Enrollment Trends, 1998-2002


State 1998 1999 2000 2001 2002
National Total 16,573,996 17,756,603 18,786,137 20,773,813 23,117,668
Alabama 362,272 377,952 325,059 350,485 405,090
Alaska 0 0 0 0 0
Arizona 368,344 363,662 442,254 527,674 697,171
Arkansas 186,215 232,123 222,261 257,662 336,111
California 2,246,406 2,540,902 2,525,406 2,870,514 3,191,168
Colorado 215,936 216,357 254,232 247,181 278,095
Connecticut 220,803 230,217 229,995 239,829 280,106
Delaware 62,010 68,869 75,535 83,422 87,465
District of 51,022 75,499 78,864 79,673
Columbia 80,300
Florida 915,554 912,045 1,016,641 1,184,506 1,267,998
Georgia 673,528 638,082 806,009 878,140 1,043,154
Hawaii 131,761 120,246 121,581 127,779 132,787
Idaho 30,866 31,184 32,338 37,913 58,284
Illinois 175,649 158,888 137,622 136,497 130,988
Indiana 233,065 331,363 376,066 433,014 484,116
Iowa 190,692 176,487 182,251 206,751 227,495
Kansas 84,437 95,868 108,093 118,209 130,162
Kentucky 325,233 324,447 464,191 489,711 500,987
Louisiana 40,729 44,741 48,802 56,542 206,992
Maine 16,295 23,720 57,151 96,051 110,922
Maryland 306,474 347,937 385,687 421,355 451,307
Massachusetts 532,971 575,186 583,324 616,241 628,832
Michigan 752,568 1,130,608 1,063,557 1,023,264 1,208,803
Minnesota 225,498 268,360 291,365 322,640 368,186
Mississippi* 153,562 200,347 218,431 297,916 0
Missouri 252,097 276,628 304,499 378,771 413,361
Montana 66,331 69,738 42,312 46,995 52,209
Nebraska 110,606 122,006 140,199 150,840 163,772
Nevada 35,089 36,945 37,945 47,518 60,823
New Hampshire 7,368 5,812 4,432 6,200 9,206
New Jersey 376,839 356,956 371,641 459,087 523,904
New Mexico 193,818 208,528 199,297 212,456 243,069
New York 634,233 659,569 691,422 728,709 1,099,900
North Carolina 559,035 689,104 598,852 674,133 722,089
North Dakota 22,045 23,886 23,962 25,540 30,808
Ohio 292,819 244,888 239,460 277,617 378,476
Oklahoma 154,270 193,902 279,205 299,272 338,819
Oregon 299,826 308,798 312,064 360,926 378,739
Pennsylvania 904,701 1,004,601 975,211 1,037,374 1,140,211
Puerto Rico 813,791 764,068 828,021 898,171 865,285
Rhode Island 74,446 85,900 104,041 111,624 117,024
South Carolina 15,823 23,149 32,149 41,716 64,272
South Dakota 43,834 50,220 67,835 79,641 85,868
Tennessee 1,268,769 1,312,969 1,323,319 1,426,622 1,430,966
Texas 437,898 352,062 606,238 753,613 839,798
Utah 112,803 118,601 119,200 128,898 154,784
Vermont 52,153 65,692 55,605 78,181 82,261
Virgin Islands 0 0 0 0 0
Virginia 299,266 292,214 280,978 291,767 323,863
Washington 718,023 706,202 800,481 766,366 829,625
West Virginia 131,349 111,532 90,631 122,230 144,911
Wisconsin 194,874 187,543 210,423 266,577 317,106
Wyoming 0 0 0 0 0

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards.
*As of 2002, HealthMacs no longer participates in the Medicaid program in Mississippi.
Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 1998; 1999; 2000; 2001 and 2002. DHHS, CMS, Center for Medicaid
& State Operations.

National Pharmaceutical Council 2-27


Pharmaceutical Benefits 2002

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


Commercial Medicaid-only
State HIO MCO MCO PCCM PHP Other
National Total 5 189 120 39 159 25
Alabama 0 0 0 2 1 0
Alaska - - - - - -
Arizona 0 2 26 0 1 0
Arkansas 0 0 0 1 1 0
California 5 24 0 2 14 5
Colorado 0 5 1 1 7 0
Connecticut 0 3 1 0 0 0
Delaware 0 2 0 0 0 0
District of Columbia 0 0 4 0 1 0
Florida 0 12 2 1 2 1
Georgia 0 0 0 1 2 0
Hawaii 0 4 1 0 2 1
Idaho 0 0 0 1 0 0
Illinois 0 4 1 0 0 0
Indiana 0 0 3 1 0 0
Iowa 0 3 0 1 1 0
Kansas 0 1 0 1 0 0
Kentucky 0 0 1 1 1 0
Louisiana 0 0 0 1 0 0
Maine 0 0 0 1 0 0
Maryland 0 0 6 0 0 0
Massachusetts 0 2 2 1 1 0
Michigan 0 10 11 0 48 0
Minnesota 0 6 2 0 0 1
Mississippi 0 0 0 0 0 0
Missouri 0 4 4 0 0 0
Montana 0 0 0 1 0 0
Nebraska 0 1 0 1 0 1
Nevada 0 2 0 0 0 0
New Hampshire 0 1 0 0 0 0
New Jersey 0 1 4 0 0 0
New Mexico 0 3 0 0 0 0
New York 0 13 15 6 1 16
North Carolina 0 2 0 2 0 0
North Dakota 0 1 0 1 0 0
Ohio 0 5 2 0 0 0
Oklahoma 0 1 3 1 0 0
Oregon 0 5 9 1 18 0
Pennsylvania 0 2 9 1 25 0
Puerto Rico 0 4 0 0 3 0
Rhode Island 0 3 0 0 0 0
South Carolina 0 0 1 1 0 0
South Dakota 0 0 0 1 1 0
Tennessee 0 6 3 0 2 0
Texas 0 11 2 2 1 0
Utah 0 3 2 1 10 0
Vermont 0 0 0 1 0 0
Virgin Islands 0 0 0 0 0 0
Virginia 0 6 1 1 0 0
Washington 0 6 2 1 14 0
West Virginia 0 2 0 1 0 0
Wisconsin 0 29 2 0 2 0
Wyoming - - - - - -

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.

2-28 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Managed Care Enrollment by Plan Type,


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

* This table provides duplicated figures that include enrollees receiving comprehensive and limited benefits. Total number
of enrollees includes those who were enrolled in more than one managed care plan. Figures also include individuals
enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.

National Pharmaceutical Council 2-29


Pharmaceutical Benefits 2002

Medicaid Managed Care Enrollment by Payment Arrangement,


As of June 30, 2002
State Fee-For-Service (FFS) Fully Capitated (FUL) Partially Capitated (PAR)
National Total 5,595,064 26,127,344 211,970
Alabama 387,947 392,196 -
Alaska - - -
Arizona - 747,476 -
Arkansas 292,712 336,111 -
California 26,775 3,451,629 -
Colorado 56,163 405,489 -
Connecticut - 280,106 -
Delaware - 87,465 -
District of Columbia - 80,300 2,662
Florida 656,142 722,453 -
Georgia 1,043,154 998,269 -
Hawaii - 144,800 -
Idaho 58,284 - -
Illinois - 130,988 -
Indiana 279,538 204,578 -
Iowa 67,014 284,926 -
Kansas 68,995 61,167 -
Kentucky 293,560 623,959 -
Louisiana 206,992 - -
Maine 110,922 - -
Maryland - 451,307 -
Massachusetts 390,899 649,410 -
Michigan - 1,993,219 -
Minnesota 777 372,263 -
Mississippi - - -
Missouri - 413,361 -
Montana 52,209 - -
Nebraska 201,151 32,426 -
Nevada - 60,823 -
New Hampshire - 9,206 -
New Jersey - 523,904 -
New Mexico - 243,069 -
New York 6,077 1,072,514 21,309
North Carolina 701,351 20,738 -
North Dakota 30,214 594 -
Ohio - 378,476 -
Oklahoma - 183,503 155,316
Oregon - 994,185 13,812
Pennsylvania 129,901 1,933,098 -
Puerto Rico - 1,730,570 -
Rhode Island - 117,024 -
South Carolina - 45,401 18,871
South Dakota 68,649 85,868 -
Tennessee - 2,861,932 -
Texas 197,544 748,563 -
Utah 13,068 390,484 -
Vermont 82,261 - -
Virgin Islands - - -
Virginia 71,897 237,762 -
Washington 4,146 1,274,257 -
West Virginia 96,722 48,189 -
Wisconsin - 317,106 -
Wyoming - - -

Individual State totals will not sum to total managed care enrollment (page 2-5) because State totals include individuals enrolled in more than one plan type
including dental, mental, and long-term care.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2002. DHHS, CMS, Center for Medicaid & State Operations.

2-30 National Pharmaceutical Council


Pharmaceutical Benefits 2002

MEDICAID MANAGED CARE WAIVERS

In 1981, Congress authorized States to implement Section 1915(b) and Section


1115 Medicaid waivers to increase access to managed care and test innovative
health care financing and delivery options. The U.S. Department of Health and
Human Services (DHHS) granted these waivers to allow States to “waive”
certain Medicaid requirements in Sections 1902 and 1903 of the Social Security
Act and “mandate” enrollment of Medicaid eligibles in managed care programs.

SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS

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

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


subsection(s) of Section 1915(b);

• Paragraph (b) (1) - Case Management: States are allowed to implement case
management systems which can be as simple as requiring each beneficiary to
choose a primary care provider or as comprehensive as mandating enrollment in
a prepaid health plan.
• Paragraph (b) (2) - Central Broker: Localities are allowed to act as a central
broker in assisting Medicaid eligibles in selecting among competing health care
plans, if such a restriction does not substantially impair access to medically
necessary services of adequate quality.
• Paragraph (b) (3) - Shared Cost Saving: States are allowed to share (through
provision of additional services) cost savings (resulting from use by the recipient
of more cost-effective medical care) with recipients of medical assistance under
the State Plan.
• Paragraph (b) (4) - Restrict Providers: States can limit the number of providers
of certain services. These waivers are sometimes referred to as selective
contracting waivers and are gaining in popularity. Recently approved 1915(b)(4)
waivers included programs to restrict the number of providers of transportation
services, organ transplants, and inpatient obstetrical care.
Refer to the table on page 2-13 for a listing of 1915(b) waivers.

Although Section 1915(b) waivers allow States to increase access to managed


care plans, States are still limited under Federal regulations and cannot use them
to serve beneficiaries beyond Medicaid State Plan Eligibility or change their

National Pharmaceutical Council 2-31


Pharmaceutical Benefits 2002

benefits package. In order to expand their Medicaid programs even further than
under Section 1915(b) waivers, States apply for Section 1115 research and
demonstration waivers.

SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS

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

To receive approval of a Section 1115 waiver, States submit a proposal to CMS


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

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

2-32 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

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

National Pharmaceutical Council 2-33


Pharmaceutical Benefits 2002

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.

2-34 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Section 1115 Research and Demonstration Waivers


As of June 30, 2002
State Program Implemented Expiration
Arizona Health Care Cost Containment System
Arizona 10/1/82 9/30/06
(AHCCCS)
Arkansas ARKids First 9/1/97 9/30/05
Altamed Health Senior Buencare 11/01/98 11/24/02
Center For Elders Independence 4/1/95 11/24/02
California On Lok Senior Health Services 11/1/83 11/24/02
Senior Care Action Network 1/1/85 7/31/03
Sutter Senior Care 5/1/94 11/24/02
Delaware Diamond State Health Plan 1/1/96 3/15/04
Hawaii Hawaii QUEST 8/1/94 3/31/03
Kentucky Kentucky Health Care Partnership Program 11/1/97 11/1/02
Maryland HealthChoice 6/2/97 5/31/05
Massachusetts Mass Health 7/1/97 6/30/05
MinnesotaCare Program for Families and Children 7/1/95 6/30/05
Minnesota
Prepaid Medical Assistance Program 7/1/85 6/30/05
Missouri MC+ Managed Care/1115 9/1/98 3/1/04
Partnership Plan – Family Health Plus 9/04/01 3/31/03
New York
Partnership Plan Medicaid Managed Care Program 10/1/97 3/31/03
Oklahoma SoonerCare 1/1/96 12/31/03
Oregon Oregon Health Plan 2/1/94 1/31/05
Rhode Island Rite Care 8/1/94 7/31/05
Tennessee TennCare 1/1/94 6/30/07
Vermont Vermont Health Access 1/1/96 12/31/03
BadgerCare (SCHIP) 7/01/99 3/31/04
Wisconsin
Wisconsin Partnership Program 1/1/96 12/31/02
Source: 2002 National Summary of State Medicaid Managed Care Programs. Program Descriptions as of June 30, 2002. Centers for
Medicare and Medicaid Services, Center for Medicare & State Operations.

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Section 3:
State Characteristics

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STATE CHARACTERISTICS

Presented in Section 3 of the Compilation is State-by-State information on


several topics. The Section begins with a series of tables showing select State
demographic characteristics including age composition and racial/Hispanic
status. Next, income, employment, and insurance coverage data for each State
are presented. The final group of tables show select components of each State’s
health care system including Medicare and Medicaid certified facilities
(hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics),
licensed pharmacies, and health manpower (physicians, Registered Nurses, and
pharmacists).

The data in Section 3 have been compiled from a myriad of sources. These
include:

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

Because of the unevenness with which the various government agencies and
other organizations have released updated information, we have carefully
reviewed all possible information sources and made judgments on which data to
present. In the final analysis, we have included those data that, in our opinion,
best reflect the factors and characteristics on which we have reported. However,
certain limitations in the different sources have resulted in some inconsistencies
among the tables. The following examples illustrate this problem.

The table showing the age distribution of the population is derived from the 2001
Current Population Survey conducted by the U.S. Bureau of the Census. It is the
only 2001 age breakout on a State-by-State basis that the Bureau had released
while data collection for the 2002 Compilation was ongoing. Unfortunately, the
approximately 5 million individuals residing in “group quarters” were not
included. Hence, the total population figure (and the corresponding figures for
each State) presented in this table is lower than the population total in the table
showing insurance status.

The data on insurance status was compiled from the March Supplement to the
Current Population Survey, a collaborative effort by the Census Bureau and
BLS. Hence, the estimates on the number of Medicare and Medicaid
beneficiaries differ slightly from those published by CMS.

HRSA’s Bureau of Health Professions, Division of Nursing is responsible for


conducting the National Sample Survey of Registered Nurses. This survey is the
Nation’s most extensive and comprehensive source of nursing statistics. The
most recent survey, which is conducted every four years, is the 2000 version.
Nothing more current is available from any other source that we examined.
Hence, the nursing information included in 2002 Compilation is a repeat of the
data presented in last year’s version.

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Despite the limitations confronted while compiling these statistics, we believe


that the data presented in Section 3 provide a useful and meaningful picture of
State characteristics. Users of the Compilation are urged to carefully read the
source information and notes at the bottom of each table in order to understand
the limitations of the data contained therein.

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Age Demographics, 2001*


Percent Ages Percent Percent Percent
State Total Population 19 and under Ages 20-44 Ages 45-64 Ages 65+
National Total 277,017,622 28.5% 36.5% 23.0% 12.0%
Alabama 4,349,601 28.4% 35.1% 23.8% 12.7%
Alaska 615,531 34.0% 37.2% 23.4% 5.0%
Arizona 5,197,474 30.9% 35.0% 21.0% 13.0%
Arkansas 2,618,137 21.9% 34.4% 23.3% 13.5%
California 33,681,509 31.3% 37.5% 20.8% 10.3%
Colorado 4,314,724 29.0% 38.7% 23.0% 9.3%
Connecticut 3,317,131 26.6% 35.4% 24.8% 13.2%
Delaware 771,580 27.7% 36.5% 23.1% 12.7%
District of Columbia 536,260 22.3% 42.6% 23.3% 11.8%
Florida 16,007,098 26.1% 33.6% 23.2% 17.1%
Georgia 8,150,008 30.1% 38.8% 21.9% 9.2%
Hawaii 1,188,615 27.8% 35.1% 23.8% 13.3%
Idaho 1,289,492 32.2% 34.4% 22.4% 11.0%
Illinois 12,160,474 28.2% 37.4% 22.9% 11.5%
Indiana 5,936,550 27.5% 37.0% 23.7% 11.8%
Iowa 2,818,957 21.3% 34.4% 23.7% 14.1%
Kansas 2,612,636 27.9% 36.6% 23.0% 12.6%
Kentucky 3,950,704 27.6% 36.3% 24.0% 12.1%
Louisiana 4,329,436 31.2% 35.3% 22.4% 11.2%
Maine 1,251,745 24.2% 35.0% 26.9% 13.9%
Maryland 5,241,087 28.8% 36.4% 23.7% 11.0%
Massachusetts 6,159,307 25.0% 37.9% 24.1% 13.0%
Michigan 9,740,127 27.6% 36.6% 23.9% 11.9%
Minnesota 4,836,367 27.3% 37.8% 23.6% 11.3%
Mississippi 2,762,576 40.6% 35.1% 22.4% 11.7%
Missouri 5,467,596 28.4% 35.2% 23.6% 12.8%
Montana 879,639 27.6% 33.6% 25.9% 12.9%
Nebraska 1,662,378 29.0% 35.4% 22.8% 12.9%
Nevada 2,072,391 29.3% 36.4% 23.2% 11.1%
New Hampshire 1,223,636 26.1% 37.0% 25.6% 11.4%
New Jersey 8,289,599 25.5% 37.5% 24.3% 12.7%
New Mexico 1,792,823 30.9% 34.4% 23.2% 11.5%
New York 18,433,370 27.1% 37.0% 23.5% 12.5%
North Carolina 7,932,350 13.5% 37.2% 23.0% 11.7%
North Dakota 610,793 25.5% 36.2% 24.3% 14.0%
Ohio 11,074,368 27.0% 36.0% 24.2% 12.7%
Oklahoma 3,347,660 28.9% 34.7% 23.5% 12.9%
Oregon 3,395,357 27.7% 35.2% 24.6% 12.4%
Pennsylvania 11,853,829 25.8% 34.7% 24.6% 15.0%
Rhode Island 1,020,102 25.8% 36.7% 23.7% 13.8%
South Carolina 3,927,982 28.3% 35.8% 24.0% 11.9%
South Dakota 727,968 27.9% 35.1% 23.4% 13.6%
Tennessee 5,592,019 27.5% 36.3% 24.2% 8.4%
Texas 20,764,441 32.1% 37.3% 20.9% 9.6%
Utah 2,229,295 35.6% 38.4% 17.6% 8.4%
Vermont 592,321 25.0% 35.5% 27.1% 12.4%
Virginia 6,956,276 28.0% 37.3% 23.7% 11.0%
Washington 5,849,311 28.5% 36.9% 23.7% 10.9%
West Virginia 1,758,747 24.8% 33.8% 26.5% 14.9%
Wisconsin 5,245,913 27.1% 36.6% 24.0% 12.4%
Wyoming 480,332 28.5% 34.3% 25.8% 11.4%
This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided
is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters,
which is less than 5 million people. This accounts for the difference in the estimates of the U.S. population from this source compared to
other estimates presented by the Bureau of the Census. The data are based on a sample and are subject to sampling variability.
*Sum of percentages may not equal 100 percent due to rounding.
Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey.

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Race Demographics, 2001*


Percent
Total State Percent Percent Percent Indicated 2 or
State Population White Black Other** More Races
National Total 277,017,622 76.52% 11.97% 9.22% 2.29%
Alabama 4,349,601 71.33% 25.80% 1.69% 1.18%
Alaska 615,531 69.37% 3.36% 19.41% 7.86%
Arizona 5,197,474 76.19% 2.97% 17.94% 2.90%
Arkansas 2,618,137 80.78% 15.47% 2.14% 1.61%
California 33,681,509 66.28% 6.21% 23.68% 3.83%
Colorado 4,314,724 85.18% 3.65% 8.34% 2.83%
Connecticut 3,317,131 83.17% 8.73% 6.28% 1.82%
Delaware 771,580 75.82% 18.62% 4.16% 1.40%
District of Columbia 536,260 29.29% 60.29% 7.55% 2.87%
Florida 16,007,098 78.59% 14.77% 4.76% 1.88%
Georgia 8,150,008 66.18% 27.99% 4.41% 1.43%
Hawaii 1,188,615 24.67% 1.44% 50.22% 23.67%
Idaho 1,289,492 92.11% 0.48% 5.59% 1.81%
Illinois 12,160,474 74.68% 14.56% 8.98% 1.77%
Indiana 5,936,550 87.86% 7.95% 2.67% 1.51%
Iowa 2,818,957 93.89% 2.07% 2.83% 1.21%
Kansas 2,612,636 86.49% 6.02% 5.01% 2.48%
Kentucky 3,950,704 89.99% 6.90% 1.62% 1.48%
Louisiana 4,329,436 63.98% 32.12% 2.60% 1.31%
Maine 1,251,745 96.93% 0.40% 1.25% 1.42%
Maryland 5,241,087 63.55% 26.85% 6.86% 2.74%
Massachusetts 6,159,307 85.62% 5.51% 7.33% 1.54%
Michigan 9,740,127 80.49% 13.73% 3.77% 2.01%
Minnesota 4,836,367 89.45% 3.41% 5.62% 1.52%
Mississippi 2,762,576 61.40% 36.37% 1.34% 0.89%
Missouri 5,467,596 84.90% 11.13% 2.17% 1.80%
Montana 879,639 90.34% 0.13% 7.61% 1.93%
Nebraska 1,662,378 90.14% 3.98% 4.34% 1.54%
Nevada 2,072,391 79.18% 6.50% 10.91% 3.40%
New Hampshire 1,223,636 96.14% 0.72% 2.03% 1.11%
New Jersey 8,289,599 74.12% 13.29% 10.83% 1.77%
New Mexico 1,792,823 66.49% 1.73% 27.23% 4.55%
New York 18,433,370 69.43% 15.46% 13.27% 1.84%
North Carolina 7,932,350 72.48% 20.97% 4.95% 1.60%
North Dakota 610,793 92.19% 0.47% 6.01% 1.34%
Ohio 11,074,368 85.36% 11.17% 2.08% 1.38%
Oklahoma 3,347,660 75.95% 6.54% 10.20% 7.31%
Oregon 3,395,357 87.86% 1.62% 7.02% 3.50%
Pennsylvania 11,853,829 85.71% 9.68% 3.34% 1.28%
Rhode Island 1,020,102 85.67% 4.51% 8.20% 1.62%
South Carolina 3,927,982 67.17% 29.61% 1.64% 1.58%
South Dakota 727,968 93.08% 0.77% 4.22% 1.92%
Tennessee 5,592,019 80.55% 16.08% 2.16% 1.21%
Texas 20,764,441 71.96% 10.96% 14.96% 2.13%
Utah 2,229,295 90.86% 0.44% 5.65% 3.06%
Vermont 592,321 96.95% 0.38% 1.33% 1.34%
Virginia 6,956,276 73.02% 19.39% 5.80% 1.79%
Washington 5,849,311 81.35% 3.02% 11.15% 4.48%
West Virginia 1,758,747 95.46% 2.74% 0.76% 1.03%
Wisconsin 5,245,913 89.04% 5.50% 3.90% 1.56%
Wyoming 480,332 92.69% 0.76% 4.26% 2.30%
This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided is limited to the household population and
excludes the population living in institutions, college dormitories, and other group quarters, which is less than 5 million people. This accounts for the difference in the estimates of
the U.S. population from this source compared to other estimates presented by the Bureau of the Census. The data are based on a sample and are subject to sampling variability.
*Sum of percentages may not equal 100 percent due to rounding.
** Percent other includes American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and other.
Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile.

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Hispanic Demographics, 2001


Total State Percent
State Population Hispanic Population Hispanic
National Total 277,017,622 36,200,781 13.07%
Alabama 4,349,601 70,025 1.61%
Alaska 615,531 25,870 4.20%
Arizona 5,197,474 1,363,226 26.23%
Arkansas 2,618,137 87,579 3.35%
California 33,681,509 11,334,407 33.65%
Colorado 4,314,724 760,078 17.62%
Connecticut 3,317,131 319,796 9.64%
Delaware 771,580 38,207 4.95%
District of Columbia 536,260 47,397 8.84%
Florida 16,007,098 2,815,847 17.59%
Georgia 8,150,008 440,915 5.41%
Hawaii 1,188,615 84,236 7.09%
Idaho 1,289,492 105,802 8.20%
Illinois 12,160,474 1,573,733 12.94%
Indiana 5,936,550 213,412 3.59%
Iowa 2,818,957 81,958 2.91%
Kansas 2,612,636 172,339 6.60%
Kentucky 3,950,704 55,611 1.41%
Louisiana 4,329,436 103,771 2.40%
Maine 1,251,745 8,976 0.72%
Maryland 5,241,087 235,511 4.49%
Massachusetts 6,159,307 424,203 6.89%
Michigan 9,740,127 318,727 3.27%
Minnesota 4,836,367 140,825 2.91%
Mississippi 2,762,576 36,572 1.32%
Missouri 5,467,596 113,203 2.07%
Montana 879,639 16,168 1.84%
Nebraska 1,662,378 94,904 5.71%
Nevada 2,072,391 425,077 20.51%
New Hampshire 1,223,636 19,597 1.60%
New Jersey 8,289,599 1,140,886 13.76%
New Mexico 1,792,823 765,015 42.67%
New York 18,433,370 2,895,976 15.71%
North Carolina 7,932,350 375,913 4.74%
North Dakota 610,793 6,687 1.09%
Ohio 11,074,368 216,561 1.96%
Oklahoma 3,347,660 178,525 5.33%
Oregon 3,395,357 283,882 8.36%
Pennsylvania 11,853,829 384,586 3.24%
Rhode Island 1,020,102 91,935 9.01%
South Carolina 3,927,982 80,044 2.04%
South Dakota 727,968 11,361 1.56%
Tennessee 5,592,019 120,199 2.15%
Texas 20,764,441 6,882,466 33.15%
Utah 2,229,295 204,245 9.16%
Vermont 592,321 5,061 0.85%
Virginia 6,956,276 337,887 4.86%
Washington 5,849,311 455,874 7.79%
West Virginia 1,758,747 12,272 0.70%
Wisconsin 5,245,913 191,829 3.66%
Wyoming 480,332 31,605 6.58%
This information was taken from the 2001 Supplementary Survey Profile conducted by the U.S. Census Bureau. The information provided
is limited to the household population and excludes the population living in institutions, college dormitories, and other group quarters,
which is less than 5 million people. This accounts for the difference in the estimates of the U.S. population from this source compared to
other estimates presented by the Bureau of the Census. The data are based on a sample and are subject to sampling variability.

Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile.

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Insurance Status-Populations, 2001*

Total State Medicaid Medicare Privately Military


State
Population Population Population Insured Insurance Not Insured
National Total 282,082 31,601 38,043 199,860 9,552 41,207
Alabama 4,388 581 677 3,090 189 573
Alaska 634 84 49 419 95 100
Arizona 5,316 553 679 3,552 287 950
Arkansas 2,657 390 466 1,689 133 428
California 34,488 4,810 3,530 21,943 987 6,718
Colorado 4,410 258 481 3,256 225 687
Connecticut 3,392 245 514 2,679 71 346
Delaware 791 60 117 630 30 73
District of Columbia 554 97 65 377 12 70
Florida 16,348 1,779 2,896 10,740 661 2,856
Georgia 8,289 855 868 5,710 350 1,376
Hawaii 1,213 140 175 888 121 117
Idaho 1,315 161 164 931 57 210
Illinois 12,331 1,129 1,650 9,069 169 1,676
Indiana 6,036 364 925 4,726 116 714
Iowa 2,861 224 429 2,435 56 216
Kansas 2,642 212 447 1,998 165 301
Kentucky 3,996 515 618 2,812 276 492
Louisiana 4,390 532 566 2,753 262 845
Maine 1,279 169 242 914 58 132
Maryland 5,326 323 679 4,213 166 653
Massachusetts 6,322 839 865 4,706 135 520
Michigan 9,892 1,001 1,389 7,733 117 1,028
Minnesota 4,922 376 501 4,121 81 392
Mississippi 2,799 617 362 1,694 131 459
Missouri 5,525 645 746 4,226 167 565
Montana 892 91 148 630 58 121
Nebraska 1,683 151 222 1,313 109 160
Nevada 2,135 133 252 1,555 87 344
New Hampshire 1,258 75 193 1,018 43 119
New Jersey 8,470 675 1,363 6,390 105 1,109
New Mexico 1,804 316 290 1,023 75 373
New York 18,827 2,900 2,634 12,557 332 2,916
North Carolina 8,098 937 1,176 5,547 515 1,167
North Dakota 621 55 91 471 49 60
Ohio 11,191 1,060 1,624 8,611 184 1,248
Oklahoma 3,382 378 477 2,226 180 620
Oregon 3,462 440 431 2,520 91 443
Pennsylvania 12,102 1,240 1,838 9,582 216 1,119
Rhode Island 1,043 139 175 795 26 80
South Carolina 4,009 509 654 2,904 196 493
South Dakota 739 55 117 590 51 69
Tennessee 5,682 1,047 737 3,894 250 640
Texas 21,065 2,165 2,258 13,260 605 4,960
Utah 2,262 182 189 1,708 47 335
Vermont 607 102 78 446 12 58
Virginia 7,105 501 958 5,280 754 774
Washington 5,930 685 800 4,395 276 780
West Virginia 1,772 272 357 1,157 56 234
Wisconsin 5,336 487 817 4,342 89 409
Wyoming 488 46 68 342 33 78
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one
category. Data provided in thousands.
Source: Bureau of the Census & Bureau of Labor Statistics, Annual Demographic Survey, March Supplement 2002

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Pharmaceutical Benefits 2002

Insurance Status - Percentages, 2001*


% Covered by % Covered by
Total State % Covered by % Covered by Private Military
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 282,082 11.2% 13.5% 70.9% 3.4% 14.6%
Alabama 4,388 13.2% 15.4% 70.4% 4.3% 13.1%
Alaska 634 13.2% 7.7% 66.1% 15.0% 15.8%
Arizona 5,316 10.4% 12.8% 66.8% 5.4% 17.9%
Arkansas 2,657 14.7% 17.5% 63.6% 5.0% 16.1%
California 34,488 13.9% 10.2% 63.6% 2.9% 19.5%
Colorado 4,410 5.9% 10.9% 73.8% 5.1% 15.6%
Connecticut 3,392 7.2% 15.2% 79.0% 2.1% 10.2%
Delaware 791 7.6% 14.8% 79.6% 3.8% 9.2%
District of Columbia 554 17.5% 11.7% 68.1% 2.2% 12.6%
Florida 16,348 10.9% 17.7% 65.7% 4.0% 17.5%
Georgia 8,289 10.3% 10.5% 68.9% 4.2% 16.6%
Hawaii 1,213 11.5% 14.4% 73.2% 10.0% 9.6%
Idaho 1,315 12.2% 12.5% 70.8% 4.3% 16.0%
Illinois 12,331 9.2% 13.4% 73.5% 1.4% 13.6%
Indiana 6,036 6.0% 15.3% 78.3% 1.9% 11.8%
Iowa 2,861 7.8% 15.0% 85.1% 2.0% 7.5%
Kansas 2,642 8.0% 16.9% 75.6% 6.2% 11.4%
Kentucky 3,996 12.9% 15.5% 70.4% 6.9% 12.3%
Louisiana 4,390 12.1% 12.9% 62.7% 6.0% 19.2%
Maine 1,279 13.2% 18.9% 71.5% 4.5% 10.3%
Maryland 5,326 6.1% 12.7% 79.1% 3.1% 12.3%
Massachusetts 6,322 13.3% 13.7% 74.4% 2.1% 8.2%
Michigan 9,892 10.1% 14.0% 78.2% 1.2% 10.4%
Minnesota 4,922 7.6% 10.2% 83.7% 1.6% 8.0%
Mississippi 2,799 22.0% 12.9% 60.5% 4.7% 16.4%
Missouri 5,525 11.7% 13.5% 76.5% 3.0% 10.2%
Montana 892 10.2% 16.6% 70.6% 6.5% 13.6%
Nebraska 1,683 9.0% 13.2% 78.0% 6.5% 9.5%
Nevada 2,135 6.2% 11.8% 72.8% 4.1% 16.1%
New Hampshire 1,258 6.0% 15.3% 80.9% 3.4% 9.5%
New Jersey 8,470 8.0% 16.1% 75.4% 1.2% 13.1%
New Mexico 1,804 17.5% 16.1% 56.7% 4.2% 20.7%
New York 18,827 15.4% 14.0% 66.7% 1.8% 15.5%
North Carolina 8,098 11.6% 14.5% 68.5% 6.4% 14.4%
North Dakota 621 8.9% 14.7% 75.8% 7.9% 9.7%
Ohio 11,191 9.5% 14.5% 76.9% 1.6% 11.2%
Oklahoma 3,382 11.2% 14.1% 65.8% 5.3% 18.3%
Oregon 3,462 12.7% 12.4% 72.8% 2.6% 12.8%
Pennsylvania 12,102 10.2% 15.2% 79.2% 1.8% 9.2%
Rhode Island 1,043 13.3% 16.8% 76.2% 2.5% 7.7%
South Carolina 4,009 12.7% 16.3% 72.4% 4.9% 12.3%
South Dakota 739 7.4% 15.8% 79.8% 6.9% 9.3%
Tennessee 5,682 18.4% 13.0% 68.5% 4.4% 11.3%
Texas 21,065 10.3% 10.7% 62.9% 2.9% 23.5%
Utah 2,262 8.0% 8.4% 75.5% 2.1% 14.8%
Vermont 607 16.8% 12.9% 73.5% 2.0% 9.6%
Virginia 7,105 7.1% 13.5% 74.3% 10.6% 10.9%
Washington 5,930 11.6% 13.5% 74.1% 4.7% 13.2%
West Virginia 1,772 15.3% 20.1% 65.3% 3.2% 13.2%
Wisconsin 5,336 9.1% 15.3% 81.4% 1.7% 7.7%
Wyoming 488 9.4% 13.9% 70.1% 6.8% 16.0%
*Sum of percentages may be greater than 100 because individuals may have dual coverage and appear in more than one category. Data
provided in thousands.
Source: Bureau of the Census & Bureau of Labor Statistics, Annual Demographic Survey, March Supplement 2002.

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Pharmaceutical Benefits 2002

Income and Employment, 2001


Total State Percent Below 100% Percent
State Population Poverty Level Unemployed
National Total 277,017,622 11.5% 6.0%
Alabama 4,349,601 14.6% 5.3%
Alaska 615,531 8.1% 6.3%
Arizona 5,197,474 13.2% 4.7%
Arkansas 2,618,137 17.1% 5.1%
California 33,681,509 12.6% 5.3%
Colorado 4,314,724 9.2% 3.7%
Connecticut 3,317,131 7.5% 3.3%
Delaware 771,580 7.6% 3.5%
District of Columbia 536,260 16.7% 6.5%
Florida 16,007,098 11.9% 4.8%
Georgia 8,150,008 12.5% 4.0%
Hawaii 1,188,615 10.2% 4.6%
Idaho 1,289,492 12.0% 5.0%
Illinois 12,160,474 10.4% 5.4%
Indiana 5,936,550 8.5% 4.4%
Iowa 2,818,957 7.8% 3.3%
Kansas 2,612,636 9.1% 4.3%
Kentucky 3,950,704 12.6% 5.5%
Louisiana 4,329,436 16.7% 6.0%
Maine 1,251,745 10.2% 4.0%
Maryland 5,241,087 7.3% 4.1%
Massachusetts 6,159,307 9.4% 3.7%
Michigan 9,740,127 9.6% 5.3%
Minnesota 4,836,367 6.5% 3.7%
Mississippi 2,762,576 17.1% 5.5%
Missouri 5,467,596 9.4% 4.7%
Montana 879,639 13.7% 4.6%
Nebraska 1,662,378 9.0% 3.1%
Nevada 2,072,391 7.9% 5.3%
New Hampshire 1,223,636 5.5% 3.5%
New Jersey 8,289,599 7.7% 4.2%
New Mexico 1,792,823 17.7% 4.8%
New York 18,433,370 14.0% 4.9%
North Carolina 7,932,350 12.5% 5.5%
North Dakota 610,793 12.1% 2.8%
Ohio 11,074,368 10.3% 4.3%
Oklahoma 3,347,660 15.0% 3.8%
Oregon 3,395,357 11.3% 6.3%
Pennsylvania 11,853,829 9.1% 4.7%
Rhode Island 1,020,102 9.9% 4.7%
South Carolina 3,927,982 13.1% 5.4%
South Dakota 727,968 9.6% 3.3%
Tennessee 5,592,019 13.8% 4.5%
Texas 20,764,441 15.2% 4.9%
Utah 2,229,295 9.1% 4.4%
Vermont 592,321 9.9% 3.6%
Virginia 6,956,276 8.1% 3.5%
Washington 5,849,311 10.8% 6.4%
West Virginia 1,758,747 15.6% 4.9%
Wisconsin 5,245,913 8.6% 4.6%
Wyoming 480,332 9.7% 3.9%
Source: U.S. Department of Commerce, Bureau of the Census, 2001 Supplementary Survey Profile and Current Population Survey; U.S.
Department of Labor, Bureau of Labor Statistics, Current Population Survey.

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Medicaid/Medicare Certified Facilities, 2002


Skilled Nursing ICFs-MR Home Health Rural Health
State Hospitals Facilities Facilities Agencies Clinics
National Total* 6,017 14,840 6,689 7,007 3,319
Alabama 121 224 8 141 58
Alaska 24 15 0 16 6
Arizona 84 133 13 63 7
Arkansas 103 191 41 176 76
California 447 1,263 1,084 555 245
Colorado 83 199 3 126 42
Connecticut 46 244 8 82 0
Delaware 11 37 2 13 0
District of Columbia 14 20 131 12 0
Florida 229 695 107 375 136
Georgia 176 332 13 94 108
Hawaii 27 41 20 14 0
Idaho 45 79 65 48 43
Illinois 216 676 315 281 189
Indiana 152 499 573 161 52
Iowa 120 337 128 183 124
Kansas 17 256 38 131 157
Kentucky 116 303 14 110 89
Louisiana 193 266 473 236 50
Maine 42 121 0 34 50
Maryland 67 233 5 54 0
Massachusetts 116 482 16 121 0
Michigan 175 388 1 204 160
Minnesota 148 404 240 229 62
Mississippi 106 154 13 62 129
Missouri 138 464 19 160 212
Montana 65 101 2 48 38
Nebraska 95 175 4 63 73
Nevada 42 42 19 38 6
New Hampshire 30 68 15 35 19
New Jersey 252 360 9 53 0
New Mexico 54 71 44 62 10
New York 106 672 738 207 9
North Carolina 134 413 331 167 115
North Dakota 50 84 66 30 73
Ohio 211 916 468 342 19
Oklahoma 146 238 59 191 51
Oregon 62 122 1 61 32
Pennsylvania 249 739 205 302 48
Rhode Island 15 97 0 23 1
South Carolina 76 176 136 72 89
South Dakota 66 90 1 47 53
Tennessee 148 301 83 139 35
Texas 486 978 904 893 334
Utah 49 79 14 41 15
Vermont 16 43 1 13 20
Virginia 115 241 21 158 56
Washington 100 256 15 61 89
West Virginia 66 119 62 70 60
Wisconsin 142 361 39 122 60
Wyoming 28 33 2 38 19
*National total does not include certified facilities in Puerto Rico and U.S. territories.
Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations. January 6, 2003.

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Licensed Pharmacies (As of June 30, 2002)*


Non-Independent
Hospital/ Community Out-of-State or
Total Institutional Independent Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 74,950 8,328 20,000 15,035 9,852
Alabama 1,771 176 734 559 302
Alaska 127 (a) 14 (b) - - 156
Arizona 974 111 160 676 135
Arkansas 746 150 420 326 158
California 6,028 519 - - 187
Colorado 821 - - - 252
Connecticut 582 (c) 45 (c) 165 (c) 417 (c) 235 (c)
Delaware 159 11 37 120 239
District of Columbia 123 13 27 61 0
Florida 6,567 2,097 4098 (d) (d) 341
Georgia 3,538 204 (e) (e) -
Hawaii 213 - - - 131
Idaho 573 54 251 (d,f) - 196
Illinois 2,451 342 2,183 (d) (d) 296
Indiana 1,350 197 - - 293
Iowa 1,198 130 (g) 786 (d,g) (d) 265
Kansas 807 171 637 (d) - 302
Kentucky 1,438 125 466 671 176
Louisiana 1,771 192 576 535 313
Maine 290 42 - - 187
Maryland 1,384 (h) 70 250 698 263
Massachusetts 1,100 (i) 158 346 740 0
Michigan 2,505 - - - 125
Minnesota 1,409 137 521 526 229
Mississippi 962 130 - - 220
Missouri 1,570 (j) 160 516 569 274
Montana 317 99 - - 153
Nebraska 455 N/A - - 235 (k)
Nevada 702 47 - - 252
New Hampshire 259 32 40 167 208
New Jersey 2,489 - - - -
New Mexico 612 61 298 (d) - 283
New York 4,424 485 1,938 1,987 N/A (l)
North Carolina 2024 (g) 156 551 961 229
North Dakota 486 45 150 29 262
Ohio 2875 (m) 224 483 1,471 275
Oklahoma 1,311 89 (c) 893 (d) (d) 308
Oregon 1,061 120 300 413 232
Pennsylvania 3,166 293 - - 0
Rhode Island 191 20 41 150 227
South Carolina - - - - -
South Dakota 462 43 125 74 220
Tennessee 1,807 403 443 865 96
Texas 5676 (n) 587 1,654(d) 2,310(d) 252
Utah 734 107 415 (d) (d) 235
Vermont 155 17 138 - 0
Virginia 1,513 - - - 378
Washington 1,502 222 (o) 358 710 214
West Virginia 826 (i) - - - 270
Wisconsin 1,286 - - 0 -
Wyoming 128 (g) 30 - - 248
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to total. Total
includes other Pharmacies not specified in the four practice settings. Blanks (-) indicate that information was not available.
Source: 2002-2003 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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LEGEND

a – Includes nine wholesalers drug distributors.


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

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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.

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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.

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Section 4:
Pharmacy Program
Characteristics

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THE MEDICAID DRUG PROGRAM


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

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

On July 31, 1987, CMS published a notice of the final rule for limits on
payments for drugs in the Medicaid program. The regulations adopted in the rule
became effective October 29, 1987 (52 FR 28648). In this final rule, CMS
attempted to (1) respond to public comments on the NPRM (51 FR 2956); (2)
provide maximum flexibility to the States in their administration of the Medicaid
program; (3) provide responsible but not burdensome Federal oversight of the
Medicaid program; and (4) take advantage of savings in the marketplace for
multiple-source drugs.

To accomplish this, CMS adopted a Federal upper limit standard for certain
multiple-source drugs, based on application of a specific formula. The upper
limit for other drugs is similar, in that it retains the estimated acquisition cost
(EAC) as the upper limit standard that State agencies must meet. However, this
standard is applied on an aggregate basis rather than on a prescription-specific
basis. State agencies are therefore encouraged to exercise maximum flexibility in
establishing their own payment methods (see the Federal Register, Vol. 52, No.
147, Friday, July 31, 1987, page 28648).

Multiple-Source Drugs

A multiple-source drug is one that is marketed or sold by two or more


manufacturers or labelers, or a drug marketed or sold by the same manufacturer
or labeler under two or more different proprietary names or under a proprietary
name and without such a name.

A specific upper limit for a multiple-source drug may be established if the


following requirements are met:

• All of the formulations of the drug approved by the Food and Drug
Administration (FDA) have been evaluated as therapeutically equivalent in
the current edition of the publication, Approved Drug Products with
Therapeutically Equivalent Evaluations; and
• At least three suppliers list the drug (which is classified by the FDA as
Category A in its publication) in the current editions of published compendia
of cost information for drugs available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been
established does not apply if a physician certifies in his or her own handwriting
that a specific brand is “medically necessary” for a particular recipient.

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The handwritten phrase “brand necessary,” “medically necessary,” or “brand
medically necessary” must appear on the face of the prescription. The rule
specifically states that a check-off box on a prescription form is not acceptable,
but it does not address the use of two-line prescription forms.

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

Other Drugs

A drug described as an “other drug” is (1) a brand name drug certified as


medically necessary by the physician, (2) a multiple-source drug not subject to
the 150% formula; or (3) a single-source drug. Payments for these drugs must
not exceed, in the aggregate, payment levels determined by applying the lower
of:

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


• The provider’s usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method,
as long as their aggregate expenditures do not exceed what would have been paid
under EAC principles.

Other Requirements

The rule requires States to submit a State plan that describes their payment
methods for prescribed drugs. The rule does not prescribe a preferred payment
method, as long as the State’s aggregate spending in each category is equal to or
below the upper limit requirements. States are also required to submit assurances
to CMS that the requirements are met.

The rule does not prescribe a preferred payment method for the States, but gives
States the flexibility to determine how they will pay for prescription drugs under
Medicaid. As long as the State’s aggregate spending is at or below the amount
derived from the formula, the State is free to maintain its current payment
program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases
for other drugs so that, in the aggregate, the program does not exceed the
established limit. With the establishment of upper limit payment maximums,
some States may alter their current payment methods to comply with the
established limits.

State programs vary, depending upon whether or not State maximum allowable
cost (MAC) programs cover the same drugs listed by CMS. States with
established MAC programs may be unaffected if their MAC rates are already
low, or they may have to make certain adjustments in their MAC levels to meet
the Federal aggregate expenditure limits. States without MAC programs may
develop a new payment method to increase the use of lower cost generic drug
products in order to stay within the upper payment limits, or may simply adopt
CMS’ formula for listed drug products.

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DRUG RECIPIENTS

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

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Drug Expenditures Trends1


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

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

1
Rebates have not been subtracted from these figures.

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Ranking Based on Drug Expenditures1


% of 2001 National
2001 2001 Medicaid Drug 2000 2000
State Payments Ranking Expenditures Payments Ranking
National Total $24,656,812,921 $20,551,215,451
New York $2,986,292,455 12.1% 1 $2,540,602,423 1
California $2,984,162,770 12.1% 2 $2,472,137,448 2
Florida $1,475,766,739 6.0% 3 $1,359,073,656 3
Texas $1,325,987,804 5.4% 4 $1,121,832,241 4
Ohio $1,099,697,768 4.5% 5 $879,595,616 5
Illinois $984,653,306 4.0% 6 $803,739,171 7
North Carolina $884,018,166 3.6% 7 $805,790,014 6
Massachusetts $797,859,072 3.2% 8 $698,428,250 8
New Jersey $735,944,558 3.0% 9 $578,085,759 12
Missouri $692,665,382 2.8% 10 $594,222,924 11
Pennsylvania $681,454,847 2.8% 11 $273,537,047 23
Georgia $675,647,147 2.7% 12 $596,733,995 10
Louisiana $651,442,945 2.6% 13 $598,193,627 9
Kentucky $592,096,755 2.4% 14 $463,275,891 14
Indiana $585,388,809 2.4% 15 $508,229,794 13
Michigan $584,670,445 2.4% 16 $396,533,784 16
Washington $561,642,082 2.3% 17 $462,862,435 15
Virginia $493,177,297 2.0% 18 $368,769,294 19
Mississippi $458,332,414 1.9% 19 $394,782,642 17
South Carolina $438,897,100 1.8% 20 $350,270,353 20
Wisconsin $417,689,526 1.7% 21 $387,722,448 18
Alabama $386,876,131 1.6% 22 $333,069,288 22
Tennessee $382,272,975 1.6% 23 $347,245,591 21
Connecticut $304,780,286 1.2% 24 $265,685,933 24
Minnesota $265,726,228 1.1% 25 $231,735,404 25
West Virginia $259,638,952 1.1% 26 $215,222,053 26
Arkansas $244,203,084 1.0% 27 $204,698,146 28
Maryland $241,558,369 1.0% 28 $206,168,873 27
Iowa $234,716,795 1.0% 29 $197,279,041 29
Maine $228,670,426 0.9% 30 $168,325,265 31
Oregon $191,785,942 0.8% 31 $170,901,428 30
Kansas $185,017,060 0.8% 32 $165,290,804 32
Oklahoma $171,188,873 0.7% 33 $164,022,317 33
Colorado $170,897,014 0.7% 34 $143,192,600 35
Nebraska $166,000,664 0.7% 35 $143,925,427 34
Utah $117,170,006 0.5% 36 $100,910,520 36
Rhode Island $104,250,880 0.4% 37 $85,889,049 38
Vermont $102,975,196 0.4% 38 $82,041,976 39
Idaho $102,708,476 0.4% 39 $89,490,129 37
New Hampshire $91,703,067 0.4% 40 $81,721,512 40
Delaware $81,156,928 0.3% 41 $66,226,440 41
Hawaii $74,869,859 0.3% 42 $61,762,044 42
Montana $72,577,455 0.3% 43 $60,174,213 43
Dist. of Columbia $63,504,500 0.3% 44 $55,739,551 44
Nevada $61,500,721 0.2% 45 $50,370,705 45
New Mexico $57,995,801 0.2% 46 $48,486,325 46
Alaska $55,754,050 0.2% 47 $44,910,326 47
South Dakota $51,748,770 0.2% 48 $44,180,275 48
North Dakota $44,067,986 0.2% 49 $39,031,804 49
Wyoming $31,435,835 0.1% 50 $27,472,115 50
Arizona $2,573,205 0.0% 51 $1,627,485 51

Source: CMS, HCFA-64 Report, FY 1999 and FY 2000.

1
Rebates have not been subtracted from these figures.

4-8 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drugs as a Percentage of Total Net Expenditures, 2001


Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures1 Net Expenditures
National Total $ 215,809,899,631.00 $ 24,656,812,912.00 11.4%
Alabama $ 2,875,372,953.00 $ 386,876,131.00 13.5%
Alaska $ 576,586,201.00 $ 55,754,050.00 9.7%
Arizona $ 2,665,261,328.00 $ 2,573,205.00 0.1%
Arkansas $ 1,852,176,546.00 $ 241,558,369.00 13.0%
California $ 23,870,521,004.00 $ 2,984,162,770.00 12.5%
Colorado $ 2,142,029,851.00 $ 166,000,664.00 7.7%
Connecticut $ 3,213,848,086.00 $ 304,780,286.00 9.5%
Delaware $ 591,974,246.00 $ 81,156,928.00 13.7%
District of Columbia $ 979,941,105.00 $ 63,504,500.00 6.5%
Florida $ 8,557,796,303.00 $ 1,475,766,739.00 17.2%
Georgia $ 5,037,084,881.00 $ 735,944,558.00 14.6%
Hawaii $ 634,781,970.00 $ 74,869,859.00 11.8%
Idaho $ 693,205,598.00 $ 102,975,196.00 14.9%
Illinois $ 7,764,611,352.00 $ 884,018,166.00 11.4%
Indiana $ 4,008,812,857.00 $ 561,642,082.00 14.0%
Iowa $ 1,666,923,701.00 $ 234,716,795.00 14.1%
Kansas $ 1,686,410,544.00 $ 185,017,060.00 11.0%
Kentucky $ 3,304,053,663.00 $ 592,096,755.00 17.9%
Louisiana $ 4,201,982,590.00 $ 585,388,809.00 13.9%
Maine $ 1,315,523,163.00 $ 191,785,942.00 14.6%
Maryland $ 3,256,576,882.00 $ 244,203,084.00 7.5%
Massachusetts $ 6,619,524,971.00 $ 797,859,072.00 12.1%
Michigan $ 7,218,697,113.00 $ 584,670,445.00 8.1%
Minnesota $ 3,835,870,579.00 $ 265,726,228.00 6.9%
Mississippi $ 2,438,979,981.00 $ 493,177,297.00 20.2%
Missouri $ 4,744,963,426.00 $ 675,647,147.00 14.2%
Montana $ 482,357,404.00 $ 72,577,455.00 15.0%
Nebraska $ 1,187,237,577.00 $ 170,897,014.00 14.4%
Nevada $ 674,337,888.00 $ 61,500,721.00 9.1%
New Hampshire $ 873,248,831.00 $ 91,703,067.00 10.5%
New Jersey $ 7,123,653,988.00 $ 651,442,945.00 9.1%
New Mexico $ 1,467,417,736.00 $ 57,995,801.00 4.0%
New York $ 31,367,464,639.00 $ 2,986,292,455.00 9.5%
North Carolina $ 6,150,681,587.00 $ 984,653,306.00 16.0%
North Dakota $ 406,418,593.00 $ 44,067,986.00 10.8%
Ohio $ 8,433,412,161.00 $ 1,099,697,768.00 13.0%
Oklahoma $ 2,021,033,069.00 $ 171,188,873.00 8.5%
Oregon $ 2,658,358,391.00 $ 228,670,426.00 8.6%
Pennsylvania $ 10,908,343,146.00 $ 692,665,382.00 6.3%
Rhode Island $ 1,187,880,819.00 $ 102,708,476.00 8.6%
South Carolina $ 3,019,387,228.00 $ 438,897,100.00 14.5%
South Dakota $ 464,455,469.00 $ 51,748,770.00 11.1%
Tennessee $ 5,501,312,153.00 $ 681,454,847.00 12.4%
Texas $ 11,583,679,558.00 $ 1,325,987,804.00 11.4%
Utah $ 833,720,115.00 $ 117,170,006.00 14.1%
Vermont $ 601,467,093.00 $ 104,250,880.00 17.3%
Virginia $ 3,036,846,387.00 $ 417,689,526.00 13.8%
Washington $ 4,305,724,247.00 $ 458,332,414.00 10.6%
West Virginia $ 1,548,398,817.00 $ 259,638,952.00 16.8%
Wisconsin $ 3,976,142,914.00 $ 382,272,975.00 9.6%
Wyoming $ 243,408,927.00 $ 31,435,835.00 12.9%

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

1
Rebates have not been subtracted from these figures.

National Pharmaceutical Council 4-9


Pharmaceutical Benefits 2002

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


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

Source: CMS, HCFA-64 Report, FY 1999 - FY 2001.

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

4-10 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Share of Drug Expenditures by Category, 2001


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

National Pharmaceutical Council 4-11


Pharmaceutical Benefits 2002

Source: CMS, State Drug Utilization Data, FY 2001

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


Unclassified
Therapeutic Autonomic Blood Formation
State Agents Drugs and Coagulation Other Total
National Average $1,063,152,822 $1,028,952,289 $785,918,834 $2,943,352,187 $25,275,460,864
Alabama $16,955,251 $18,650,460 $12,004,092 $58,823,365 $401,942,443
Alaska $2,566,881 $2,902,600 $6,261,887 $5,702,252 $75,207,226
Arizona* $0 $0 $0 $0 $0
Arkansas $11,144,000 $11,115,606 $10,883,361 $28,938,742 $251,968,943
California $124,581,157 $91,334,228 $93,422,560 $291,956,950 $3,098,610,478
Colorado $8,795,844 $7,967,549 $3,432,932 $17,562,417 $171,809,633
Connecticut $11,732,148 $10,879,820 $8,794,472 $29,014,156 $308,910,514
Delaware $3,811,685 $3,637,319 $2,088,704 $10,285,623 $81,862,490
District of Columbia $1,899,260 $1,579,699 $2,413,817 $7,671,551 $59,114,928
Florida $69,968,728 $64,556,228 $61,211,843 $196,661,367 $1,512,198,408
Georgia $27,495,435 $39,039,132 $22,520,980 $104,097,938 $741,962,934
Hawaii $3,575,178 $2,269,442 $2,510,057 $5,655,938 $64,673,820
Idaho $4,420,179 $3,563,999 $3,327,150 $9,703,966 $98,019,769
Illinois $45,881,686 $40,522,287 $37,814,229 $118,096,377 $965,922,880
Indiana $24,101,346 $28,790,598 $28,689,170 $77,289,403 $596,023,018
Iowa $11,938,064 $11,652,048 $6,029,279 $24,769,010 $244,458,923
Kansas $7,754,377 $9,117,381 $3,139,768 $21,010,491 $191,909,396
Kentucky $26,118,631 $38,811,640 $15,480,779 $76,943,751 $634,276,549
Louisiana $21,435,938 $29,783,501 $20,051,806 $97,083,682 $582,334,668
Maine $9,196,068 $10,005,325 $5,694,133 $17,957,255 $205,387,830
Maryland $8,426,414 $6,764,305 $10,229,180 $21,540,807 $252,403,623
Massachusetts $30,253,249 $28,374,659 $23,341,885 $76,527,259 $827,360,889
Michigan $29,248,137 $22,325,625 $23,231,954 $61,639,188 $626,286,949
Minnesota $11,188,028 $10,116,255 $7,419,684 $24,268,247 $273,032,546
Mississippi $21,004,683 $21,685,206 $9,715,898 $61,393,881 $469,925,380
Missouri $29,339,094 $31,631,025 $23,614,163 $84,533,793 $694,331,151
Montana $4,525,672 $3,473,799 $2,276,660 $7,280,917 $74,530,133
Nebraska $6,599,038 $8,008,770 $2,547,222 $24,075,547 $174,800,367
Nevada $3,734,490 $2,808,787 $935,663 $6,768,659 $69,644,039
New Hampshire $2,194,717 $2,322,457 $1,147,658 $6,365,592 $68,309,149
New Jersey $28,740,083 $26,279,953 $31,722,908 $77,173,351 $644,444,873
New Mexico $3,462,038 $2,487,371 $916,146 $7,318,548 $62,801,857
New York $121,792,676 $106,996,809 $99,695,534 $343,225,967 $2,928,330,409
North Carolina $40,762,884 $43,077,183 $25,335,051 $134,831,755 $1,018,136,904
North Dakota $1,682,824 $1,816,397 $931,188 $5,147,701 $44,960,030
Ohio $47,450,121 $54,970,871 $28,847,394 $142,559,328 $1,172,581,643
Oklahoma $11,474,788 $11,711,703 $7,396,109 $26,641,391 $226,819,155
Oregon $8,736,837 $8,408,534 $2,833,445 $13,936,790 $238,595,384
Pennsylvania $32,089,921 $32,256,288 $25,035,011 $77,314,971 $704,720,136
Rhode Island $3,758,453 $3,689,513 $1,550,919 $9,987,786 $106,163,069
South Carolina $17,234,250 $18,093,111 $9,472,932 $60,874,605 $442,708,952
South Dakota $2,400,726 $2,329,163 $1,921,158 $6,338,991 $53,426,526
Tennessee $29,336,208 $24,234,955 $8,995,605 $50,680,851 $728,918,321
Texas $58,170,851 $57,364,635 $44,675,444 $229,571,576 $1,378,764,205
Utah $4,687,680 $4,222,931 $1,365,372 $12,725,157 $114,555,745
Vermont** $0 $0 $0 $0 $0
Virginia $18,028,216 $18,158,465 $22,019,067 $52,648,431 $431,674,685
Washington $21,919,193 $17,980,786 $11,868,778 $45,476,265 $478,690,387
West Virginia $11,270,651 $12,926,285 $3,253,119 $29,224,384 $250,538,289
Wisconsin $18,803,432 $16,759,088 $6,710,399 $40,317,421 $399,215,780
Wyoming $1,465,610 $1,498,497 $1,142,270 $3,738,798 $32,195,437
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Due to inconsistencies, Vermont data are not included in this table.
Source: CMS, State Drug Utilization Data, FY 2001.

4-12 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Share of Prescriptions Processed, 2001


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

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

National Pharmaceutical Council 4-13


Pharmaceutical Benefits 2002

Share of Prescriptions Processed, 2001 (con't)


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

*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.

4-14 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Average Cost Per Prescription, 2001


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

*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.

National Pharmaceutical Council 4-15


Pharmaceutical Benefits 2002

4-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

MEDICAID DRUG REBATES


In 1990, Congress considered a number of proposals designed to reduce and
control Federal and State expenditures for prescription drug products provided to
Medicaid patients (S.2605, the Pharmaceutical Access and Prudent Purchasing
Act; S.3029, the Medicaid Anti-Discriminatory Drug Act, sponsored by Senator
David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access and
Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A
vigorous Congressional debate ensued over which of these approaches to pursue.
Several pharmaceutical manufacturers voluntarily offered rebates to the States in
exchange for open access for their products, while the Pharmaceutical
Manufacturers Association proposed a set rebate amount in exchange for open
formularies. Numerous public interest groups offered opinions on the proposals
and in some cases proposals of their own.

The Congressional debate ended in both the House and Senate offering
somewhat similar proposals. During the ensuing Conference between the House
and Senate, the Office of Management and Budget (OMB) argued for the
inclusion of several proposals into the provisions in budget bill, the Omnibus
Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-
508, enacted November 5, 1990, required a drug manufacturer to enter into and
have in effect a national rebate agreement with the Secretary of the Department
of Health and Human Services (HHS) for States to receive Federal funding for
outpatient drugs dispensed to Medicaid patients. (For a detailed account of the
debate and genesis of various provisions see Robert Betz’s analysis of the
Medicaid Best Price Law and its effect on pharmaceutical manufacturers’ pricing
policies.*)

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

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

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

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

National Pharmaceutical Council 4-17


Pharmaceutical Benefits 2002
pharmaceutical assistance programs, and prices that are nominal in amount,
and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of
11 percent of each product’s AMP.

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

4-18 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Drug Rebates, 2001


Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $4,948,222,331 $2,852,290,258
Alabama Medicaid Drug Budget $76,624,463 $53,711,251
Alaska General Fund $11,337,883 $6,817,468
Arizona* - - -
Arkansas Medicaid General $45,744,406 $33,463,178
California Medicaid Drug Budget $786,113,991 $405,347,024
Colorado General Fund $34,264,574 $17,334,298
Connecticut Medicaid Drug Budget $61,916,192 $30,997,965
Delaware Medicaid General $17,042,045 $8,613,851
District of Columbia Medicaid General $10,446,499 $7,312,880
Florida Medicaid Drug Budget $297,362,792 $169,183,635
Georgia Medicaid General $110,087,285 $65,735,246
Hawaii General Fund, Medicaid Drug Budget $14,363,603 $7,734,801
Idaho Medicaid General $18,841,154 $13,332,002
Illinois Medicaid Drug Budget $170,733,612 $85,686,875
Indiana General Fund $103,148,144 $63,993,109
Iowa General Fund $42,602,101 $26,784,295
Kansas Medicaid General $39,731,568 $23,842,174
Kentucky General Fund $104,759,238 $73,815,957
Louisiana Medicaid Drug Budget $115,254,842 $81,440,444
Maine Medicaid Drug Budget $41,847,632 $27,707,958
Maryland Medicaid General $34,263,429 $23,731,558
Massachusetts Medicaid General $180,517,139 $90,866,756
Michigan Medicaid Drug Budget $111,716,756 $62,886,976
Minnesota General Fund $54,548,714 $27,879,847
Mississippi Medicaid General $88,481,567 $68,095,766
Missouri Medicaid General $133,927,028 $82,365,392
Montana General Fund $13,359,968 $9,792,644
Nebraska Medicaid Drug Budget $30,219,685 $18,481,621
Nevada General Fund $16,330,579 $8,278,764
New Hampshire General Fund $13,934,765 $7,001,525
New Jersey Medicaid Drug Budget $124,127,231 $62,188,060
New Mexico General Fund $12,110,896 $8,937,842
New York General Fund $543,984,948 $271,992,475
North Carolina Medicaid General $207,551,841 $129,996,009
North Dakota Medicaid Drug Budget $8,780,182 $6,156,520
Ohio General Fund $217,702,350 $128,509,697
Oklahoma Medicaid Drug Budget $40,177,945 $28,622,768
Oregon General Fund $34,991,037 $21,217,459
Pennsylvania Outpatient Appropriation $129,265,110 $69,520,225
Rhode Island General Fund $21,467,002 $11,547,100
South Carolina Medicaid Drug Budget $95,438,155 $67,719,218
South Dakota Medicaid Drug Budget $9,405,933 $6,462,840
Tennessee Medicaid General $102,644,077 $65,476,656
Texas Medicaid Drug Budget $268,557,241 $163,037,466
Utah General Fund $21,949,963 $15,701,560
Vermont Medicaid General $22,045,277 $13,823,428
Virginia Medicaid General, Medicaid Drug Budget $79,484,868 $42,334,830
Washington General Fund $91,250,830 $46,412,894
West Virginia Medicaid General $52,402,218 $39,479,831
Wisconsin Medicaid General $79,554,207 $47,158,148
Wyoming Medicaid General $5,809,366 $3,759,972

*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2002 NPC Survey. 2
CMS, CMS-64 Report, FY 2001.

National Pharmaceutical Council 4-19


Pharmaceutical Benefits 2002

Medicaid Drug Rebate Trends, 1997-2001


State 1997 1998 1999 2000 2001
National Total $2,212,579,458 $2,469,136,949 $3,338,497,983 $3,980,646,518 $4,948,222,331
Alabama $47,135,670 $36,537,095 $49,785,076 $60,984,826 $76,624,463
Alaska $4,900,641 $5,026,624 $7,050,981 $8,594,014 $11,337,883
Arizona* - - - - -
Arkansas $24,514,373 $22,518,230 $37,931,853 $40,814,931 $45,744,406
California $307,645,326 $362,808,597 $539,928,783 $600,895,711 $786,113,991
Colorado $16,950,071 $20,424,896 $25,151,080 $28,832,989 $34,264,574
Connecticut $27,318,565 $32,128,587 $38,656,394 $49,164,014 $61,916,192
Delaware $5,851,285 $7,096,836 $9,787,444 $13,780,359 $17,042,045
District of Columbia $6,668,493 $7,100,983 $8,379,982 $9,215,651 $10,446,499
Florida $128,466,755 $150,733,077 $195,512,719 $248,637,014 $297,362,792
Georgia $59,756,017 $64,320,077 $95,237,778 $91,886,605 $110,087,285
Hawaii $4,654,126 $5,992,722 $8,378,292 $10,947,632 $14,363,603
Idaho $8,369,523 $8,614,444 $11,901,778 $13,984,004 $18,841,154
Illinois $85,128,380 $100,811,862 $121,540,781 $143,590,170 $170,733,612
Indiana $43,645,256 $50,710,861 $62,691,135 $84,453,135 $103,148,144
Iowa $21,755,142 $25,265,390 $32,369,409 $36,040,216 $42,602,101
Kansas $11,797,675 $19,852,439 $26,878,486 $31,022,023 $39,731,568
Kentucky $59,890,925 $57,082,387 $72,676,810 $93,688,165 $104,759,238
Louisiana $54,650,344 $65,994,910 $76,147,317 $84,800,897 $115,254,842
Maine $18,246,061 $19,650,719 $30,032,364 $31,598,262 $41,847,632
Maryland $34,567,082 $25,017,660 $32,311,299 $42,081,781 $34,263,429
Massachusetts $73,047,452 $89,011,664 $140,102,747 $146,225,538 $180,517,139
Michigan $74,116,928 $72,526,027 $75,674,128 $75,687,945 $111,716,756
Minnesota $31,873,349 $31,058,740 $37,389,033 $43,228,324 $54,548,714
Mississippi $37,108,638 $39,983,265 $49,332,307 $61,260,326 $88,481,567
Missouri $54,614,194 $66,460,159 $84,620,799 $110,025,619 $133,927,028
Montana $6,775,176 $7,378,206 $9,290,653 $10,985,923 $13,359,968
Nebraska $14,931,313 $16,545,572 $21,609,490 $31,004,940 $30,219,685
Nevada $5,391,025 $5,143,136 $7,727,267 $4,863,879 $16,330,579
New Hampshire $8,788,296 $9,676,461 $12,956,727 $15,073,211 $13,934,765
New Jersey $66,748,605 $70,992,525 $90,472,488 $105,535,091 $124,127,231
New Mexico $13,367,028 $10,670,766 $7,972,600 $8,901,456 $12,110,896
New York $200,157,978 $251,273,382 $356,088,488 $470,317,992 $543,984,948
North Carolina $68,332,867 $81,211,796 $111,326,116 $140,047,825 $207,551,841
North Dakota $4,651,348 $4,990,065 $5,954,387 $6,503,601 $8,780,182
Ohio $84,238,194 $110,484,575 $148,477,399 $171,685,793 $217,702,350
Oklahoma $20,776,998 $23,329,251 $31,992,100 $37,135,809 $40,177,945
Oregon $13,852,833 $14,433,179 $21,360,688 $32,056,386 $34,991,037
Pennsylvania $115,510,606 $95,692,149 $119,340,064 $118,989,849 $129,265,110
Rhode Island $10,121,820 $11,041,552 $14,440,971 $19,223,034 $21,467,002
South Carolina $34,643,502 $39,156,574 $55,971,288 $73,052,676 $95,438,155
South Dakota $4,940,121 $5,070,643 $5,971,015 $7,198,848 $9,405,933
Tennessee** - $840 $22,434,760 $41,302,450 $102,644,077
Texas $130,576,891 $145,635,499 $185,695,267 $222,314,531 $268,557,241
Utah $8,374,299 $9,988,037 $15,145,126 $21,889,639 $21,949,963
Vermont $8,255,707 $8,868,263 $10,579,999 $17,869,053 $22,045,277
Virginia $45,240,474 $51,079,391 $67,715,512 $75,630,717 $79,484,868
Washington $38,326,646 $39,191,376 $54,331,249 $69,782,396 $91,250,830
West Virginia $26,079,819 $26,753,285 $35,941,495 $46,762,149 $52,402,218
Wisconsin $37,146,544 $40,776,543 $51,869,264 $66,358,433 $79,554,207
Wyoming $2,679,097 $3,025,632 $4,364,795 $4,720,686 $5,809,366

*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, HCFA-64 Report, FY 1997-FY 2001.

4-20 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Drug Rebate Trends


Annual Percent Change, 1996-2001
% Change % Change % Change % Change % Change
State 96-97 97-98 98-99 99-00 00-01
National Total 12.8% 11.6% 35.2% 19.2% 24.3%
Alabama 31.9% -22.5% 36.3% 22.5% 25.6%
Alaska 34.9% 2.6% 40.3% 21.9% 31.9%
Arizona* - - - - -
Arkansas 22.9% -8.1% 68.4% 7.6% 12.1%
California 18.5% 17.9% 48.8% 11.3% 30.8%
Colorado -2.3% 20.5% 23.1% 14.6% 18.8%
Connecticut -11.2% 17.6% 20.3% 27.2% 25.9%
Delaware 32.2% 21.3% 37.9% 40.8% 23.7%
District of Columbia 17.6% 6.5% 18.0% 10.0% 13.4%
Florida 16.5% 17.3% 29.7% 27.2% 19.6%
Georgia 5.0% 7.6% 48.1% -3.5% 19.8%
Hawaii 25.1% 28.8% 39.8% 30.7% 31.2%
Idaho 28.1% 2.9% 38.2% 17.5% 34.7%
Illinois 0.0% 18.4% 20.6% 18.1% 18.9%
Indiana -4.8% 16.2% 23.6% 34.7% 22.1%
Iowa 15.9% 16.1% 28.1% 11.3% 18.2%
Kansas 29.3% 68.3% 35.4% 15.4% 28.1%
Kentucky 38.8% -4.7% 27.3% 28.9% 11.8%
Louisiana -1.9% 20.8% 15.4% 11.4% 35.9%
Maine 13.1% 7.7% 52.8% 5.2% 32.4%
Maryland 21.3% -27.6% 29.2% 30.2% -18.6%
Massachusetts 12.3% 21.9% 57.4% 4.4% 23.5%
Michigan 9.0% -2.1% 4.3% 0.0% 47.6%
Minnesota 355.8% -2.6% 20.4% 15.6% 26.2%
Mississippi 15.3% 7.7% 23.4% 24.2% 44.4%
Missouri 6.0% 21.7% 27.3% 30.0% 21.7%
Montana 12.3% 8.9% 25.9% 18.2% 21.6%
Nebraska 21.1% 10.8% 30.6% 43.5% -2.5%
Nevada 22.5% -4.6% 50.2% -37.1% 235.8%
New Hampshire 11.1% 10.1% 33.9% 16.3% -7.6%
New Jersey 2.1% 6.4% 27.4% 16.6% 17.6%
New Mexico 16.1% -20.2% -25.3% 11.7% 36.1%
New York 33.0% 25.5% 41.7% 32.1% 15.7%
North Carolina 19.7% 18.8% 37.1% 25.8% 48.2%
North Dakota 24.6% 7.3% 19.3% 9.2% 35.0%
Ohio -18.6% 31.2% 34.4% 15.6% 26.8%
Oklahoma 5.5% 12.3% 37.1% 16.1% 8.2%
Oregon -29.6% 4.2% 48.0% 50.1% 9.2%
Pennsylvania 16.4% -17.2% 24.7% -0.3% 8.6%
Rhode Island 8.4% 9.1% 30.8% 33.1% 11.7%
South Carolina 13.6% 13.0% 42.9% 30.5% 30.6%
South Dakota 52.1% 2.6% 17.8% 20.6% 30.7%
Tennessee** - - - 84.1% 148.5%
Texas 14.1% 11.5% 27.5% 19.7% 20.8%
Utah -8.4% 19.3% 51.6% 44.5% 0.3%
Vermont 21.5% 7.4% 19.3% 68.9% 23.4%
Virginia 10.2% 12.9% 32.6% 11.7% 5.1%
Washington 14.1% 2.3% 38.6% 28.4% 30.8%
West Virginia -4.4% 2.6% 34.3% 30.1% 12.1%
Wisconsin 7.7% 9.8% 27.2% 27.9% 19.9%
Wyoming 2.1% 12.9% 44.3% 8.2% 23.1%

*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, CMS-64 Report, FY 1996 – FY 2001.

National Pharmaceutical Council 4-21


Pharmaceutical Benefits 2002

Rebates as Percent Drug Expenditures, 2001


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

*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, CMS-64 Report, FY 2001

4-22 National Pharmaceutical Council


Pharmaceutical Benefits 2002

MEDICAID DRUG COVERAGE


In general, all prescription products sold by a manufacturer that has signed a drug
rebate agreement are covered outpatient drugs reimbursable by Medicaid. A
State Medicaid program may require prior approval before dispensing of any
drug product and may design and implement a formulary intended to limit
coverage for specific drugs. Drug formularies and prior authorization programs
must meet specific requirements established in Medicaid law.

A State Medicaid program can restrict coverage for a drug product through a
formulary, if based on official labeling or information in designated official
medical compendia, “the excluded drug does not have a significant, clinically
meaningful therapeutic advantage in terms of safety, effectiveness or clinical
outcome of such treatment” over other drug products, and there is a written
explanation (available to the public) of the basis for the exclusion. However,
drug products excluded from the formulary under these conditions, nevertheless,
must be available through prior authorization.

Drugs in certain specific classes may be restricted or excluded from coverage


without regard to the formulary conditions and need not be available through
prior authorization. These classes include:

• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect,
symptomatic relief of cough or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal prescription vitamins and fluoride
preparations) or non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively
from the manufacturer or his designee.
• Barbiturates or benzodiazepines.

PRIOR AUTHORIZATION

Whether or not a drug product is on a formulary, States may require physicians to


request and receive official permission before a particular product can be
dispensed. This procedure is called Prior Authorization or Prior Approval.

States may not operate prior authorization plans unless the State provides for a
response within 24 hours of a request and provides for a 72-hour emergency
supply of the medication.

The Congressional intent for the prior authorization provision was not to
encourage the use of such programs, but rather to make them available to the
States for the purpose of controlling utilization of products that have very narrow
indications or high abuse potential.

The majority of States report the establishment of prior authorization programs


and have plans to apply prior authorization to a select number of drugs. Some
States will do so only after their Drug Utilization Review (DUR) program has
identified areas of therapeutic concern.

National Pharmaceutical Council 4-23


Pharmaceutical Benefits 2002

DRUG UTILIZATION REVIEW

DUR Program. Each State must establish a Drug Utilization Review (DUR)
Program in order to assure that prescriptions are appropriate, medically
necessary, and not likely to result in adverse medical results. A DUR Program
consists of prospective and retrospective components as well as components to
educate physicians and pharmacists on common drug therapy problems.

Specifically, the program educates physicians and pharmacists how to identify


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

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

Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS)


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

• Name and description of the medication;


• The route of administration, dosage form, dosage, and duration of therapy;
• Special directions and precautions for preparation, administration and use by
the patient;
• Common severe side or adverse effects or interactions and therapeutic
contraindications that may be encountered, including their avoidance, and the
action required if they occur;
• Techniques for self-monitoring prescription therapy;
• Proper storage;
• Prescription refill information; and
• Action to be taken in the event of a missed dose.
State law must also require pharmacists to make a reasonable effort to obtain,
record, and maintain at least the following information for each Medicaid
recipient:

• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states,
known allergies and drug reactions, and a comprehensive list of medications
and relevant devices; and

4-24 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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


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

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

National Pharmaceutical Council 4-25


Pharmaceutical Benefits 2002

4-26 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Pharmacy Advisory Committees


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

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

National Pharmaceutical Council 4-27


Pharmaceutical Benefits 2002

Pharmacy Benefit Design - Coverage


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

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

4-28 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Pharmacy Benefit Design - Coverage (con’t)


Disposable Needles for Syringe Combinations Blood Glucose Test
State Prescribed Insulin Insulin Use for Insulin Use Strips
Alabama Covered Covered Covered Covered as DME
Alaska Covered Covered Covered Covered
Arizona* - - - -
Arkansas Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
California Covered Covered Covered Covered
Colorado Covered DME DME DME
Connecticut Covered Covered Covered Covered
Delaware Covered Covered Covered Covered
District of Columbia Covered Covered Covered N/A
Florida Covered Covered Covered Covered
Georgia Covered Covered Covered Covered with Restrictions
Hawaii Covered Covered Covered Covered
Idaho Covered Covered Covered DME
Illinois Covered Covered Covered with Restrictions Covered
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered as DME Covered as DME Covered as DME
Kentucky Covered Not Covered Covered Not Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered Covered with Restrictions
Maryland Covered Covered Not Covered Not Covered
Massachusetts Covered Covered Covered Covered
Michigan Covered Covered Covered Covered
Minnesota Covered Covered Covered Covered
Mississippi Covered Covered Covered Covered
Missouri Covered Covered Covered Covered as DME
Montana Covered Not Covered Not Covered Not Covered
Nebraska Covered Covered in Supplier Program Covered (med. necess.) Covered (med. necess.)
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Covered Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Covered as DME Covered as DME Covered as DME
North Dakota Covered Covered Covered Covered
Ohio Covered Covered as DME Covered as DME Covered as DME
Oklahoma Covered Covered as DME Covered as DME Covered as DME
Oregon Covered Covered as DME Covered Covered as DME
Pennsylvania Covered Covered Covered Covered
Rhode Island Covered Covered Covered Covered as DME
South Carolina Covered Covered Covered Covered as DME
South Dakota Covered Covered Covered Covered
Tennessee* - - - -
Texas Covered Covered Covered Not Covered
Utah Covered Covered Covered with Restrictions Covered
Vermont Covered Covered Covered Covered
Virginia Covered Covered Covered Covered with Restrictions
Washington Covered Covered Covered Covered
West Virginia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Wisconsin Covered Covered Covered Covered
Wyoming Covered Covered Covered Covered

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

National Pharmaceutical Council 4-29


Pharmaceutical Benefits 2002

Pharmacy Benefit Design - Coverage (con’t)


Urine Ketone Total Interdialytic Parenteral
State Test Strips Parenteral Nutrition Nutrition
Alabama Covered as DME Covered as DME Covered as DME
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered PA Required Not Covered
Colorado DME PA Required Not Covered
Connecticut Covered Covered Covered
Delaware Covered Covered Not Covered
District of Columbia N/A N/A N/A
Florida Covered with Restrictions Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered Covered, PA Required Covered, PA Required
Idaho DME DME Not Covered
Illinois Covered Covered with Restrictions Covered with Restrictions
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered as DME Covered as DME Not Covered
Kentucky Not Covered Covered with Restrictions Covered with Restrictions
Louisiana Covered Covered as DME Covered as DME
Maine Covered Not Covered Not Covered
Maryland Not Covered Covered Covered
Massachusetts Covered Covered with Restrictions Not Covered
Michigan Covered Covered as DME Covered as DME
Minnesota Covered Covered Covered
Mississippi Covered Covered with Restrictions Covered with Restrictions
Missouri Covered as DME Covered as DME Covered as DME
Montana Not Covered Not Covered Covered in Supplier Program
Nebraska Covered in Supplier Program Covered in Supplier Program Not Covered
Nevada Covered Covered as DME Covered as DME
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered with Restrictions
New York Covered Covered Covered
North Carolina Covered as DME Covered Covered
North Dakota Covered Covered Not Covered
Ohio Covered as DME Not Covered Not Covered
Oklahoma Covered as DME Covered with Restrictions N/A
Oregon Covered as DME PA Required PA Required
Pennsylvania Covered Covered Covered
Rhode Island Covered Covered as DME, PA required Covered as DME, PA Required
South Carolina Covered as DME Covered as DME Covered as DME
South Dakota Covered Not Covered Not Covered
Tennessee* - - -
Texas Not Covered Not Covered Not Covered
Utah Covered Covered as DME Covered as DME
Vermont Covered Covered Covered
Virginia Covered as DME Covered Not Covered
Washington Covered Covered Covered
West Virginia Covered with Restrictions Covered as DME Not Covered
Wisconsin Covered Covered Covered
Wyoming Covered Covered as DME Covered as DME

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

4-30 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

State Physicians Office Home Health Care Extended Care Facility


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

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

National Pharmaceutical Council 4-31


Pharmaceutical Benefits 2002

Coverage of Vaccines and Unit Dose


State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama EPSDT, VCP Yes
Alaska EPSDT, VCP Yes
Arizona* - -
Arkansas VCP Yes
California VCP Yes
Colorado EPSDT No
Connecticut CHIP No
Delaware VCP, CHIP No
District of Columbia EPSDT No
Florida VCP Yes
Georgia EPSDT, VCP Yes
Hawaii EPSDT, CHIP, VCP Yes
Idaho ESPDT, CHIP, VCP Yes
Illinois VCP No
Indiana EPSDT, CHIP, VCP Yes
Iowa EPSDT, VCP Yes
Kansas CHIP, VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Services Yes
Louisiana EPSDT, VCP Yes
Maine EPSDT, CHIP No
Maryland VCP No
Massachusetts EPSDT, Department of Public Health No
Michigan EPSDT, CHIP Yes
Minnesota EPSDT, CHIP, VCP Yes
Mississippi EPSDT, CHIP No
Missouri EPSDT, CHIP, VCP Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska EPSDT, CHIP, VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes
New Jersey EPSDT, VCP Yes, LTC
New Mexico Admin. only reimbursable, Vaccines free through Health Dept. No
New York EPSDT, CHIP, VCP No
North Carolina EPSDT, VCP No
North Dakota EPSDT No
Ohio VCP No
Oklahoma ESPDT, VCP Yes
Oregon VCP Yes
Pennsylvania EPSDT, CHIP, VCP, Pharmacy Services No
Rhode Island VCP No
South Carolina VCP Yes
South Dakota VCP Yes
Tennessee* - -
Texas EPSDT, CHIP, VCP Yes
Utah VCP No
Vermont EPSDT Yes
Virginia VCP Yes
Washington EPSDT Yes
West Virginia CHIP, VCP Yes
Wisconsin VCP Yes
Wyoming EPSDT, CHIP, VCP No

^ Early and Periodic Screening, Diagnostic and Treatment (EPSDT), Children Health Insurance Program (CHIP), Vaccines for Children
Program (VCP), or other.
LTC = Long Term Care
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.

4-32 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Coverage of Over-the-Counter Medications


Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered Covered Covered Not Covered
Alaska Not Covered Not Covered Not Covered Not Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
California Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Not Covered Not Covered Covered Not Covered
Delaware Covered Covered Covered Covered
District of Columbia N/A N/A N/A N/A
Florida Not Covered Covered with Restrictions Not Covered Covered
Georgia Not Covered Covered with Restrictions Covered with Restrictions Not Covered
Hawaii Limited Coverage Limited Coverage Limited Coverage Not Covered
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Covered Not Covered Covered
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Kansas Not Covered Covered Limited Coverage Limited Coverage
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered Covered Covered with Restrictions Covered
Maryland Not Covered Not Covered Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Not Covered
Michigan Limited Coverage Limited Coverage Not Covered Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Mississippi Limited Coverage Limited Coverage Limited Coverage Covered
Missouri Covered Covered Covered Not Covered
Montana Not Covered Limited Coverage Not Covered Covered with Restrictions
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Limited Coverage Limited Coverage Limited Coverage Limited Coverage
New Mexico Covered Covered Covered Covered
New York Limited Coverage Limited Coverage Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Limited Coverage Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Covered with Restrictions Covered
Rhode Island Not Covered Covered with Restrictions Covered with Restrictions Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Limited Coverage Covered Covered Not Covered
Vermont PA Required PA Required PA Required PA Required
Virginia Covered with Restrictions Covered Covered with Restrictions Not Covered
Washington Limited Coverage Limited Coverage Limited Coverage Not Covered
West Virginia Limited Coverage Limited Coverage Limited Coverage PA Required
Wisconsin Covered Covered Covered Not Covered
Wyoming Covered Covered Covered Not Covered

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

National Pharmaceutical Council 4-33


Pharmaceutical Benefits 2002

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


Digestive Products
State (no H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered Covered Not Covered Covered with Restrictions
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Covered Limited Coverage Limited Coverage
California Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered with Restrictions Covered with Restrictions Not Covered Covered
Delaware Covered Covered Limited Coverage Limited Coverage
District of Columbia N/A N/A N/A N/A
Florida Not Covered Not Covered Covered with Restrictions Not Covered
Georgia Not Covered Not Covered Not Covered Not Covered
Hawaii Limited Coverage Limited Coverage N/A Limited Coverage
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Not Covered Not Covered PA Required
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Not Covered Not Covered Not Covered Covered with Restrictions
Kansas Not Covered Covered Not Covered Not Covered
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Maryland Not Covered Not Covered Limited Coverage Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Mississippi Limited Coverage Covered with Restrictions Limited Coverage Limited Coverage
Missouri Covered Covered Not Covered Not Covered
Montana Covered with Restrictions Covered with Restrictions Not Covered Not Covered
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Nevada Covered Covered Not Covered Covered with Restrictions
New Hampshire Covered Covered Covered Covered
New Jersey Not Covered Not Covered Not Covered Limited Coverage
New Mexico Covered Covered Not Covered Covered with Restrictions
New York Limited Coverage Not Covered Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Not Covered Not Covered
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Not Covered Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Not covered Covered with Restrictions Covered Covered
Rhode Island Covered Not Covered Covered with Restrictions Covered with Restrictions
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* - - - -
Texas Covered Covered Covered Covered
Utah Not Covered Limited Coverage Covered with Restrictions Limited Coverage
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered with Restrictions Covered with Restrictions
Washington Covered Not Covered Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage
Wisconsin Covered Not Covered Not Covered Not Covered
Wyoming Not Covered Covered Covered Covered with Restrictions

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

4-34 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Prior Authorization Process and Procedures


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

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

National Pharmaceutical Council 4-35


Pharmaceutical Benefits 2002

Prior Authorization Process and Procedures (Con’t)


State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph. N/A N/A
Alaska M.D., R.Ph. 1,200 85%
Arizona* - - -
Arkansas M.D., R.Ph. 136,750 65%
California M.D., R.Ph. 2,060,000 88%
Colorado M.D. 166,000 80%
Connecticut N/A N/A N/A
Delaware M.D., R.Ph. 200 90%
District of Columbia N/A N/A N/A
Florida M.D. 40,000 78%
Georgia M.D., R.Ph. 104,000 92%
Hawaii M.D., R.Ph. N/A N/A
Idaho M.D., R.Ph. N/A N/A
Illinois M.D., R.Ph. 500,000 20%
Indiana M.D., R.Ph. N/A N/A
Iowa M.D., R.Ph. 56,000 93%
Kansas M.D., R.Ph. N/A N/A
Kentucky M.D., R.Ph. 623,000 50%
Louisiana M.D. 70,000 95%
Maine M.D. 44,000 91%
Maryland M.D., R.Ph 5,300 95%
Massachusetts M.D 29,000 40%
Michigan M.D. 18,000 82%
Minnesota R.Ph. 6,000 N/A
Mississippi M.D. 255,000 87%
Missouri M.D. 35,000 N/A
Montana M.D., R.Ph., Pharm. Tech. 25,000 79%
Nebraska M.D., R.Ph. 24,000 40%
Nevada M.D. - -
New Hampshire M.D. 7,500 75%
New Jersey R.Ph., DME Supplier 351,000 97%
New Mexico M.D. 400 98%
New York Ordering Provider N/A N/A
North Carolina M.D. N/A N/A
North Dakota M.D., R.Ph. 600 90%
Ohio M.D. 31,000 99%
Oklahoma R.Ph. 99,000 68%
Oregon M.D. 31,750 80%
Pennsylvania M.D., Other Licensed Prescriber N/A N/A
Rhode Island M.D. N/A 85%
South Carolina M.D. 37,700 60%
South Dakota M.D., R.Ph. 28 100%
Tennessee* - - -
Texas M.D., R.Ph. 2,000 75%
Utah M.D., R.Ph. N/A N/A
Vermont M.D. N/A 99%
Virginia M.D. 416 30%
Washington M.D., R.Ph., Pharm. Tech. 1,618,000 80%
West Virginia M.D., R.Ph. 160,000 78%
Wisconsin R.Ph. 50,000 95%
Wyoming M.D., R.Ph., Pharm. Tech. 18,000 90%

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

4-36 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Prior Authorization Process and Procedures (Con’t)


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

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

National Pharmaceutical Council 4-37


Pharmaceutical Benefits 2002

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.

4-38 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Prior Authorization (Con’t)


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2002 NPC Survey.

National Pharmaceutical Council 4-39


Pharmaceutical Benefits 2002

Prior Authorization (Con’t)


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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2002 NPC Survey.

4-40 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drug Utilization Review


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

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

National Pharmaceutical Council 4-41


Pharmaceutical Benefits 2002

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.

4-42 National Pharmaceutical Council


Pharmaceutical Benefits 2002

PHARMACY PAYMENT AND PATIENT COST SHARING


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

Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a


Medicaid managed care organization, payment is made to the MCO in
accordance with its contract with the State Medicaid agency to the extent the
contract covers outpatient prescribed drugs.

Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must


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

PATIENT COST SHARING

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

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

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


option);
• Pregnancy-related services (or, at State option, any service provided to
pregnant women);
• Services provided to certain institutionalized individuals, who are required to
spend all of their income for medical care except for a personal needs
allowance;
• Emergency services;
• Family planning services and supplies;

National Pharmaceutical Council 4-43


Pharmaceutical Benefits 2002

• Services furnished to categorically needy HMO enrollees (or, at State option,


services provided to both categorically needy and medically needy HMO
enrollees).
In addition, the law prohibits imposing more than one type of charge on any
service.

While emergency services are excluded from cost sharing, States may apply for
waivers of nominal amounts for non-emergency services furnished in hospital
emergency rooms. Such a waiver allows States to impose a copayment amount
up to twice the current maximum for such services. Approval of a waiver request
by CMS is based partly on the State’s assurance that recipients will have access
to alternative sources of care.

4-44 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Pharmacy Payment and Patient Cost Sharing


State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45 minimum AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 AWP-10.5% $0.50 - $5.00
California $4.05 AWP-10% $1.00
Colorado $4.00; $1.89 for Institutions AWP-13.5% or WAC+18%, whichever is G: $0.75, B: $3.00
lowest; AWP-35% (for generics)
Connecticut $3.85 AWP-12% None
Delaware $3.65 AWP-12.9% None
DC $3.75 AWP-10% $1.00
Florida $4.23-$4.73 (LTC) AWP-13.25%; WAC+7% None
Georgia $4.63 + $0.50 (for generics) AWP-10% G/P: $0.50, B/NP: $0.50 - $3.00
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-12% None
Illinois G: $5.10, B: $4.00 B: AWP-11%, G: AWP-20% $1.00
Indiana $4.90 B: AWP-13.5%, G: AWP-20% $0.50 - $3.00
Iowa $5.17 AWP-10% $1.00
Kansas $3.40 B: AWP-15%, G: AWP-27% IV AWP-50%, $3.00
blood AWP-30%
Kentucky $4.51 AWP-12% $1.00
Louisiana $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 (+extra fees for compounding) AWP-13% $0.50 - $3.00
Maryland $4.21 Lowest of :WAC+10%, direct+10%, AWP-10% $1.00
Massachusetts B: $3.50 G: $5.00 WAC+5% $2.00
Michigan $3.72 AWP-13.5% (1-4 stores), AWP-15.1% $1.00
(5+stores)
Minnesota $3.65 AWP-9% None
Mississippi $3.91 AWP-12% $1.00 - $3.00
Missouri $4.09 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some
1115 waiver pop.
Montana $2.00 - $4.70 AWP-15%, direct price for some labelers $1.00 - $5.00
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% None
New Hampshire $2.50 AWP-12% G: $0.50, B: $1.00
New Jersey $3.73 - $4.07 AWP-10%, WAC+30%, AAC for injectables None
New Mexico $3.65 AWP-12.5% None (except CHIP and
working disabled)
New York B: $3.50 G: $4.50 AWP-10% G: $0.50, B: $2.00
North Carolina B: $4.00 G: $5.60 AWP-10% G: $1.00, B: $3.00
North Dakota $5.10 AWP-10% $3.00 (Brand)
Ohio $3.70 WAC + 9% None
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00
Oregon Retail: $3.50 Inst./NF: $3.80 AWP-13% None
Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for Gas)
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* - - -
Texas (EAC+$5.27)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90-$4.40 (based on area) AWP-15% $3.00 - $5.00/mo.
Vermont $4.25 AWP-11.9% $1.00 - $2.00
Virginia $4.25 AWP-10.25% G: $1.00, B: $2.00
Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None
West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $2.00
Wisconsin $4.88 (to a maximum $40.11) AWP-11.25% $1.00, max $5/recip/pharm/mo
Wyoming $5.00 AWP-11% $2.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
Source: As reported by State drug program administrators in the 2002 NPC Survey.

National Pharmaceutical Council 4-45


Pharmaceutical Benefits 2002

Maximum Allowable Cost (MAC) Programs


Federal Upper State-Specific
State Limits Upper Limits MAC Override Provisions
Alabama Yes Yes Dispense as written, brand medically necessary
Alaska Yes No Brand medically necessary and reason for medical necessity
Arizona* - - -
Arkansas Yes Yes Brand medically necessary, prior authorization
California Yes Yes Medically necessary and other products unavailable at MAC rate
Colorado Yes Yes Brand medically necessary
Connecticut Yes No Brand medically necessary
Delaware Yes Yes Brand medically necessary
District of Columbia Yes No Brand medically necessary plus an explanation
Florida Yes Yes If drug is on Florida Negative Formulary
Georgia Yes Yes Prior authorization
Hawaii Yes No brand Medically necessary
Idaho Yes Yes Prior authorization
Illinois Yes Yes Prior authorization request by M.D. or R.Ph.
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary, Med Watch form and prior authorization
Kansas Yes Yes N/A
Kentucky Yes No Brand necessary, brand medically necessary, PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Medically necessary, brand Medically necessary PA on some drugs
Maryland Yes Yes Brand medically necessary and reason for medical necessity
Massachusetts Yes Yes Dispense as written, brand medically necessary, prior authorization
Michigan Yes Yes Dispense as written and prior authorization
Minnesota Yes Yes Brand medically necessary or dispense as written. Brand medically
necessary must be handwritten on the prescription by the prescriber, no
pre-printed DAW allowed.
Mississippi Yes No Prior authorization for brand multi-source
Missouri Yes Yes Prior authorization
Montana Yes No Brand necessary, prior authorization
Nebraska Yes Yes Medically necessary
Nevada No No Brand medically necessary
New Hampshire Yes Yes Brand medically necessary, MedWatch form for PA
New Jersey Yes No Brand medically necessary
New Mexico Yes Yes Medically necessary, Brand necessary
New York Yes No Dispense as written, brand necessary, or brand medically necessary
North Carolina Yes Yes Brand medically necessary
North Dakota Yes Yes Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary
Oregon Yes No Dispense as written, brand medically necessary
Pennsylvania Yes Yes Brand necessary, brand medically necessary, or prior authorization
Rhode Island Yes No Brand medically necessary with medical justification
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and P.A.
South Dakota Yes Yes Brand medically necessary
Tennessee* - - -
Texas Yes Yes Brand necessary, brand medically necessary
Utah Yes Yes Brand medically necessary plus prior approval
Vermont Yes Yes Dispense as written
Virginia Yes Yes Brand necessary
Washington No Yes Brand medically necessary
West Virginia Yes No Brand medically necessary (hand written by prescriber)
Wisconsin No Yes Brand medically necessary
Wyoming Yes Yes Brand medically necessary
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug
decisions.

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

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Pharmaceutical Benefits 2002

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.

National Pharmaceutical Council 4-47


Pharmaceutical Benefits 2002

Counseling Requirements and Payment for Cognitive Services


Medicaid Payment
State Patient Counseling Required1 for Cognitive Services2
Alabama All Yes, Clozaril case management
Alaska All No
Arizona All -
Arkansas All No
California All No
Colorado Medicaid Only No
Connecticut Medicaid Only No
Delaware All No
District of Columbia Medicaid Only, Pending for others No
Florida All No
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All No
Kansas All No
Kentucky All No
Louisiana All No
Maine All No
Maryland Medicaid Only No
Massachusetts All No
Michigan All No
Minnesota All No
Mississippi All Yes
Missouri All Yes (diabetes education)
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All Yes
New Mexico All No
New York All No
North Carolina All No
North Dakota All No
Ohio All No
Oklahoma All No
Oregon All No
Pennsylvania All No
Rhode Island All No
South Carolina Medicaid Only No
South Dakota All No
Tennessee All -
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All Yes (emergency contraceptive counseling)
West Virginia All No
Wisconsin All Yes
Wyoming All No

Source: 12001-2002 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug program
administrators in the 2002 NPC Survey.

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Pharmaceutical Benefits 2002

Prescription Price Updating


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

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

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

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Pharmaceutical Benefits 2002

4-50 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Section 5:
State Pharmacy Program
Profiles

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Pharmaceutical Benefits 2002

5-2 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Profiles of State Medicaid Drug Programs


In the following State profiles, we present a general overview of the
characteristics of State programs together with detailed information on the
pharmaceutical benefits provided. Specifically, the following information is
provided for each State:
A. Benefits Provided and Groups Eligible
B. Expenditures for Drugs
C. Administration
D. Provisions Relating to Drugs, including:
• Drug Benefit Product Coverage
• Over-the-Counter Product Coverage
• Therapeutic Category Coverage
• Coverage of Injectables, Vaccines, and Unit Dosing
• Formulary/Prior Authorization
• Prescribing or Dispensing Limitations
• Drug Utilization Review
• Dispensing Fee
• Ingredient Reimbursement Basis
• Prescription Charge Formula
• Maximum Allowable Cost
• Incentive Fee
• Patient Cost Sharing
• Cognitive Services
E. Use of Managed Care
F. State Contacts

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Pharmaceutical Benefits 2002

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Pharmaceutical Benefits 2002

Section 6:
State Pharmacy
Assistance Programs

National Pharmaceutical Council 6-1


Pharmaceutical Benefits 2002

6-2 National Pharmaceutical Council


Pharmaceutical Benefits 2002

State Pharmacy Assistance Programs


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

Authorized State Pharmacy Assistance Programs

State Program Name Law Enacted


Prescription Medication Coverage Pilot Program 2001†
Arizona
Arizona Prescription Discount Program 2003
ARx Senior Program (formerly Prescription Drug
Arkansas 2001†
Access Improvement Act)
Discount Prescription Medication Program 1999
California
Golden Bear State Pharmacy Assistance Program 2001†
Connecticut Pharmaceutical Assistance Contract to the
Connecticut 1985
Elderly and Disabled (ConnPACE)
Nemours Health Clinic Pharmaceutical Assistance
1981
Program
Delaware
Delaware Prescription Drug Assistance Program
1999
(DPAP)
Silver SaveRx (formerly Pharmaceutical Expense
Assistance Program for Seniors and Ron Silver Senior 2002
Florida
Drug Program)
Medicare Prescription Discount Program 2000
Hawaii Rx 2002†
Hawaii
Medicaid Prescription Drug Expansion Program 2002†
Pharmaceutical Assistance Program, “Circuitbreaker” 1985
Illinois Rx SeniorCare 2001
Illinois
Senior Citizens and Disabled Persons Prescription
2003†
Drug Discount Program
Indiana Indiana Prescription Drug Program, “HoosierRx” 2000
Iowa Iowa Priority Prescription Savings Program 2001
Kansas Senior Pharmacy Assistance Program 2000
Maine Rx 2000*
Maine Rx Plus 2004*
Maine Healthy Maine Prescription Drug Program 2001
Low Cost Drugs for the Elderly and Disabled Program
1975
(DEL)
Maryland Pharmacy Assistance Program 1979
Maryland Short-Term Prescription Drug Subsidy Plan 2000
Maryland Pharmacy Discount Program 2001†
Massachusetts Prescription Advantage 2000+
Michigan Elder Prescription Insurance Coverage Program 2001
Minnesota Prescription Drug Program 1999
Missouri SeniorRx Program 2001
Montana Prescription Drug Expansion Program 2003†
Nevada Senior Rx 2000

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Pharmaceutical Benefits 2002

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

†Program not yet operational.


*MaineRx is expected to be abandoned and replaced with MaineRx Plus.
+Program enrollment closed due to budget restrictions.

The following pages provide profiles of the State pharmacy assistance programs.
Details were provided by State contacts on program characteristics, including
eligibility criteria, funding and reimbursement information, and drug coverage.
Supplemental information was obtained from special surveys of State programs in
addition to the National Conference of State Legislatures (NCSL) website,
http://www.ncsl.org/programs/health/drugaid.htm, a good source for the most up-to-
date information.

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Pharmaceutical Benefits 2002

Arizona
Prescription Medication Coverage Pilot Program
Program Type: Discount
Law Enacted: 2001∗
Projected Number of Recipients: Not Available

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Participants must be either residents of a county that does not have a
Medicare HMO or residents of a county that has a Medicare HMO that
does not provide prescription medication coverage.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 02-03): None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Not Available
Ingredient Cost Calculation: Not Available
Enrollment Fee: Not Available
Deductible Amount: $500 for incomes 100-149% of FPL and $1,000 for incomes 150-
200% of FPL.
Copayment Amount: None
Dispensing Fee: Not Available
Notes: Program covers 50% of pharmaceutical costs after deductible has been
paid.

DRUGS COVERAGE

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

PROGRAM CONTACT

Del Swan Containment System


Arizona Health Care Cost Phone: 602/417-4726
801 E. Jefferson St.
Phoenix, AZ 85034


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.

National Pharmaceutical Council 6-5


Pharmaceutical Benefits 2002

Arizona
Arizona Prescription Discount Program
Program Type: Discount
Year Operational: 2003
Projected Number of Recipients: 600,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes


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

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


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

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available

PROGRAM CONTACT

Del Swan Containment System


Arizona Health Care Cost Phone: 602/417-4726
801 E. Jefferson St.
Phoenix, AZ 85034

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Pharmaceutical Benefits 2002

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

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


Eligible Income Level (Single): 90% of FPL Eligible Income Level (Married): 90% of FPL
Other Eligibility Notes: Program provides prescription drug coverage to Qualified Medicare
Beneficiary (QMB) seniors lacking prescription drug coverage. After
June 30, 2003, the upper income eligibility limit increases to 100% of
FPL.

FUNDING AND REIMBURSEMENT

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

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Legend drugs and controlled substances
Drug Coverage Restrictions: Enrollees are limited to 2 prescriptions per month.

PROGRAM CONTACT

Suzette Bridges Phone: 501/683-4120


Arkansas Department of Human Services Fax: 501/683-4124
Division of Medical Services, Slot 415 E-mail: suzette.bridges@medicaid.state.ar.us
P.O. Box 1437
Little Rock, AR 72203-1437


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.

National Pharmaceutical Council 6-7


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


Budget (FY 2002-03): $380,000
Cost per Participant: Not Available
# of Rx’s Per Participant: 850,000 price inquiries per month∗
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4:05 per prescription (-50 cents to help balance the FY 02-03 State
budget, + 15 cents for switching costs)
Notes: Pharmacies that participate in the Medi-Cal (Medicaid) program must
also allow Medicare recipients to purchase drugs for the same price
paid by Medi-Cal. Pharmacies must participate in this program in order
to participate in the Medi-Cal program.

DRUGS COVERAGE

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

PROGRAM CONTACT

Janice Hall Phone: 916/657-4302


Department of Health Services E-Mail: sb393rx@dhs.ca.gov
714 P Street, Room 1253
Sacramento, CA 95814


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

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Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: Manufacturer negotiated discounts


Budget: None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid rebate plus manufacturer-negotiated discounts
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: Not Available
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $4:05 per prescription (-50 cents to help balance the FY 2002-03 State
budget, + 15 cents for switching costs)
Notes: Medi-Cal collects a 99-cent per Rx administrative fee from drug
manufacturers and reimburses pharmacies with the remainder of the
negotiated discount.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Prescription drugs for which the State has negotiated manufacturer
discounts that supplement the Medi-Cal discount already mandated
under the California Discount Prescription Medication Program.
Drug Coverage Restrictions: Only prescription drugs with manufacturer-negotiated discounts.

PROGRAM CONTACT

Janice Hall Phone: 916/657-4302


Department of Health Services E-Mail: sb393rx@dhs.ca.gov
714 P Street, Room 1253
Sacramento, CA 95814
*
Not yet operational.

National Pharmaceutical Council 6-9


Pharmaceutical Benefits 2002

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

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): $20,300 Eligible Income Level (Married): $27,500
Other Eligibility Notes: The Connecticut Department of Social Services has also submitted an
1115 waiver application that, if approved by the Centers for Medicare
and Medicaid Services, would increase eligible income levels for both
single and married individuals to 300% of FPL.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


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

DRUGS COVERAGE

Formulary: Open formulary


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

6-10 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Notes: Generic drugs must be substituted for brand-name drugs, unless


otherwise indicated by the prescribing physician.

PROGRAM CONTACT

Evelyn A. Dudley Phone: 860/424-5654


Manager Fax: 860/424-5206
Department of Social Services E-mail: evelyndudley@po.state.ct.us
25 Sigourney Street
Hartford, CT 06106

National Pharmaceutical Council 6-11


Pharmaceutical Benefits 2002

Delaware
Nemours Health Clinic Pharmaceutical Assistance Program
Program Type: Private Discount
Year Operational: 1981
Number of Enrollees (November 2002): 8,616

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 65+


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

FUNDING AND REIMBURSEMENT

Funding Source: Nemours Foundation


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

DRUGS COVERAGE

Formulary: None
Drugs Covered: Due to severe budgetary constraints, covered drugs are chosen
individually, based on physician recommendations.
Drug Coverage Restrictions: As many recommended drugs as allowed by the budget are purchased
and made available to enrollees.
Notes: One central pharmacy distributes all drugs by courier to branch
locations where citizens can pick up a 2-3 month supply.

PROGRAM CONTACT

W. Frank Morris, Jr. Phone: 302/651-4405


Nemours Clinic Pharmacy Assistance Fax: 302/651-4445
1801 Rockland Road E-mail: fmorris@nemours.org
Wilmington, DE 19803

6-12 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Delaware
Prescription Drug Assistance Program (DPAP)
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients (December 2002): 5,510

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Must be a U.S. citizen and resident of Delaware. Disabled, must be
eligible for SSDI.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


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

DRUGS COVERAGE

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

PROGRAM CONTACT

Cynthia R. Denemark Phone: 302/453-8453


Division of Social Services Fax: 302/454-7603
248 Chapman Road Suite 100 E-mail: cynthia.denemark@eds.com
Newark, DE 19702

National Pharmaceutical Council 6-13


Pharmaceutical Benefits 2002

Florida
Silver SaveRx∗
Program Type: Direct Assistance (1115 waiver)
Year Operational: 2002
Number of Enrollees (May 2003): 46,312

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): 120% of FPL Eligible Income Level (Married): 120% of FPL
Other Eligibility Notes: Must be dually-eligible Medicare-Medicaid.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund, Federal matching funds, and
manufacturer rebates
Budget (FY 03): $109.0 million
Cost per Enrollee : Not Available
# of Rx’s Per Enrollee: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13.25%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $2.00 for generic drugs, $5.00 for brand name drugs on the preferred
drug list, and $15.00 for brand name drugs not on the preferred drug
list
Dispensing Fee: $4.23
Notes: Enrollees receive a cash benefit of up to $160.00 per month.

DRUGS COVERAGE

Formulary: Preferred drug list


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Matthew Dull Phone: 850/414-8306


Agency for Health Care E-mail: dullm@fdhc.state.fl.us
Administration
2727 Mahan Drive
Tallahassee, FL 32308-7703


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.

6-14 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: None


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

DRUGS COVERAGE

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

PROGRAM CONTACT

Matthew Dull Phone: 850/414-8306


Agency for Health Care E-mail: dullm@fdhc.state.fl.us
Administration
2727 Mahan Drive
Tallahassee, FL 32308-7703


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

National Pharmaceutical Council 6-15


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 02-03): $200,000 for plan development and implementation
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Efforts will be made to obtain an initial rebate amount equal to or
greater than the rebate calculated for Medicaid.
Ingredient Cost Calculation: Not Available
Enrollment Fee: Not Available
Deductible Amount: Not Available
Copayment Amount: Not Available
Dispensing Fee: Not less than fee provided under the State Medicaid program.

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available
Notes: Each pharmacy participating in the program will discount the price of
drugs covered by the program and sold to program participants.
Participating pharmacies will submit claims to the Department of
Human Services and will be reimbursed for the discounted drugs.

PROGRAM CONTACT

Department of Human Services Phone: 808/692-8050


Medquest
1390 Miller Street
Room 209
Honolulu, HI 96813

6-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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:

FUNDING AND REIMBURSEMENT

Funding Source: Medicaid Rebates


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

DRUGS COVERAGE

Formulary: Not Available


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

PROGRAM CONTACT

Department of Human Services Phone: 808/692-8050


Medquest
1390 Miller Street
Room 209
Honolulu, HI 96813

*
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).

National Pharmaceutical Council 6-17


Pharmaceutical Benefits 2002

Illinois
Pharmaceutical Assistance Program, “Circuitbreaker”
Program Type: Direct Assistance
Year Operational: 1985
Number of Recipients (May 2003): 57,444

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 16+


Eligible Income Level (Single): $21,218 (’03) Eligible Income Level (Married): $28,480 (’03)
Other Eligibility Notes: A widow or widower who turns 63 or 64 before a deceased enrollee’s death
is eligible for PAP. Also, a married couple with a $35,740 annual
household income would be eligible if they were filing with one other
resident. An individual would be eligible with a $35,740 annual household
income if they were filing with two other residents.

FUNDING AND REIMBURSEMENT


Funding Source: State General Revenue Fund and Tobacco Settlement
Budget (FY 03): $83 million
Cost per Participant (2001): $1,040.00
# of Rx’s Per Participant (2001): 29.0
Manufacturer Rebate Type Negotiated by a PBM on behalf of State
Ingredient Cost Calculation: AWP – 10% or MAC if generic is available
Enrollment Fee: $5.00 if income is below 100% of FPL and $25.00 if income is at or above
100% of FPL
Deductible Amount: None
Copayment Amount: For income less than 100% of FPL, there is no copayment until annual drug
cost exceeds $2,000; then copayment is 20% of drug cost. For income at
100% of FPL or greater, there is a $3.00 copayment until annual drug cost
exceeds $2,000.00; then copayment is 20% of drug cost.
Dispensing Fee: $3.60

DRUGS COVERAGE
Formulary: Preferred product formulary
Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease, Parkinson’s
disease, glaucoma, lung disease and smoking-related diseases, cardiovascular,
arthritis, diabetes, and osteoporosis
Drug Coverage Restrictions Participants are able to receive brand-name drugs even if generics are
available provided the doctor marks “dispense as written” on the prescription
and the drug is classified as a “Narrow Therapeutic Index Drug.”

PROGRAM CONTACT
Susan Rohrer 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

6-18 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Illinois
Illinois Rx SeniorCare
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 2002
Number of Recipients (May 2003): 170,482

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:

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund and Tobacco Settlement


Budget (FY 03): $102 million
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type Negotiated by PBM on behalf of State
Ingredient Cost Calculation: AWP- 10% or MAC if generic is available
Enrollment Fee: None, but participants must reapply every year.
Deductible Amount: None
Copayment Amount: If the participant is a single individual with an income of no more than
$8,859 a year or if the participants are a married couple with a
household income of no more than $11,939 a year, SeniorCare pays up
to $1,750 per person for covered medications. After that limit is met,
the participant pays 20% of the cost of each prescription.

If the participant is a single individual with an income of $8,860 to


$17,720 a year, or if the participants are a married couple with a total
household income of $11,940 to $23,880 a year, SeniorCare pays for
the first $1,750 per person. The participants are also required to pay
$1 for a generic drug and $4 for each brand name drug. After the
$1,750 limit is met, the participants continue to pay $1 for a generic
drug and $4 for each brand name drug plus 20% of the cost of each
prescription.

If a generic drug is available but the participant requests a brand name


drug, participants must pay $1 for each prescription plus the difference
in price between the generic and the brand-name drug.

Dispensing Fee: $3.60

DRUGS COVERAGE

Formulary: Preferred product formulary plus over-the-counter medications like


analgesics, stool softeners, laxatives and antacids.

National Pharmaceutical Council 6-19


Pharmaceutical Benefits 2002

Drugs Covered: Prescription medication used for cancer, Alzheimer’s disease,


Parkinson’s disease, glaucoma, lung disease and smoking-related
diseases, cardiovascular, arthritis, diabetes, osteoporosis and the over-
the-counter medications listed above.
Drug Coverage Restrictions Only covered medications

PROGRAM CONTACT

Susan Rohrer 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

6-20 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

FUNDING AND REIMBURSEMENT


Funding Source: Not available
Budget: Not available
Cost per Participant: Not available
# of Rx’s Per Participant: Not available
Manufacturer Rebate Type: State negotiated
Ingredient Cost Calculation: AWP – 12% for brand name drugs and newly released generics,
AWP – 35% for all other generics
Enrollment Fee: $25 annually
Deductible Amount: None
Copayment Amount: Not available
Dispensing Fee: $3.50 for brand name drugs and newly released generics, $4.25 for all
other generics
Notes:

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

PROGRAM CONTACT

National Pharmaceutical Council 6-21


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: Tobacco Settlement Fund
Budget (FY 03): $20.8 million
Cost per Participant (FY 02): $1,156.00
# of Rx’s Per Participant (FY 02): 10.0-15.0 (estimated)
Manufacturer Rebate Type: Currently only commercial rebates. Once CMS approves 1115
Pharmacy Plus Waiver, OBRA 90 rebates will be applied.
Ingredient Cost Calculation: AWP – 13.5% for brand name drugs, AWP – 20% for generics
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: 50% of HoosierRx negotiated price, up to the maximum benefit limit
($500.00, $750.00 or $1,000.00 per year, depending on income)
Dispensing Fee: $4.90
Notes: Once maximum benefit limit is reached, recipients may continue to
receive the HoosierRx discounted rate during the rest of the enrollment
year.

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

PROGRAM CONTACT
Lola Sawyerr 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

6-22 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: Federal grant
Budget (FY 03): $1.2 million
Cost per Enrollee: $48.00
# of Rx’s Per Enrollee (FY 02): 36.0
Manufacturer Rebate Type: A pharmacy benefit manager company negotiates discounted
prescription costs rather than setting mandatory price reductions.
Ingredient Cost Calculation: AWP – 10% (in certain cases up to AWP – 20%)
Enrollment Fee: $20.00 per year
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $2.50 for brand name drugs and $3.25 for generics
Notes: Discounts are available on participating manufacturers’ drugs (Bristol-
Myers Squibb, Merck and Schering-Plough).

DRUGS COVERAGE
Formulary: Preferred drug list
Drugs Covered: Allergy (antihistamines, nasal steroids), cholesterol lowering agents,
dermatological products (topical steroids), hypertension/high blood
pressure and cardiovascular (ACE inhibitors, alpha/beta blockers,
angiotensin receptor blockers, potassium supplements, nitrates),
diabetes (biguanides), arthritis and analgesia (COX-2 inhibitors),
asthma (Beta-2 agonists, leukotiene blockers), enlarged prostate
treatment, osteoporosis treatment, glaucoma
Drug Coverage Restrictions: None

PROGRAM CONTACT
David Fries 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

National Pharmaceutical Council 6-23


Pharmaceutical Benefits 2002

Kansas
Kansas Senior Pharmacy Assistance Program
Program Type: Reimbursement
Year Operational: 2001
Number of Enrollees (September 2002): 1,286

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 67+ Eligibility Age (Disabled): 67+


Eligible Income Level (Single): 135% of FPL Eligible Income Level (Married): 135% of FPL
Other Eligibility Notes: Must be a Kansas resident; not covered under a private prescription
reimbursement plan; not eligible for or enrolled in any other local,
state, or Federal prescription program; not have voluntarily canceled a
local, State, Federal, or private prescription drug program within six
months of application to the program. Must be current recipient of
benefits through the Qualified Medicare Beneficiary Program or
Specified Low Income Medicare Beneficiary Program.

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


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

DRUGS COVERAGE

Formulary: None
Drugs Covered: Legend drugs, diabetic supplies not covered by Medicare, and
prescription drugs that treat chronic illness
Drug Coverage Restrictions: Program does not cover over-the-counter and lifestyle drugs.

PROGRAM CONTACT

Gail Smith Phone: 800/432-3535


Department on Aging E-mail: gailes@aging.state.ks.us
503 S. Kansas Avenue
Topeka, KS 66603-3404

6-24 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


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

DRUGS COVERAGE

Formulary: Open formulary


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

PROGRAM CONTACT

Ed Bauer Phone: 207/287-4018


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: ed.bauer@state.me.us
Augusta, ME 04333-0011


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

National Pharmaceutical Council 6-25


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


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

DRUGS COVERAGE

Formulary: Open formulary


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

PROGRAM CONTACT

Ed Bauer Phone: 207/287-4018


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: ed.bauer@state.me.us
Augusta, ME 04333-0011


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

6-26 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


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

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All prescription drugs from manufacturers with Federal rebate
agreements.
Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for generic
drugs. Some prescriptions require prior approval to assure quality, dose
strength, and cost effectiveness.

PROGRAM CONTACT

Ed Bauer Phone: 207/287-4018


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: ed.bauer@state.me.us
Augusta, ME 04333-0011

±
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).

National Pharmaceutical Council 6-27


Pharmaceutical Benefits 2002

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

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 19+


Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL
Other Eligibility Notes: This program is made available to Maine residents fitting the age and
income eligibility criteria. Individuals with full Maine Care benefits
are not eligible. Medicare recipients are not necessarily excluded.

FUNDING AND REIMBURSEMENT

Funding Source: State appropriations and subsidies


Budget: $20 million∗∗
Cost per Participant (7/1/02- $400.00
12/11/02):
# of Rx’s Per Participant (7/1/02- 15.5
12/11/02):
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP –13%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Greater of $2.00 or 20% of the cost of generic drugs. Greater of $2.00
or 20% of the cost of prescriptions for select medical conditions. 84%
of the cost of other covered prescriptions
Dispensing Fee: $3.35
Notes: A $1,000.00 catastrophic spending limit is one additional component
of this program where the State pays for 80% of the cost of additional
prescriptions once a person exceeds this dollar limit.

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All prescription drugs from manufacturers with Federal rebate agreements.
Drug Coverage Restrictions: 34-day supply limit for brand name drugs, 90-day limit for generic drugs.
Some prescriptions require prior approval to assure quality, dose strength,
and cost effectiveness.


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

6-28 National Pharmaceutical Council


Pharmaceutical Benefits 2002

PROGRAM CONTACT

Ed Bauer Phone: 207/287-4018


Department of Human Services Fax: 207/287-8601
11 State House Station E-mail: ed.bauer@state.me.us
Augusta, ME 04333-0011

National Pharmaceutical Council 6-29


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: State General Revenue Fund
Budget (FY 03): $73.2 million
Cost per Participant (FY 02): $1,534.00
# of Rx’s Per Participant (FY 02): 29.0
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: For brand name drugs, lower of AWP-10%, Wholesalers Acquisition
Cost (WAC) +10%, Direct Manufacturer’s Cost (DMC)+10%, or
Direct Cost (DC)+10%. For generic drugs, lower of Estimated
Acquisition Cost (EAC), State MAC, or Federal MAC.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00 per prescription
Dispensing Fee: $4.21

DRUGS COVERAGE
Formulary: Closed formulary
Drugs Covered: Specified categories of maintenance drugs used to treat chronic
conditions, anti-infective drugs, and insulin syringes and needles
Drug Coverage Restrictions: Prior authorization for certain medications, including steroids and some
controlled substances. 75% utilization required for prescription refill.

PROGRAM CONTACT
Paul A. Roeger 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.

6-30 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: 37.5% of Substantial Availability and Affordability Coverage (SAAC)
Differential, plus additional funding from MAMSI and Aetna.
Budget (FY 02): $18 million
Cost per Participant (FY 02): $65.12 member/month
# of Rx’s Per Participant (FY 02): 28.1
Manufacturer Rebate Type: Negotiated with individual drug companies
Ingredient Cost Calculation: Negotiated with contracted pharmacies
Enrollment Fee: $10 monthly premium
Deductible Amount: None
Copayment Amount: $10 for generics, $20 for branded products, $35 non-preferred brand
Dispensing Fee: Varies between contracted pharmacy chains.
Notes: Maximum benefit is $1,000 per enrollee per 12-month period.
Funding information for this program will change on April 1, 2003.
The program will then receive funding through CareFirst alone. It is
estimated that the budget will change at that time to $20 million.

DRUGS COVERAGE
Formulary: Open formulary
Drugs Covered: Most generic and brand drugs approved by the Food and Drug
Administration (FDA) are included under this program.
Drug Coverage Restrictions: Anorexants are excluded. Over the counter drugs are excluded.
Quantity limits on certain drugs such as Viagra, migraine medicines
and Oxycontin. Prior authorizations on certain drugs such as growth
hormones.

PROGRAM CONTACT
Robin Vahle 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.

National Pharmaceutical Council 6-31


Pharmaceutical Benefits 2002

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

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): see notes


Eligible Income Level (Single): 175% of FPL Eligible Income Level (Married): 175% of FPL
Other Eligibility Notes: Must be a Medicare recipient and a Maryland resident. Disabled are
eligible.

FUNDING AND REIMBURSEMENT

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

DRUGS COVERAGE

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

PROGRAM CONTACT

Paul A. Roeger Phone: 410/767-5394


Division Chief Fax: 410/333-5027
Office of Operations & Eligibility E-mail: roegerp@dhmh.state.md.us
Department of Health and Mental
Hygiene
201 West Preston Street
Baltimore, MD 21201

6-32 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Massachusetts
Prescription Advantage+
Program Type: Direct Assistance
Year Operational: 2001∗
Number of Recipients (August 2002): 83,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 188% of Eligible Income Level (Married): 188% of
FPL∗∗ FPL**
Other Eligibility Notes: Individuals receiving drug coverage from MassHealth or
CommonHealth are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 03): $95.6 million
Cost per Participant (FY 02): $90.44 per member per month
# of Rx’s Per Participant (FY 02): No limit. Average is 2.7 per member per month.
Manufacturer Rebate Type: Advance PCS negotiates price and rebates with drug manufacturers.
Ingredient Cost Calculation: AWP-14%
Enrollment Fee: Single: $0-$99 per month per enrollee, depending on income; Married: $0-
$74 per month per enrollee, depending on income
Deductible Amount: $0-$500 annually, depending on income. Payments are accepted quarterly.
Copayment Amount: 30-day prescriptions retail:
Generic-$6 or $10
Brand-Name-$16 or $28
Additional Brand-Name-the greater of 50% or $40.

90-day prescriptions mail:


Generic-$12 or $20
Brand-Name-$32 or $56
Additional Brand-Name-the greater of 50% or $60.
Dispensing Fee: $2.40 per prescription
Notes: The annual out-of-pocket limit per enrollee is $2,000 or 10% of income,
whichever is less. For married members, the out-of-pocket spending limit is
$3,000 combined, or 10% of gross annual household income, whichever is
less. The lower premium for married members only applies to those married
members who are both enrolled in the plan; when not joining as a couple, a
married member must pay the individual rate.
+
Program enrollment closed as of February 1, 2003, due to budget reductions.

The first year of the plan was extended through June 30, 2002, and totaled 15 months in order to synchronize with the State’s fiscal
year.
∗∗
Upper Income eligibility levels apply only to disabled applicants under the age of 65.

National Pharmaceutical Council 6-33


Pharmaceutical Benefits 2002

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All therapeutic classes, except those excluded from MassHealth.
Includes all FDA approved oral drugs as well as many injectable
drugs, including insulin and disposable insulin syringes with needles.
Drug Coverage Restrictions: Some drugs require prior authorization.

PROGRAM CONTACT

David Morales Phone: 617/727-7750


Massachusetts Executive Office of Elder Affairs 800/AGE-INFO
One Ashburton Place 800/243-4636
Boston, MA 02108 Fax: 617/727-9368
David.morales@state.ma.us

6-34 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Michigan
Elder Prescription Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Enrollees (May 2003): 13,034

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: EPIC enrollment is currently closed due to budget constraints, except
for 45-day emergency coverage, which is available up to two times a
year. In addition to normal coverage eligibility requirements, to be
eligible for emergency coverage:
• A single applicant must make less than 150% of FPL;
• A married applicant must make equal to or less than $17,910
(150% of FPL);
• A true medical emergency must exist.

To be eligible for normal coverage, an applicant:


• Must be a resident of Michigan for three months prior to
application;
• Cannot be residing in an institution;
• Cannot have other insurance or program coverage for prescription
drugs;
• Cannot currently receive Medicaid benefits.

Additionally, the Appropriations Act for FY 02-03 provides


authorization for the Department of Community Health to accept
additional Federal revenues either as the result of the approval of a
Pharmacy Plus waiver or Federal legislation providing pharmaceutical
assistance to seniors.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund plus rebate revenue


Budget (FY 01-02): $50 million. Budget for FY 2002-03 has not been determined as of
November 2002; it depends on whether a Pharmacy Plus waiver is
sought.
Cost per Enrollee: Not Available
# of Rx’s Per Enrollee: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: Lesser of usual and customary charge, AWP – 15.1% or 13.5%
(depending on the pharmacy), or the State MAC price
Enrollment Fee: $25.00
Deductible Amount: Based on the participant’s total annual household income. Maximum
annual amount is divided into twelfths so that a monthly amount must
be met.
National Pharmaceutical Council 6-35
Pharmaceutical Benefits 2002

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

Doris Gellert Phone: 517/335-5182


Department of Community Health E-mail: gellert@michigan.gov
611 West Ottawa, P.O. Box 30676
Lansing, MI 48909-8176

6-36 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): 120% of FPL Eligible Income Level (Married): 120% of FPL
Other Eligibility Notes: On July 1, 2002, the program expanded to include coverage for
persons on Medicare due to a disability. To be eligible, enrollees
must:
• Be a Medicare enrollee, age 65 or older, or disabled;
• Be a Minnesota resident for six months;
• Have liquid assets (other than home, car, burial funds, etc.) Of
$10,000 or less for one person or $18,000 or less for a married
couple;
• Not have eligibility for Medicaid;
• Not have prescription drug coverage within four months of
applying;
• Not be enrolled in MinnesotaCare;
• Be enrolled in, or applying for, one of the following Medicare
supplement programs, which help enrollees pay their
Medicare premiums: Qualified Medicare Beneficiary (QMB),
or Specified Low-Income Medicare Beneficiary (SLMB).

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund plus rebates


Budget (FY 02-03): $5.4 million appropriated for FY 2002 and $8.5 million appropriated
for FY 2003
Cost per Enrollee (2002): $1,200.00
# of Rx’s Per Enrollee (2002): 31.0
Manufacturer Rebate Type: Same as Medicaid less any Consumer Price Index add-on
Ingredient Cost Calculation: AWP – 9%
Enrollment Fee: None
Deductible Amount: $35.00 per month
Copayment Amount: None
Dispensing Fee: $3.65

DRUGS COVERAGE

Formulary: Closed formulary


Formerly the Senior Citizen Drug Program.

National Pharmaceutical Council 6-37


Pharmaceutical Benefits 2002

Drugs Covered: Same drugs as covered under Medicaid if manufacturer signs rebate
agreement with Department of Human Services. Covers over-the-
counter drugs for antacid, insulin products, smoking cessation
products, lice medication and vitamins.
Drug Coverage Restrictions: Most other over-the-counter drugs are not covered.

PROGRAM CONTACT

Steve Hamilton Phone: 651/297-7699


Prescription Drug Program Rebate Analyst E-mail: steve.hamilton@state.mn.us
Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3853

6-38 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Missouri
SeniorRx Program
Program Type: Direct Assistance
Year Operational: 2002
Number of Enrollees (November 2002): 29,722

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): $17,000 Eligible Income Level (Married): $23,000
Other Eligibility Notes: Applicant must be a Missouri resident and have lived in the State for
12 months by July 1, 2003. Applicants may not receive Medicaid or
veterans pharmacy benefits or have prescription insurance that is
equivalent to or greater than the Missouri SenioRx Program.

FUNDING AND REIMBURSEMENT

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.

National Pharmaceutical Council 6-39


Pharmaceutical Benefits 2002

Notes: An enrollee may receive a name-brand drug when a generic drug is


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

PROGRAM CONTACT

Jerry Simon Phone: 573/522-3066


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

6-40 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Montana
Prescription Drug Expansion Program
Program Type: Discount
Projected Operational Date: 2004
Projected Number of Recipients: not available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 200% FPL Eligible Income Level (Married): 200% FPL
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Discounts only through Medicaid


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

DRUGS COVERAGE

Formulary: Not available


Drugs Covered: Not available
Drug Coverage Restrictions: Not available

PROGRAM CONTACT

Not available

National Pharmaceutical Council 6-41


Pharmaceutical Benefits 2002

Nevada
Senior Rx
Program Type: Subsidy
Year Operational: 2001
Number of Recipients (November 2002): 7,500

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 62+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): see notes Eligible Income Level (Married): see notes
Other Eligibility Notes: Must be a Nevada resident for at least one year and not eligible for full
Medicaid benefits. Family income eligibility: $21,500

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 02-03): $7.6 million
Cost per Enrollee (FY 01-02): $1,023.00
# of Rx’s Per Enrollee (FY 01-02): 36.0
Manufacturer Rebate Type: Not Available
Ingredient Cost Calculation: Not Available
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $10.00 for generics; $25.00 for preferred drugs or medically necessary
brand name drugs; and provider’s discounted rate for all other drugs
Dispensing Fee: Average of $2.25
Notes: Maximum benefit of $5,000.00 per year. An annual per enrollee
deductible of $100.00 is paid by the State to Pharmaceutical Care
Network, the Pharmacy Benefit Manager that manages the program.

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: Most prescription drugs
Drug Coverage Restrictions: General exclusions for over-the-counter drugs; blood glucose meters;
insulin injecting devices; biologicals; durable medical equipment;
nutritional supplements; and cosmetic drugs.

PROGRAM CONTACT

Jane Smedes Phone: 775/684-4000


Department of Human Resources E-mail: jasmedes@dhr.state.nv.us
505 E. King Street, Room 201
Carson City, NV 89701-4797

6-42 National Pharmaceutical Council


Pharmaceutical Benefits 2002

New Hampshire
Senior Prescription Drug Discount Program
Program Type: Discount
Year Operational: 2000
Number of Enrollees (November 2002): 77,132

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a New Hampshire resident.

FUNDING AND REIMBURSEMENT

Funding Source: Rebates and incentives from pharmaceutical manufacturers negotiated


through National Prescription Administrators, a division of Express
Scripts, which operates the program.
Budget: The State has not had to fund the program, since it is based on rebates
and incentives
Cost Per Enrollee: There is no associated cost per enrollee.
# of Rx’s Per Enrollee: Not Available
Manufacturer Rebate Type: Rebates negotiated with manufacturer.
Ingredient Cost Calculation: Not Available
Deductible Amount: None
Enrollment Fee: None
Copayment Amount: Participant receives discount and must pay remainder of cost of
prescription.
Dispensing Fee: None
Notes: Discounts vary depending on pharmacy and medication. Discounts can
be up to 40% for generics and up to 15% for brand name products.

DRUGS COVERAGE

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

PROGRAM CONTACT

Kim Hadank Phone: 603/271-7857


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

National Pharmaceutical Council 6-43


Pharmaceutical Benefits 2002

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

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 21


Eligible Income Level (Single): $19,739 Eligible Income Level (Married): $24,203
Other Eligibility Notes: For calendar year 2003, eligible income levels for the program will
increase to $20,016 for single individuals and $24,524 for married
individuals. Disabled individuals are only eligible if they receive Title
II Social Security Disability benefits.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund and Casino Revenue Fund


Budget (FY 03): $312.9 million
Projected Cost per Participant (FY Senior: $2,200.00
03): Disabled: $4,200.00
Projected # of Rx’s Per Participant Senior: 34.0
(FY 03): Disabled: 45.0
Manufacturer Rebate Type: Medicaid less Consumer Price Index
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00 per prescription
Dispensing Fee: $3.73 to $4.07

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing
materials, and injectables used in treatment of multiple sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. DESI drugs are not covered.

PROGRAM CONTACT

Jennifer Barron Phone: 609/588-3460


PAAD/Senior Gold Operations Fax: 609/588-7139
P.O. Box 715 E-mail: jennifer.barron@doh.state.nj.us
Trenton, NJ 08625-0715

6-44 National Pharmaceutical Council


Pharmaceutical Benefits 2002

New Jersey
Senior Gold Prescription Discount Program
Program Type: Direct Assistance
Year Operational: 2001
Projected Number of Recipients (FY 03): 61,972

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18-64


Eligible Income Level (Single): $29,739 Eligible Income Level (Married): $34,203
Other Eligibility Notes: For calendar year 2003, eligible income levels for the program will
increase to $30,016 for single individuals and $34,542 for married
individuals. Senior citizens and disabled individuals eligible for the
Pharmaceutical Assistance for the Aged and Disabled program are not
eligible for the Senior Gold Prescription Discount Program. Disabled
individuals are only eligible if they receive Title II Social Security
Disability benefits.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund


Budget (FY 03): $32.8 million
Projected Cost Per Participant (FY Senior: $574.00
03): Disabled: $764.00
Projected # of Rx’s Per Participant Senior: 21.0
(FY 03): Disabled: 26.0
Manufacturer Rebate Type: Medicaid less Consumer Price Index
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $15.00 plus 50% of the remaining cost of the prescription or the actual
cost if less than $15.00. After unreimbursed out of pocket costs reach
$2,000.00 for an individual, or $3,000.00 for a couple, copayments for
additional prescriptions that year are $15.00.
Dispensing Fee: $3.73 to $4.07
Notes: Once an enrollee incurs in one year unreimbursed out-of-pocket costs
of $2,000.00, if single, or $3,000.00, if married, prescriptions may be
obtained for the balance of that eligibility period for a flat $15.00
copayment or the actual price, if less than $15.00.

DRUGS COVERAGE

Formulary: No formulary
Drugs Covered: Legend drugs, insulin, syringes, needles, certain diabetic testing
materials, and injectables used in treatment of multiple sclerosis
Drug Coverage Restrictions: Drugs must be purchased in New Jersey, and must be covered by a
Manufacturer’s Rebate Agreement. DESI drugs are not covered.

National Pharmaceutical Council 6-45


Pharmaceutical Benefits 2002

PROGRAM CONTACT

Jennifer Barron Phone: 609/588-3460


PAAD/Senior Gold Operations Fax: 609/588-7139
P.O. Box 715 E-mail: jennifer.barron@doh.state.nj.us
Trenton, NJ 08625-0715

6-46 National Pharmaceutical Council


Pharmaceutical Benefits 2002

New Mexico
Senior Prescription Drug Program
Program Type: Discount
Projected Operational Date: Unknown∗
Number of Recipients: N/A

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a New Mexico resident and have no other prescription drug
benefit through private insurance or other government programs.

FUNDING AND REIMBURSEMENT

Funding Source: None


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

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available

PROGRAM CONTACT

Milton Sanchez Phone: 505/986-8556


Executive Director Fax: 505/983-8667
New Mexico Retiree Health Care Authority
810 West San Mateo, Suite D
Santa Fe, NM 87505


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.

National Pharmaceutical Council 6-47


Pharmaceutical Benefits 2002

New Mexico
Prescription Drug Waiver Program
Program Type: Direct Assistance
Projected Operational Date: Unknown
Number of Recipients: N/A

ELIGIBILITY CRITERIA

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


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

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


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

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available

PROGRAM CONTACT

Milton Sanchez Phone: 505/986-8556


Executive Director Fax: 505/983-8667
New Mexico Retiree Health Care Authority
810 West San Mateo, Suite D
Santa Fe, NM 87505

6-48 National Pharmaceutical Council


Pharmaceutical Benefits 2002

New York
Elderly Pharmaceutical Insurance Coverage (EPIC) Program
Program Type: Direct Assistance
Year Operational: 1987
Number of Recipients (November 2002): 297,000
ELIGIBILITY CRITERIA

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


Eligible Income Level, Fee Plan $20,000 Eligible Income Level, Fee Plan $26,000
(Single): (Married):
Eligible Income Level, Deductible $20,001- Eligible Income Level, Deductible $26,001-
Plan (Single): $35,000 Plan (Married): $50,000
Other Eligibility Notes: Medicaid enrollees are not eligible.

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 03-04): $610.0 million
Cost per Participant (FY 02): $1,970.00
# of Rx’s Per Participant (FY 02): 36.0
Manufacturer Rebate Type: Full Medicaid rate (base rate plus Consumer Price Index penalty)
Ingredient Cost Calculation: Federal upper limit, when available, on generics and AWP - 10% on
brands
Enrollment Fee: $2.00 - $75.00 per quarter, based on income level
Deductible Amount: $530.00 - $1,715.00 annually, based on income level
Copayment Amount: $3.00 (prescription cost up to $15.00); $7.00 (prescription cost from
$15.01 to $35.00); $15.00 (prescription cost from $35.01 to $55.00);
and $20.00 (prescription cost over $55.00)
Dispensing Fee: $4.50 for generics and $3.50 for brand-name drugs

DRUGS COVERAGE

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

PROGRAM CONTACT

Julie A. Naglieri Phone: 518/452-6828


Acting Director Fax: 518/452-6882
NYS EPIC Program E-mail: jab15@health.state.ny.us
1 Corporate Plaza
260 Washington Avenue Ext.
Albany, NY 12203

National Pharmaceutical Council 6-49


Pharmaceutical Benefits 2002

North Carolina
Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2000∗
Number of Recipients (FY 2002): 1,800∗∗

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% FPL
Other Eligibility Notes: Individuals must have cardiovascular disease and/or diabetes

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund


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

DRUGS COVERAGE

Formulary: Limited formulary (category based)


Drugs Covered: All drugs used to treat cardiovascular disease and/or diabetes
Drug Coverage Restrictions: Program will not pay for over-the-counter drugs, potassium
supplements, or cholesterol lowering drugs.
Notes: Prescriptions may be issued for up to a 100-day supply.

PROGRAM CONTACT

Michael Keough Phone: 919/733-2040


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


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.

6-50 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: North Carolina Health and Wellness Trust Fund
Budget (FY 03): $32 million
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $6.00
Dispensing Fee: $5.60 (40 cents retained by claims processor)
Notes: Maximum annual prescription benefit of $600.00. Senior Care pays for 60%
of the first $1,000.00 of prescription costs, and members pay the remaining
40%.

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

PROGRAM CONTACT
Michael Keough 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.

National Pharmaceutical Council 6-51


Pharmaceutical Benefits 2002

Ohio
Golden Buckeye Prescription Drug Program
Program Type: Negotiated Discounts
Projected Operational Date: 2003
Estimated Eligibles: up to 500,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): no age limit


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be an Ohio resident.

FUNDING AND REIMBURSEMENT

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


running the program.
Budget: None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Negotiated by PBM with individual manufacturers
Ingredient Cost Calculation: For drugs purchased in a pharmacy, AWP – 13% for brand names and
AWP – 20% for generics. For drugs purchased via mail order, AWP –
17% for brand names and AWP – 40% for generics.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50

DRUGS COVERAGE

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

PROGRAM CONTACT

Gary Panek Phone: 800/422-1976


Manager of Golden Buckeye Program E-mail: gpanek@age.state.oh.us
Department of Aging
50 W. Broad Street, 9th Floor
Columbus, OH 43215

6-52 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Oregon
Senior Prescription Drug Assistance Program
Program Type: Discount
Projected Operational Date: not available*
Projected Number of Recipients: up to 100,000

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): 185% of FPL Eligible Income Level (Married): 185% of FPL
Other Eligibility Notes: Individuals must not be covered under any public or private
prescription drug benefit program for the previous six months and
must have less than $2,000.00 in liquid resources. Enrollees are issued
enrollment cards that entitle them to Medicaid prices.

FUNDING AND REIMBURSEMENT

Funding Source: Enrollment fees


Budget: N/A
Cost per Participant: N/A
# of Rx’s Per Participant: N/A
Manufacturer Rebate Type: N/A
Ingredient Cost Calculation: AWP – 14%
Enrollment Fee: $50.00 annually
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: May not exceed Medicaid dispensing fee. Pharmacies designated
“critical access” may charge an additional $2.00 dispensing fee.
Notes : The law authorizing the program allows for coverage up to 50% of
pharmaceutical cost, with a maximum annual benefit of $2,000.00.
However, because the program was not funded in FY 02 or FY 03, the
program will operate as a discount program. The program will operate
as a direct assistance program when funding is available.

DRUGS COVERAGE

Formulary: None
Drugs Covered: All legend drugs.

PROGRAM CONTACT

Sandy Wood, Program Manager Phone: 503/945-6530


Office of Medical Assistance Programs Email: sandy.a.wood@state.or.us
500 Summer St. NE
Salem, OR 97301-107

*
Postponed due to lack of funds.

National Pharmaceutical Council 6-53


Pharmaceutical Benefits 2002

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

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


Eligible Income Level (Single): $14,000 Eligible Income Level (Married): $17,200
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the
date of application.

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement Fund


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

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,
drugs for baldness and wrinkles, over-the-counter drugs, or most off-
label uses. Mandatory generic substitution for A-rated (therapeutically
equivalent) products. DESI drugs require documentation of medical
necessity.

PROGRAM CONTACT
Thomas Snedden 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

6-54 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Pennsylvania
PACE Needs Enhancement Tier (PACENET)
Program Type: Direct Assistance
Year Operational: 1996
Number of Recipients (May 2003): 32,142

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): $14,000 - Eligible Income Level (Married): $17,200 -
$17,000 $20,200
Other Eligibility Notes: Must be a resident of Pennsylvania for at least 90 days prior to the date
of application

FUNDING AND REIMBURSEMENT

Funding Source: State Lottery, Tobacco Settlement Funds


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

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: All Federal legend drugs and insulin, insulin syringes and needles
Drug Coverage Restrictions: 30-day supply or 100 units, whichever is less. No experimental drugs,
drugs for baldness and wrinkles, over-the-counter drugs, or most off-
label uses. Mandatory generic substitution for A-rated (therapeutically
equivalent) products. DESI drugs require documentation of medical
necessity.

PROGRAM CONTACT

Thomas Snedden 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

National Pharmaceutical Council 6-55


Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT


Funding Source: State General Revenue Fund and manufacturer rebates
Budget (FY 03): $12.6 million
Cost per Enrollee (FY 02): $290.00
# of Rx’s Per Enrollee (FY 02): 13.5
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 13%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: Copayment covers 40%, 70%, or 85% of prescription cost depending
on income. For members in the lowest income class, the program will
pay 100% of the cost of covered medications after the member has
paid $1,500.00 in copayments.
Dispensing Fee: $2.75

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.

6-56 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council 6-57


Pharmaceutical Benefits 2002

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

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


Eligible Income Level (Single): 200% of FPL Eligible Income Level (Married): 200% of FPL
Other Eligibility Notes: Must be a South Carolina resident. Must be ineligible for Medicaid
with no prescription benefits from any other source.

FUNDING AND REIMBURSEMENT

Funding Source: Tobacco Settlement Fund and Federal matching funds


Budget (FY 03): $81.0 million
Cost per Enrollee (FY 02): $500.00
# of Rx’s Per Enrollee (FY 02): 54.0
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 10%
Enrollment Fee: None
Deductible Amount: $500.00 per calendar year
Copayment Amount: Members receive a small discount, up to 10%, on prescriptions while
meeting the deductible. After the $500.00 deductible is met, the
copayment is $10.00 for generic drugs, $15.00 for brand name drugs,
and $21.00 for drugs requiring prior authorization.
Dispensing Fee: $4.05

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: Same as Medicaid
Drug Coverage Restrictions: Same as Medicaid

PROGRAM CONTACT

Ray Sharpe Phone: 803/898-2673


SilverRxCard Manager Fax: 803/898-4517
Office of Insurance Services E-mail: rsharpe@ois.state.sc.us
1201 Main Street, Suite 350
Columbia, SC 29201


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

6-58 National Pharmaceutical Council


Pharmaceutical Benefits 2002

South Dakota
Senior Citizen Prescription Drug Benefit Program
Program Type: Discount
Year Operational: Not Yet Operational
Number of Enrollees: Not Available

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): no age limit


Eligible Income Level (Single): no limit Eligible Income Level (Married): no limit
Other Eligibility Notes:

FUNDING AND REIMBURSEMENT

Funding Source: Not Available


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

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available

PROGRAM CONTACT

Not Available

National Pharmaceutical Council 6-59


Pharmaceutical Benefits 2002

Texas
State Prescription Drug Program
Program Type: State-Subsidy
Law Enacted: 2001∗
Estimated Eligibles: N/A

ELIGIBILITY CRITERIA

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


Eligible Income Level (Single): 100% of FPL Eligible Income Level (Married): 100% of FPL
Other Eligibility Notes: Upper income limits may increase if funding becomes available.
However, the categories most likely to receive qualify for the program
at proposed FY 04-05 funding levels are Qualified Medicare
Beneficiaries (QMBS) and Specified Low-Income Medicare
Beneficiaries (SLMBS).

FUNDING AND REIMBURSEMENT

Funding Source: State General Revenue Fund, unless funds are available under Federal
law to fund all or part of the program
Budget (FY 02-03): None
Cost per Participant: Not Available
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Not Available
Ingredient Cost Calculation: Not Available
Enrollment Fee: Not Available
Deductible Amount: Not Available
Copayment Amount: Not Available
Dispensing Fee: Not Available
Notes: According to statute, the Health and Human Services Commission
may require a cost-sharing payment.

DRUGS COVERAGE

Formulary: Not Available


Drugs Covered: Not Available
Drug Coverage Restrictions: Not Available


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

6-60 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

PROGRAM CONTACT

Charles Stewart Phone: 512/424-6514


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

National Pharmaceutical Council 6-61


Pharmaceutical Benefits 2002

Vermont
VSCRIPT
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1989∗
Number of Recipients (October 2002): 3,032

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


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

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 03): $5.1 million
Cost per Participant (FY 02): $1,603.00
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $5.00 for generic drugs, $10.00 for brand-name drugs. Once a
maximum of $100.00 in copayments is reached in a calendar quarter, no
further copayments are required for the rest of the quarter.
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


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

PROGRAM CONTACT

Paul Wallace-Brodeur Phone: 802/241-3985


Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201


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

6-62 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Vermont
VSCRIPT Expanded
Program Type: Direct Assistance
Year Operational: 2000
Number of Recipients: 3,200

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


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

FUNDING AND REIMBURSEMENT

Funding Source: State General Fund


Budget (FY 03): $2.0 million
Cost per Participant (FY 02): $530.00
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: None
Deductible Amount: $275.00 per year
Copayment Amount: The coinsurance rate for maintenance prescriptions is 41%. Once the
maximum annual coinsurance contribution of $2,500.00 is reached,
there is no charge for rest of the year. (July 1-June 30)
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


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

PROGRAM CONTACT

Paul Wallace-Brodeur Phone: 802/241-3985


Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

National Pharmaceutical Council 6-63


Pharmaceutical Benefits 2002

Vermont
Vermont Health Access Plan (VHAP)
Program Type: Direct Assistance (1115 Waiver)
Year Operational: 1996
Number of Recipients (November 2002): 11,550

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 150% of FPL Eligible Income Level (Married): 150% of FPL
Other Eligibility Notes: This program is for individuals not eligible for Medicaid.

FUNDING AND REIMBURSEMENT

Funding Source: State Revenue Fund


Budget (FY 03): $16.3 million
Cost per Participant (FY 02): $1,752.00
# of Rx’s Per Participant: Not Available
Manufacturer Rebate Type: Medicaid
Ingredient Cost Calculation: AWP – 11.9%
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: $3.00 copayment for generic drugs; $6.00 copayment for brand-name
drugs. Once a maximum of $50.00 in copayments is reached in a
calendar quarter, no further copayments are required for the rest of the
quarter.
Dispensing Fee: $4.25

DRUGS COVERAGE

Formulary: Preferred Drug List


Drugs Covered: All drugs covered by Vermont Medicaid, including insulin and insulin
syringes, and eyeglasses and the services to obtain them
Drug Coverage Restrictions: No experimental or over-the-counter drugs

PROGRAM CONTACT

Paul Wallace-Brodeur Phone: 802/241-3985


Office of Vermont Health Access Fax: 802/241-2897
103 South Main Street E-mail: paulw@wpgate1.ahs.state.vt.us
Waterbury, VT 05671-1201

6-64 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): All ages


Eligible Income Level (Single): 400% of FPL Eligible Income Level (Married): 400% of FPL
Other Eligibility Notes: Vermont residents of any age who have an income at or below 300% FPL
are also eligible. This program is for those who have no insurance for
prescriptions or those who have a commercial insurance plan with a yearly
limit. VSCRIPT and VSCRIPT Expanded beneficiaries will be
automatically enrolled and have the advantage of Healthy Vermonters
benefits for prescriptions not covered under the VSCRIPT programs.

FUNDING AND REIMBURSEMENT

Funding Source: State Revenue Fund


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

DRUGS COVERAGE

Formulary: Medicaid Formulary


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

PROGRAM CONTACT

Jackie Levine Phone: 802/241-2992


Department of PATH E-mail: jackiel@path.state.vt.us
103 South Main Street
Waterbury, CT 05676

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

National Pharmaceutical Council 6-65


Pharmaceutical Benefits 2002

West Virginia
Gold Mountaineer Discount Card Program
Program Type: Direct Assistance
Year Operational: 2001
Number of Recipients (October 2002): 17,061

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 60+ Eligibility Age (Disabled): Not eligible


Eligible Income Level (Single): All income Eligible Income Level (Married): All income
levels levels
Other Eligibility Notes: Must be a resident of West Virginia.

FUNDING AND REIMBURSEMENT

Funding Source: Lottery funds and State General Fund


Budget (FY 03): $12,420
Cost per Participant (2002): $0.69
# of Rx’s Per Participant (2002): 35.00
Manufacturer Rebate Type: Rebates negotiated by PBM with individual manufacturers
Ingredient Cost Calculation: AWP – 13% for brand name drugs and generics and AWP – 60% for
MAC drugs.
Enrollment Fee: None
Deductible Amount: None
Copayment Amount: None
Dispensing Fee: $3.50
Notes: Enrollees will receive discounts set by PBM.

DRUGS COVERAGE

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

PROGRAM CONTACT

Kim Fetty Phone: 304/558-3317


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

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Pharmaceutical Benefits 2002

Wisconsin
Wisconsin SeniorCare Prescription Drug Assistance Program
Program Type: Direct Assistance
Year Operational: 2002
Estimated Enrollment (December 2002): 73,000

ELIGIBILITY CRITERIA

Eligibility Age (Elderly): 65+ Eligibility Age (Disabled): 18+


Eligible Income Level (Single): 240% of FPL Eligible Income Level (Married): 240% of FPL
Other Eligibility Notes: Person must not be a recipient of medical assistance and must be a
resident of the State. Wisconsin residents with incomes exceeding
240% of FPL may participate by “spending down” to 240% of FPL
level.

FUNDING AND REIMBURSEMENT

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.

National Pharmaceutical Council 6-67


Pharmaceutical Benefits 2002

PROGRAM CONTACT

Roma Rowlands Phone: 608/266-3753


Division of Health Care Financing Fax: 608/267-3380
1 West Wilson Street E-mail: rowlarm@dhfs.state.wi.us
P.O. Box 309
Madison, WI 53701-3380

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Pharmaceutical Benefits 2002

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.

FUNDING AND REIMBURSEMENT

Funding Source: General Revenue Fund


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

DRUGS COVERAGE

Formulary: Open formulary


Drugs Covered: Any FDA approved prescription medications
Drug Coverage Restrictions: No smoking cessation agents, hair growth products, anorexiant
products, or fertility promotion agents. One month supply restriction.

PROGRAM CONTACT

Roxanne Homar, R.Ph. Phone: 307/777-6032


Community and Family Health Fax: 307/777-6964
Division E-mail: rhomar@state.wy.us
Hathaway Bldg, Rm 157
2300 Capitol Ave.
Cheyenne, WY 82002


Absorbed the Minimum Medical Program.

National Pharmaceutical Council 6-69


Pharmaceutical Benefits 2002

6-70 National Pharmaceutical Council


Pharmaceutical Benefits 2002

ALABAMA

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expended Recipients

TOTAL $331,574,388 438,529 $385,168,230 465,236

RECEIVING CASH ASSISTANCE TOTAL $244,874,432 209,643


Aged $36,886,212 28,320
Blind/Disabled $194,628,187 122,355
Child $6,923,518 43,011
Adult $6,436,515 15,957

MEDICALLY NEEDY, TOTAL $0 0


Aged $0 0
Blind/Disabled $0 0
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $33,759,075 189,144


Aged $740,219 829
Blind/Disabled $703,166 808
Child $30,621,597 172,402
Adult $1,694,093 15,105

Total Other Expenditures/Recipients* $52,940,881 39,742

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2000 and Alabama Medicaid Statistical Information System, FY 2001.
Note: Alabama estimates 2002 drug expenditures to be approximately $451 million and the number of Medicaid drug recipients to be
505,000.

National Pharmaceutical Council Alabama-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Director required for appeal of prior authorization


decisions.
Alabama Medicaid Agency. Prescribing or Dispensing Limitations

D. PROVISIONS RELATING TO DRUGS Prescription Refill Limit: 30 day supply, maximum of five
Benefit Design refills.

Drug Benefit Product Coverage: Products covered: Drug Utilization Review


prescribed insulin, disposable needles used for insulin;
and syringe combinations for insulin (considered OTC). PRODUR system implemented in July 1996. State
Products covered as DME: blood glucose test strips; urine currently has a DUR Board with a quarterly review.
ketone test strips; total parenteral nutrition; and Pharmacy Payment and Patient Cost Sharing
interdialytic parenteral nutrition. Prior authorization
required for: Retin A, Accutane, Dipyridamole. Products Dispensing Fee: $5.40.
not covered: cosmetics; fertility drugs and experimental
drugs. Ingredient Reimbursement Basis: AWP-10%, WAC +
9.2%.
Over-the-Counter Product Coverage: Products covered if
prescribed by a physician: allergy, asthma and sinus Prescription Charge Formula: Medicaid pays for
products; analgesics; cough and cold preparations; prescribed legend and non-legend drugs authorized under
digestive products; prenatal vitamins; hemorrhoidal the program based upon and shall not exceed the lowest
products. Partial coverage for: topical products. Products of:
not covered: smoking deterrent products and feminine
products. 1. The Maximum Allowable Cost (MAC) of the drug
plus a dispensing fee,
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; anoretics; antibiotics; 2. The Estimated Acquisition Cost (EAC) of the drug
anticoagulants; anticonvulsants; antidepressants; plus a dispensing fee, or
antidiabetic agents; antilipemic agents; anxiolytics, 3. The provider’s usual and customary charge to the
sedatives, and hypnotics; cardiac drugs; chemotherapy public for the drug.
agents; estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic) and thyroid agents. Partial Maximum Allowable Cost: State imposes Federal Upper
coverage for: anti-psychotics; prescribed cold Limits as well as state-specific limits on generic drugs.
medications; and contraceptives. Prior authorization Override requires “Dispense as Written” and “Brand
required for: analgesics, antipyretics, and (brand name) Medically Necessary.”
NSAIDs; antihistamine drugs (adult only); ENT anti-
inflammatory agents; growth hormones; and nutritional Incentive Fee: None.
supplements. Therapeutic categories not covered:
prescribed smoking deterrents. Patient Cost Sharing: Variable copayment.
Drug Ingredient Cost Copayment
Coverage of Injectables: Injectable medicines
$0.00 to $10.00 $0.50
reimbursable through the Prescription Drug Program
$10.01 to $25.00 $1.00
when used in physician offices, home health care, and
$25.01 to $50.00 $2.00
extended care facilities.
$50.01 or more $3.00
Vaccines: Vaccines reimbursable as part of the EPSDT Exemptions: No copayment amount is to be collected by
service and the Vaccines for Children Program. Adult the pharmacy or paid by the recipient for recipients under
vaccines are available through the Health Department. age 18, pregnant or living in nursing facilities.

Unit Dose: Unit dose packaging reimbursable. Cognitive Services: Clozaril care management fee of
$3.00.
Formulary/Prior Authorization

Formulary: Open formulary.


E. USE OF MANAGED CARE

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.

2-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Roger Lander, Pharm.D. (Vice-chair)


School of Pharmacy
State Drug Program Administrator Samford University
Louise F. Jones 800 Lakeshore Drive
Alabama Medicaid Agency Birmingham, AL 35229
501 Dexter Avenue 205/726-2102
P.O. Box 5624
Montgomery, AL 36103-5624 Frank Skinner, R.Ph.
T: 334/242-5039 90 County Road 1310
F: 334/353-7014 Vinemont, AL 35179
E-mail: lljones@Medicaid.state.al.us 256/734-4933
Internet Address: www.medicaid.state.al.us
W. Thomas Geary, Jr., M.D. (Chair)
Prior Authorization Contact 2801-B Zelda Road
Louise F. Jones, 334/242-5039 Montgomery, AL 36106
334/395-5372
DUR Contact
Louise Jones, 334/242-5039 Steven Rostand, M.D.
University of Alabama Birmingham
Medicaid DUR Board Division of Nephrology
John Searcy, M.D. 2RB 606 1530 3rd Avenue South
Medical Director Birmingham, AL 35294
Alabama Medicaid Agency 205/934-2646
501 Dexter Avenue
Montgomery, AL 36130 Margaret Thrower, Pharm.D.
334/242-5619 Auburn University
105 Walker Building
Jimmy Jackson, R.Ph. Auburn University, AL 36849
1874 Cherokee Road 334/844-8287
Alexander City, AL 35010
256/234-2538 Rob Colburn, R.Ph.
909 McFarland Boulevard
Johnny Brooklere, R.Ph. Northport, AL 35476
3600 Main Street 205/339-5800
Adamsville, AL 35005
205/674-1400 Jefferson Underwood, III, M.D.
2171 Normandie Drive
John E. Brandon, M.D. Montgomery, AL 36111
Intersection Highway 82 and 86 334/288-7531
P.O. Box 390 Prescription Price Updating
Gordo, AL 35466
205/364-7135 Beverly R. Churchwell, Administrator
Alabama Medicaid Agency
Kathy B. Portner, M.D. 501 Dexter Avenue
251 Cox Street P.O. Box 5624
Suite 100 Montgomery, AL 36103-5424
Mobile, AL 36604 T: 334/242-5034
251/415-1566 F: 334/353-7014
E-mail: bchurchwell@medicaid.state.al.us
Richard Freeman, M.D.
411 B Opelika Road
Auburn, AL 36830
334/821-4766

National Pharmaceutical Council Alabama-3


Pharmaceutical Benefits 2002

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

John Searcy, M.D. Alabama Nursing Home Association


Medical Director Mr. Louis E. Cottrell, Jr., Executive Director
Alabama Medicaid Agency 4156 Carmichael Road
Montgomery, AL 36106

4-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2002

334/271-6214 334/273-4404

Alabama State Medical Association Alabama Optometric Association


Roosevelt McCorvey, M.D. Amanda Jones, Executive Director
3088 Rosa L. Parks Avenue 400 South Union Street, Suite 435
Montgomery, AL 36105 Montgomery, AL 36104
334/262-0259 334/834-1057

J.A. Powell, M.D. Alabama Association of Home Health Agencies


2212 Mallard Lane SE Melane Golson
Decatur, AL 35602 Office of Executive Director
256/340-1068 P.O. Box 40
Montgomery, AL 36101
Alabama Chap. Am. Academy of Family Physicians 334/395-9949
Holly Midgley, Executive Vice President
P.O. Box 1900 Alabama Primary Health Care Association
19 South Jackson Street Al Fox, Executive Director
Montgomery, AL 36102-1900 6008 East Shirley Lane, Suite A
334/263-6441 Montgomery, AL 36117
334/271-7068
Alabama Pharmacy Association
William S. Eley, II, Executive Director Alabama Academy of Ophthalmology
1211 Carmichael Road Leigh Jones
Montgomery, AL 36106 P.O. Box 11455
334/271-4222 Montgomery, AL 36111-0455
334/269-9900
Page Dunlap
P.O. Box 354 Assisted Living Association of Alabama
Hartselle, AL 35640 Frank Holden, President
256/773-5421 400 S. Union Street, Suite 235
Montgomery, AL 36104
Alabama Chap. American Academy of Pediatrics 334/262-5523
Karin Scott, Executive Director
735 Montgomery Highway, Suite 323 Alabama Hospice Organization
Birmingham, AL 35216 David Stone, Executive Director
205/824-0888 P.O. Box 1835
Calera, AL 35040
Alabama Dietetic Association 205/668-0460
Gayle Mask
Alabama Department of Public Health Alabama State Nurses Association
RSA Tower, Suite 1300 Karen Pakkala, Executive Director
P.O. Box 303017 360 North Hill Street
Montgomery, AL 36130-3017 Montgomery, AL 36104-3658
334/206-2922 334/262-8321

Alabama Hospital Association Consumer Representatives


J. Michael Horsley, President Lawrence F. Gardella
East Station Senior Staff Attorney
P.O. Box 210759 Montgomery Regional Office
Montgomery, AL 36121 Legal Services Corporation of Alabama
334/272-8781 600 Bell Building, 207 Montgomery Street
Montgomery, AL 36104
334/832-4570

Jody Pigg, CEO Bill Chandler


Baptist Health Services General Director
P.O. Box 11010 Montgomery YMCAs
Montgomery, AL 36111-0010 P.O. Box 2336

National Pharmaceutical Council Alabama-5


Pharmaceutical Benefits 2002

Montgomery, AL 36102-2336 Jefferson Underwood, III, M.D. (Chair)


334/269-4362 2171 Normandie Drive
Montgomery, AL 36111
Teresa Easterling
334/288-7531
325 Spigener Road
Titus, AL 36080
W. Thomas Geary, Jr., M.D.
334/567-5020
2801-B Zelda Road
Montgomery, AL 36111-1103
Linda McWilliams
334/395-5372
Top of Alabama Regional Council of Governments
(TARCOG)
Rob Colburn, R.Ph.
115 Washington Street, SE
909 McFarland Blvd.
Huntsville, AL 35801
Northport, AL 35476
205/533-3330
205/339-5800
Rogene W. Parris
John Searcy, M.D.
2061 Fire Pink Court
Medical Director
Birmingham, AL 35244
Alabama Medicaid Agency
205/987-0338
501 Dexter Avenue
Montgomery, AL 36104
Louise Pittman
334/242-5619
3355 Lexington Road
Montgomery, AL 36106
Dane Yarbrough, R.Ph.
334/264-8780
8750 Ashford Circle
Pharmacy and Therapeutics Committee Tuscaloosa, AL 35406
205/391-3636
A. Z. Holloway, M.D.
2611 Woodley Park Drive Executive Officers of State Medical and
Montgomery, AL 36116 Pharmaceutical Societies
334/288-0009
Medical Association of the State of Alabama (MASA)
Cary Kuhlmann
Richard Freeman, M.D.
Executive Director
411 B Opelika Road
19 S. Jackson Street
Auburn, AL 36830
P.O. Box 1900
334/821-4766
Montgomery, AL 36102-1900
T: 334/954-2500
Ben Main, R.Ph.
F: 334/269-5200
302 North Prairie Street
E-mail: cary@masalink.org
Union Springs, AL 36089
Internet Address: www.masalink.org
334/738-2020
Alabama Osteopathic Medical Association
Gary Magouirk, M.D.
E. Jason Hatfield, D.O.
110 23rd Street NW
Secretary of Treasure
Fayette, AL 35555
P.O. Box 1857
205/932-3891
U.S. Highway 43
Winfield, AL 35594
Ray Thweatt, M.D.
T: 205/487-7556
University of Alabama Birmingham
F: 205/487-7559
433 CPM
Internet Address: www.aloma.org
1713 6th Avenue South
Birmingham, AL 35294-0018
Alabama State Medical Association
205/934-6737
Joel Powell, M.D., President
1408 5th Avenue, SE
Suite 1
Decatur, AL 35601
T: 256/340-9445
F: 256/350-0499
Alabama Pharmacy Association (APA)

6-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

State Board of Pharmacy


Jerry Moore
Executive Director
1 Perimeter Park South, Suite 425
Birmingham, AL 35243
T: 205/967-0130
F: 205/967-1009
E-mail: jmoore@albop.com
Internet Address: www.albop.com

Alabama Independent Drugstore Association (AIDA)


Sharon Taylor, Executive Director
400 Interstate Park Drive
Suite 401
Montgomery, AL 36109
T: 334/213-2432
F: 334/213-2406
E-mail: Sharon@aidarx.org
Internet Address: www.aidarx.org

Alabama Hospital Association


Michael Horsley
President CEO
500 North East Blvd.
Montgomery, AL 36117
T: 334/272-8781
F: 334/270-9527
E-mail: mhorsley@alaha.org
Internet Address: www.alaha.org

National Pharmaceutical Council Alabama-7


Pharmaceutical Benefits 2002

8-Alabama National Pharmaceutical Council


Pharmaceutical Benefits 2002

ALASKA

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    

B. DRUG PAYMENTS AND RECIPIENTS


2000 2001**
Expended Recipients Expended Recipients

TOTAL $51,196,685 60,273 $64,923,574 65,278

RECEIVING CASH ASSISTANCE TOTAL $42,312,292 33,977 $52,946,651 33,640


Aged $7,815,093 4,574 $9,954,837 4,747
Blind/Disabled $26,292,009 8,385 $33,634,846 8,964
Child $1,717,322 10,368 $1,778,759 9,519
Adult $6,487,868 10,650 $7,578,209 10,410

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $3,540,104 20,691 $5,303,090 25,775


Aged $3,280 5 $6,244 8
Blind/Disabled $411 1 $368 2
Child $2,935,102 16,590 $4,319,775 20,919
Adult $601,311 4,095 $976,703 4,846

TOTAL OTHER EXPENDITURES/RECIPTENTS* $5,344,289 5,605 $6,673,833 5,863

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2001 data are preliminary and subject to change.
Source: CMS, MSIS Report, FY 2000 and FY 2001.

National Pharmaceutical Council Alaska-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION for appealing coverage of an excluded product and PA


decision. Medical necessity form required.
Department of Health and Social Services, Division of
Medical Assistance. Prescribing or Dispensing Limitations

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

Does not use MCOs to deliver services to Medicaid


Unit Dose: Unit dose packaging reimbursable.
recipients.
Formulary/Prior Authorization
F. STATE CONTACTS
Formulary: No formulary.
Medicaid Drug Program Administrator
Prior Authorization: State currently has a formal prior Dave Campana, R.Ph.
authorization procedure. Request for fair hearing required Pharmacy Program Manager

2-Alaska National Pharmaceutical Council


Pharmaceutical Benefits 2002

Division of Medical Assistance Disease Management Program/Initiative Contact


4501 Business Park Blvd., Suite 24
Teri Keklak
Anchorage, AK 99503
Health Policy Manager
T: 907/334-2425
Division of Medical Assistance
F: 907/561-1684
4501 Business Park Blvd, Suite 24
E-mail: david_campana@health.state.ak.us
Anchorage, AK 99503
Health and Social Services Department Officials T: 907/334-2424
F: 907/561-1684
Joel Gilbertson, Commissioner
E-mail: teri_keklak@health.state.ak.us
Department of Health and Social Services
P.O. Box 110601 Mail Order Pharmacy Benefit
Juneau, AK 99811-0601
Yes, for Medicaid recipients living in rural areas.
T: 907/465-3030
F: 907/465-3068 Physician-Administered Drug Program Contact
E-mail: joel_gilbertson@health.state.ak.us
Dave Campana, 907/334-2425
Alaska Medical Care Advisory Committee
Bob Labbe, Director
Division of Medical Assistance, DHSS Patty Hong, R.N., Chair
P.O. Box 110660 School of Nursing
Juneau, AK 99811-0660 University of Alaska Anchorage
T: 907/465-3355 3211 Providence Drive
F: 907/465-2204 Anchorage, AK 99508
E-mail: Blabbe@health.state.ak.us
Alaska DUR Committee
Jack Nielson, Director Dave Campana, R.Ph.
Division of Medical Assistance Anchorage, AK 99503
4501 Business Park Blvd., Suite 24
Anchorage, AK 99503 Richard Reem, M.D.
907/334-2400 Fairbanks, AK 99701-3639
Prior Authorization Contact
Heide Brainerd, P.H.
Dave Campana, 907/334-2425 Anchorage, AK
DUR Contact
Arthur Hansen, D.D.S.
Dave Campana, 907/334-2425 Fairbanks, AK 99712
Prescription Price Updating
Greg Polston, M.D.
Dave Campana, 907/334-2425 Fairbanks, AK.
Medicaid Drug Rebate Contact
Peter Yan
Accountant
Division of Medical Assistance
4501 Business Park Blvd., Suite 24
Anchorage, AK 99503 Executive Officers of State Medical and
T: 907/334-2409 Pharmaceutical Societies
F: 907/561-1684 Alaska State Medical Association
E-mail: peter_yan@health.state.ak.us Jim Jordan, Executive Director
Claims Submission Contact 4107 Laurel Street
Anchorage, AK 99508
Linda Walsh
T: 907/562-0304
Systems Administrator
F: 907/561-2063
Division of Medical Assistance
E-mail: asma@alaska.net
4501 Business Park Blvd, Suite 24
Anchorage, AK 99503
Alaska Osteopathic Medical Association
T: 907/334-2441
Cheryl Richards
F: 907/561-1684
Executive Secretary
E-mail: linda_walsh@health.state.ak.us

National Pharmaceutical Council Alaska-3


Pharmaceutical Benefits 2002

P.O. Box 3887


Palmer, AK 99645
907/745-8202
E-mail: akoma@mtaonline.net
Internet Address: www.nwosteo.org/alaska.html

Alaska Pharmaceutical Association


Nancy Davis, Executive Director
4107 Laurel Street
Anchorage, AK 99508-5334
T: 907/563-8880
F: 907/563-7880
E-mail: akphrmcy@alaska.net
Internet Address: www.alaskapharmacy.org

Alaska State Board of Pharmacy


Barbara Roche
Lic. Examiner
P.O. Box 110806
Juneau, AK 99811-0806
T: 907/465-2589
F: 907/465-2974
E-mail: barbara_roche@dced.state.ak.us
Internet Address: www.dced.state.ak.us/occ/ppha.htm

Alaska State Hospital and Nursing Home Association


Laraine L. Derr
President/CEO
426 Main Street
Juneau, AK 99801
T: 907/586-1790
F: 907/463-3573
E-mail: lderr@ashnha.com
Internet Address: www.ashnha.com

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Pharmaceutical Benefits 2002

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

National Pharmaceutical Council Arizona-1


Pharmaceutical Benefits 2002

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

2-Arizona National Pharmaceutical Council


Pharmaceutical Benefits 2002

• Health Plan Oversight 928/448-3585


• Provider, Member Call Center
• Grievances and Complaints Health Choice Arizona
• Fee for Service for IHS Suite 260
1600 West Broadway
AHCCCS became effective December 1, 1981, and Tempe, AZ 85282-1136
services commenced October 1, 1982. Services include: 480/968-6866
inpatient, outpatient, laboratory, x-ray, prescription drugs,
medical supplies, prosthetic devices, emergency dental Maricopa Health Plan
care including extractions and dentures, treatment of eye 2502 East University Drive
conditions and EPSDT. Phoenix, AZ 85034
602/344-8700
Though AHCCCS was a three-year experiment that was to
end in October 1985, the Federal government continues to Mercy Care Plan
extend funding for the program. In 1988, AHCCCS Suite 400
received a five-year extension from the Federal 2800 North Central
government and in 1993, it received an additional one- Phoenix, AZ 85004
year extension. In 1994, AHCCCS received a three-year 602/263-3000
extension and in 1998, it received a one-year extension.
Since then, AHCCCS has received additional extensions. Phoenix Health Plan/Community Connection
Currently, AHCCCS is operating under a five year waiver 1209 South 7th Avenue
extension that will expire on September 30, 2006. Some Phoenix, AZ 85004
20 years after it first began, AHCCCS has grown in 602/824-3700
numbers from the first wave of 180,000 enrollees to move
than 800,000 beneficiaries, representing 16 percent of Pima Health System
Arizona’s population. AHCCCS has also become a model Suite A-200
as managed care is increasingly by being implemented in 5055 East Broadway
other states’ Medicaid programs. Tucson, AZ 85711
602/512-5500
MEDICAL PLANS AND ADMINISTRATORS
AHCCCS Contracted Health Plans University Family Care
575 East River Road
Arizona Physicians IPA, Inc. Tucson, AZ 85704
3141 North 3rd Avenue 888/708-2930
Phoenix, AZ 85013
602/264-1232 Phoenix Arizona Indian Health Services (IHS)
Two Renaissance Square
CIGNA Community Choice 40 N. Central Avenue
11001 North Black Canyon Highway Phoenix, AZ 85004-5036
Phoenix, AZ 85029 602/364-5038
602/371-2621
Phoenix Indian Medical Center
4212 North 16th Street
Phoenix, AZ 85016
602/263-1200

DES/CMDP Indian Health Services (IHS)


CMDP-942-C Southern Region
Century Plaza Building, 10th Floor 7900 J.J. Stock Road
3225 North Central Avenue Tucson, AZ 85746
Phoenix, AZ 85012 520/295-2406
602/351-2245
Navajo Area Indian Health Services (IHS)
Family Health Plan of NE Arizona P.O. Box 9020
258 Justin Drive Window Rock, AZ 86515-9020
P.O. Box 2069 928/871-5811
Cottonwood, AZ 86326

National Pharmaceutical Council Arizona-3


Pharmaceutical Benefits 2002

ALTCS Contractor List Phoenix, AZ 85034


T: 602/417-4680
Cochise Health Systems
F: 602/252-6536
Cochise County Health & Social Services
E-mail: PXBiedess@ahcccs.state.az.us
1415 West Melody Lane, Building A
Bisbee, AZ 85603
C.J. Hindman, M.D.
520/432-9481
Medical Director
DES/DDD
(Additional information about AHCCCS can be found on
1789 West Jefferson, 4th Floor
the agency’s website at www.ahcccs.state.az.us)
Phoenix, AZ 85034
602/542-6866 Executive Officers of State Medical and
Pharmaceutical Societies
Evercare Select
Arizona Medical Association, Inc.
Chic Older
Maricopa Managed Care Systems
Executive Vice President
2502 East University Drive
810 West Bethany Home Road
Phoenix, AZ 85034
Phoenix, AZ 85013
602/344-8700
T: 602/246-8901
F: 602/242-6283
Mercy Care Plan
E-mail: chicolder@azmedassn.org
Suite 400
Internet address: www.azmedassn.org
2800 North Central
Phoenix, AZ 85004
Arizona Pharmacy Association
602/263-3000
Kathy Boyle
Executive Director
Pima County LTC
1845 E. Southern Ave.
Pima Health System
Tempe, AZ 852-82-5831
Suite A-200, 5055 East Broadway
T: 480/838-3385
Tucson, AZ 85711
F: 480/838-3557
520/512-5500
E-mail: azpa@azpharmacy.org
Pinal/Gila County-LTC
Arizona Osteopathic Medical Association
P.O. Box 2140
Amanda Weaver
574 South Central Avenue
Executive Director
Florence, AZ 85232-2140
5150 N. 16th St., Suite A-122
520/868-6775
Phoenix, AZ 85016
T: 602/266-6699
Yavapai County LTC
F: 602/266-1393
Yavapai County Department of Medical Assistance
E-mail: mweaver@az-osteo.org
255 East Gurley Street, First Floor
Internet address: www.az-osteo.org
Prescott, AZ 86301
520/771-3560

Arizona Board of Pharmacy


Llyn. A. Lloyd
AHCCCS FFS (ALTCS)
Executive Director
Ventilator Dependent
4425 W. Olive Avenue, Suite 140
Office of Medical Management
Glendale, AZ 85302
602/417-4283
T: 623/463-2727
F: 623/934-0583
STATE CONTACTS E-mail: info@azsbp.com
AHCCCS Officials Internet address: www.pharmacy.state.az.us
Phyllis Biedess, Director Arizona Hospital and Healthcare Association
AHCCCS John R. Rivers, FACHE
801 E. Jefferson Street President/CEO

4-Arizona National Pharmaceutical Council


Pharmaceutical Benefits 2002

2901 North Central Avenue


Suite 900
Phoenix, AZ 85012
T: 602/445-4300
F: 602/445-4299
E-mail: jrivers@azha.org
Internet address: www.azha.org

National Pharmaceutical Council Arizona-5


Pharmaceutical Benefits 2002

6-Arizona National Pharmaceutical Council


Pharmaceutical Benefits 2002

1
ARKANSAS

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $209,933,612 290,749 $248,392,084 321,920

RECEIVING CASH ASSISTANCE, TOTAL $125,221,968 111,942 $142,811,387 111,016


Aged $17,273,356 14,363 $18,083,097 13,278
Blind/Disabled $101,382,563 67,787 $117,036,376 68,665
Child $3,571,657 20,226 $4,248,875 19,495
Adult $2,994,392 9,566 $3,443,039 9,578

MEDICALLY NEEDY, TOTAL $7,336,056 16,317 $7,660,175 13,964


Aged $122,924 214 $130,249 203
Blind/Disabled $2,751,009 1,993 $2,721,983 2,036
Child $1,837,114 8,028 $1,664,186 5,912
Adult $2,625,009 6,082 $3,143,757 5,813

POVERTY RELATED, TOTAL $13,636,604 74,453 $21,594,533 100,643


Aged $511,191 470 $370,667 367
Blind/Disabled $887,917 582 $917,628 673
Child $11,290,143 63,157 $18,932,809 88,224
Adult $947,353 10,244 $1,373,429 11,379

TOTAL OTHER EXPENDITURES/RECIPIENTS* $63,738,984 88,037 $76,325,989 96,297

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

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

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

National Pharmaceutical Council Arkansas-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Department of Human Services, Division of Medical Formulary: Closed formulary. General exclusions
Services, Pharmacy Program. include:

D. PROVISIONS RELATING TO DRUGS 1. Agents used for hair growth.


Benefit Design 2. Vitamin products except prescription prenatal
vitamins.
Drug Benefit Product Coverage: Products covered:
3. Drugs determined by the FDA to be ineffective
prescribed insulin; disposable needles and syringe
(DESI drugs).
combinations used for insulin. Products not covered:
blood glucose test strips; urine ketone test strips; total 4. Sedatives and hypnotics in the benzodiazepine
parenteral nutrition, interdialytic parenteral nutrition; category (partial coverage).
cosmetics; fertility drugs; and experimental drugs. Prior
5. Compounded prescriptions (mixtures of two or more
authorization required for: nitroglycerin patches; agents
ingredients). States are not allowed to have state
for impotence; Synagis; Respigam; and Xenical-hyper
codes such as 99999-9999-99. All drugs reimbursed
lipidemia.
by the State must be traced by NDC code and appear
on the utilization report.
Over-the-Counter Product Coverage: Products covered:
digestive products (H2 antagonist). Limited coverage for: Prior Authorization: State currently has a prior
allergy, asthma and sinus products; analgesics; cough and authorization procedure.
cold preparations (under 21 years and long-term care
limited needs); digestive products (non-H2 antagonist); Prescribing or Dispensing Limitations
feminine products; topical products; and selected smoking
deterrent products (Zyban PA only). Prescription Refill Limit: 5 refills within 6 months are
allowed. New Rx required every 6 months.
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; antibiotics; anticoagulants; Monthly Quantity Limit: 31-day supply.
anticonvulsants; anti-depressants; antidiabetic agents;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Monthly Prescription Limit: Three prescriptions per
and hypnotics; cardiac drugs; chemotherapy agents; month per recipient, except unlimited in certified LTC
contraceptives; ENT anti-inflammatory agents; estrogens; recipients and recipients under 21 years old. Others can
growth hormones; hypotensive agents; sympathominetics receive extension of three more per month.
(adrenergic); and thyroid agents. Prior authorization Drug Utilization Review
required for: analgesics, antipyretics, NSAIDs;
antihistamine drugs; misc. GI drugs; prescribed smoking PRODUR system implemented in March 1997. State
deterrents. Therapeutic categories not covered: currently has a DUR Board with a quarterly review.
anorectics.
Pharmacy Payment and Patient Cost Sharing
Coverage of Injectables: Injectable medicines are
reimbursable through the Prescription Drug Program Dispensing Fee: $5.51 effective 7/1/99.
when used in home health care, extended care facilities
and through physician payment when used in physicians Ingredient Reimbursement Basis: EAC = AWP–10.5%.
offices.
Prescription Charge Formula: Legend drugs: lower of the
Vaccines: Vaccines reimbursable as part of the Vaccines EAC plus a dispensing fee or CFA/state upper limit plus a
for Children Program. dispensing fee. Total charge may not exceed provider’s
charge to the self-paying public.
Unit Dose: Unit dose packaging reimbursable.
Maximum Allowable Costs: State imposes Federal Upper
Limits as well as state-specific limits on generic drugs.
State-specific MAC list contains 800 drugs. Override
requires “Brand Medically Necessary.” PA must be
obtained once the pharmacy obtains the BNM Rx.

Incentive Fee: None.

2-Arkansas National Pharmaceutical Council


Pharmaceutical Benefits 2002

Patient Cost Sharing: Effective 9/1/92, for each DUR Contact


prescription reimbursed, the Medicaid recipient is
Pamela Ford, P.D.
responsible for paying a copayment based on the
Division of Medical Services
following:
Dept. of Human Services
P.O. Box 1437 Slot S 415
Little Rock, AR 72203
T: 501/683-4120
State Payment Copay
F: 501/683-4124
E-mail: pamela.ford@medicaid.state.ar.us
$10.00 or less $0.50
DUR Board
$10.01 to $25.00 $1.00
Steve Bryant, P.D.
Bryant’s Pharmacy
$25.01 to $50.00 $2.00
2000 Harrison Street
Batesville, AR 72501
$50.01 or more $3.00
501/793-3999
ArKids $5.00 Jason B. Hawkins, P.D.
Services to individuals under 18, pregnant women, Benji Post, P.D.
nursing home residents, emergency services, family
planning services, and services provided by an HMO to its Debbie Hayes
enrollees are excluded from the Medicaid copay policy.
Ann Blaylock, A.P.N.
Cognitive Services: Does not pay for cognitive services.
Thomas Lewellen, D.O.
E. USE OF MANAGED CARE 105 West Waterman
Dumas, AR 71639
An estimated 400,000 Medicaid recipients are enrolled 870/382-1188
with Primary Care Physicians and ArKids.
Pharmaceutical benefits are provided through the State. Michael N. Moody, M.D.
P.O. Box 829
F. STATE CONTACTS Salem, AR 72576
501/895-2541
Medicaid Drug Program Administrator
Suzette Bridges, P.D., Administrator Laurence Miller, M.D.
Prescription Drug Program
Division of Medical Services Prescription Price Updating
Dept. of Human Services
First DataBank
P.O. Box 1437, Slot S 415
1111 Bay Hill Drive
Little Rock, AR 72203
San Bruno, CA 74066
T: 501/683-4120
650/588-5454
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us Medicaid Drug Rebate Contacts
Prior Authorization Contact
Audits: Suzette Bridges, P.D., 501/683-4120
Suzette Bridges, P.D.
501/683-4120 Dispute Resolution: Mary Alice Easterling
EDS
500 President Clinton Ave, Suite 400
Little Rock, AR 72201
T: 501/374-6608
F: 501/372-2971
E-mail: mary.easterling@mediciad.state.ar.us
Claims Submission Contact
John Herzog, Account Manager
EDS

National Pharmaceutical Council Arkansas-3


Pharmaceutical Benefits 2002

500 President Clinton Ave, Suite 400 F: 501/372-0546


Little Rock, AR 72201 E-mail: rbeck@arpharmacists.org
T: 501/374-8650 Internet address: www.arpharmacists.org
F: 501/372-2971
E-mail: john.herzog@medicaid.state.ar.us Arkansas State Board of Pharmacy
Charles S. Campbell
Medicaid Managed Care Contact
Executive Director
Bob Paladino 101 E. Capitol, Suite 218
Division of Medicaid Services Little Rock, AR 72201
Dept. of Human Services T: 501/682-0190
P.O. Box 1437 F: 501/682-0195
Little Rock, AR 72203 E-mail: charlie.campbell@mail.state.ar.us
T: 501/682-8334 Internet address: www.state.ar.us/asbp
F: 501/683-4124
E-mail: bob.paladino@medicaid.state.ar.us Arkansas Osteopathic Medical Association
Ed Bullington
Mail Order Pharmacy Benefit
Executive Director
None 412 Union Station
1400 West Markham
Department of Human Services Officials Little Rock, AR 72201
Kurt Knickrehm, Director T: 501/374-8900
Department of Human Services F: 501/374-8959
P.O. Box 1437, Slot 329 E-mail: osteomed@ipa.net
Little Rock, AR 72203-1437 Internet address: www.arkosteomed.org
T: 501/682-8292
F: 501/682-6836 Arkansas Medical Society
E-mail: kurt.knickrehm@state.ar.us Ken LaMastus
Executive Vice President
Ray Hanley, Director P.O. Box 55088
Division of Medical Services Little Rock, AR 72215
P.O. Box 1437, Slot 1100 T: 501/224-8967
Little Rock, AR 72203-1437 F: 501/224-6489
T: 501/682-8292 E-mail: klamastus@arkmed.org
F: 501/682-1197 Internet address: www.arkmed.org
E-mail: ray.hanley@medicaid.state.ar.us

Executive Officers of State Medical and


Pharmaceutical Societies
Arkansas Hospital Association
James R. Teeter
419 Natural Resources Drive
Little Rock, AR 72205
T: 501/224-7878
F: 501/224-0519
E-mail: aha@arkhospital.org
Internet address: www.arkhospitals.org

Arkansas Pharmacists Association


Richard E. Beck, P.D., C.A.E.
Executive Vice President and CEO
417 S. Victory Street
Little Rock, AR 72201-2932
T: 501/372-5250

4-Arkansas National Pharmaceutical Council


Pharmaceutical Benefits 2002

CALIFORNIA

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

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $2,316,135,493 2,487,875 $2,808,298,437 2,486,910

RECEIVING ASSISTANCE, TOTAL $1,770,765,371 1,301,543 $2,143,413,178 1,334,480


Aged $389,560,223 260,790 $479,791,420 266,911
Blind/Disabled $1,284,923,008 572,336 $1,547,024,854 579,572
Children $32,410,720 288,397 $39,100,804 299,830
Adult $63,871,420 180,020 $77,496,100 188,167

MEDICALLY NEEDY, TOTAL $373,918,597 320,922 $423,154,155 279,326


Aged $156,177,417 112,375 $198,544,758 120,346
Blind/Disabled $187,650,486 58,626 $198,371,267 53,459
Children $12,528,551 99,463 $11,503,750 68,297
Adults $17,562,143 50,458 $14,734,380 37,224

POVERTY RELATED, TOTAL $20,626,801 157,404 $54,387,618 103,247


Aged $3,087,289 3,281 $14,257,426 11,923
Disabled $3,156,657 1,617 $32,358,484 10,485
Children $12,175,851 119,040 $5,572,729 51,243
Adults $2,207,004 33,466 $2,198,979 29,596

TOTAL OTHER EXPENDITURES/RECIPIENTS* $150,824,724 708,006 $187,343,486 769,857

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

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

National Pharmaceutical Council California-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Manufacturers Manufacturers frequently petition Medi-


Cal to add drugs to the list of contract drugs. Based on
Under the Health and Human Services Agency with direct Medi-Cal’s five criteria (safety, efficacy, misuse potential,
administration by the Department of Health Services. essential need, and cost), a drug may be added to the list
on contractual agreement by the manufacturer to provide
The Department of Health Services Pharmaceutical Unit the State a negotiated rebate. The Medi-Cal website at:
of the Medi-Cal Policy Division monitors the full scope http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/html/f
and quality of pharmaceutical benefits covered under the aqpage.htm has details of how the drug contracting
provisions of the California Medical Assistance Program. process works.

D. PROVISIONS RELATING TO DRUGS Examples of general limitations and exclusions (other


uses require prior authorization):
Benefit Design
1. CNS stimulants, i.e., amphetamines and
Drug Benefit Product Coverage: The Medi-Cal pharmacy methylphenidate, are restricted to attention deficit
benefit covers practically all FDA-approved drugs, disorder in individuals between 4 and 16 years of age.
including both legend and over-the-counter products.
2. Diazepam is restricted to use in cerebral palsy,
There are very few drugs or classes of drugs that are non-
athetoid states, and spinal cord degeneration.
benefits. Non-benefits include common household
remedies; non-legend analgesics and cough/cold 3. Most non-steroidal anti-inflammatory agents are
medications, except when specifically listed; multivitamin restricted to use for arthritis.
preparations except certain pre-natal and pediatric
4. Many antibiotics have diagnostic and/or age
products; cosmetics, fertility drugs, and experimental
restrictions.
drugs. Most other products are potential benefits.
5. Acyclovir capsules are restricted to herpes genitalis,
In general, products that are listed on the Medi-Cal List of immunocompromised patients and herpes zoster
Contract Drugs do not require prior authorization. Those (shingles).
not on the List of Contract Drugs requires prior
6. Codeine Combinations: payment to a pharmacy for
authorization.
ASA or APAP with codeine 30 mg is limited to a
maximum dispensing quantity of 45 tablets or
Physician-administered drugs: The Medi-Cal List of
capsules and a maximum of 3 claims for the same
Contract Drugs applies to drugs dispensed from
beneficiary in any 75-day period.
pharmacies to patients. Drugs administered directly in a
physician's, dentist's, or podiatrist's office are not bound 7. Enteral nutritional supplements or replacements are
by the List of Contract Drugs. covered, subject to prior authorization, if used as a
therapeutic regimen to prevent serious disability or
Coverage of Injectables: Injectable medicines death in patients with medically diagnosed conditions
reimbursable through the Prescription Drug Program that preclude the full use of regular foodstuffs.
when used in home health care and extended care facilities
8. Cancer, AIDS, and DESI Drugs: Any antineoplastic
and through physician payment when used in physician
drug approved by FDA for the treatment of cancer
offices.
and any drug approved by FDA for the treatment of
AIDS or AIDS-related condition is covered through
Vaccines: Vaccines reimbursable by schedule as part of
the Medi-Cal List of Contract Drugs; most DESI
the Vaccines for Children Program. Vaccines for adults
drugs rated less-than-effective by FDA are not
covered through the prescription drug program, or as
covered.
administered in a physician's office.
Prior Authorization: State currently has a formal prior
authorization procedure.

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

2-California National Pharmaceutical Council


Pharmaceutical Benefits 2002

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:

TARs may be approved for: covered items or services not


included on the Medi-Cal List of Contract Drugs 1. Estimated Acquisition Cost (EAC) + dispensing fee,
(including special circumstance such as the need to less $0.50.
override multiple source drug price ceilings or minimum 2. Federal Upper Limit (FUL) + dispensing fee, less
quantity/ frequency of billing limitations); and for patients $0.50.
exceeding the 6 Rx per month limit. Statewide mail and 3. State Maximum Allowable Ingredient Cost (MAIC) +
fax requests are accepted in the Stockton and Los Angeles dispensing fee, less $0.50.
Medi-Cal Field Offices. Requests must include adequate 4. Pharmacy’s usual price to general public, less $0.50.
information and justification. Authorization may only be
given for the lowest cost item or service that meets the
Maximum Allowable Cost: State Maximum Allowable
patient’s medical needs.
Ingredient Costs (MAICs) are established for about 50
multi-source items. Override requires “Medically
Beneficiary or Prescriber Prior Authorization: On a case
Necessary” or unavailability of drug products at or below
by case basis, the Dept. of Health Services restricts,
MAC. List is periodically revised and price limits
through the requirements of prior authorization, the
changed to reflect current market conditions.
availability of designated prescription drugs to certain
beneficiaries or prescribers found by the Department to
Incentive Fee: None.
abuse those benefits.
Prescribing or Dispensing Limitations Patient Cost Sharing: $1.00 copayment for branded and
generic products.
Prescription Refill Limit: A prescription refill can be
dispensed as authorized by prescriber. Exception is Cognitive Services: Does not pay for cognitive services,
allowed for refill of a reasonable quantity when prescriber but this is under consideration.
is unavailable (pursuant to California law). Fee is to be
pro-rated so that total fee (for partial quantity and balance E. USE OF MANAGED CARE
of the prescription after prescriber is contacted) does not
exceed fee for same prescription when refilled as routine
Approximately 3,000,000 Medicaid recipients were
service.
enrolled in MCOs in FY 2001. Recipients receive
Monthly Quantity Limit: This is flexible, but should be pharmaceutical benefits through the State and managed
consistent with the medical needs of the patient. Limited care plans.
to 100 days’ supply on most drugs. Many maintenance
Access Dental Plan, Inc.
drugs are subject to minimum quantity or maximum
555 University Ave, Suite 182
frequency of billing controls.
Sacramento, CA 95825
Monthly Prescription Limit: Limited to 6 per month
without prior authorization. The limit does not apply to AIDS Healthcare Foundation
family planning drugs, patients in nursing facilities or to 6255 W. Sunset Blvd., 16th Floor
AIDS or cancer drugs. Los Angeles, CA 90028-7403

Hospital Discharge Medications: Quantities furnished as Alameda Alliance for Health


discharge medications are limited to no more than a 10- 1850 Fairway Drive
day supply. Charges are incorporated in the hospital’s San Leandro, CA 94557-0187
claims for inpatient services.
Altamed Health Services Corp.
Drug Utilization Review 512 South Indiana Street
Los Angeles, CA 90063
Prospective DUR system implemented in August 1995.
State currently has a DUR Board with a quarterly review. American Health Guard
Pharmacy Payment and Patient Cost Sharing 30 East Santa Clara, Suite D
Arcadia, CA 91006
Dispensing Fee: $4.05, effective 8/85.
Blue Cross of California
Ingredient Reimbursement Basis: EAC = AWP-10% 5151-A Camino Ruiz
Camarillo, CA 93012

National Pharmaceutical Council California-3


Pharmaceutical Benefits 2002

Care 1st Health Plan LA Care Health Plan


1000 South Freemont Ave, Bldg. A-11, Unit 22 3530 Wilshire Boulevard, 9th Floor
Alhambra, CA 91803 Los Angeles, CA 90100

Center for Elders Independence Maxicare


1955 San Pablo Ave 1149 South Broadway, Suite 819
Oakland, CA 94612 Los Angeles, CA 90015

Cohen Medical Corp Molina Medical Centers


Tower Health Services One Golden Shore Drive
200 Oceangate, 6th Floor Long Beach, CA 90802
Long Beach, CA 90802
OnLok Senior Health Services
Community Health Group 1333 Bush Street
740 Bay Blvd. San Francisco, CA 94109
Chula Vista, CA 91910
Orange County Organized Health System
County of Contra Costa Cal Optima
Contra Costa Health Plan 1120 West La Veta Ave., 5th Floor
595 Center Avenue, Suite 100 Orange, CA 92668-4220
Martinez, CA 94553
Placer County Managed Care Network
Denticare of California 379 Nevada Street
3400 Data Dr. 3 West Auburn, CA 95603
Rancho Cordova, CA 95670

Delta Dental Plan of CA San Francisco Health Authority


1115 International Drive, Bldg. C San Francisco Health Plan
Rancho Cordova, CA 95670 568 Howard Street, Fifth Floor
San Francisco, CA 94105
Health Net Dental, Inc.
125 Technology Drive, Suite 100 San Francisco City & County Public Health
Irvine, CA 92618 Family Mosaic Project
1309 Evans Avenue
Health Plan of San Joaquin San Francisco, CA 94124
1550 W. Fremont Street, Suite 200
Stockton, CA 95203-2643 San Mateo Health Commission
Health Plan of San Mateo
Inland Empire Health Plan 701 Gateway Blvd., Suite 400
303 E. Vanderbilt Way, Suite 400 South San Francisco, CA 94080
San Bernardino, CA 92408
Santa Barbara County Regional Health Authority
Kern Health Systems Santa Barbara Health Initiative
Kern Family Health care 110 Castilian Dr.
1600 Norris Road Goleta, CA 93117-3028
Bakersfield, CA 93308
Santa Clara Family Health Plan
Kaiser Foundation Health Plan, Inc. 4050 Moopark Avenue
393 E. Walnut, 5th Floor San Jose, CA 95117
Pasadena, CA 91188-8324
Santa Cruz County -Monterey
Kaiser Foundation Managed Care Commission
Health Plan, Inc. Santa Cruz County Health Options
Northern California Region 375 Encinal Street, Suite A
1800 Harrison Street, 9th Floor Santa Cruz, CA 95060
P.O. Box 12916
Oakland, CA 94612-2998

4-California National Pharmaceutical Council


Pharmaceutical Benefits 2002

Scan Health Plan Senior Care Prior Authorization Contact


Action Network
J. Kevin Gorospe, Pharm.D.
3780 Kilroy Airport Way, Suite 600
916/657-4213
Long Beach, CA 90806-2460
DUR Contact
Sharp Health Plan
Vic Walker, R.Ph. B.C.P.P
9325 Sky Part Ct., Suite 300
Senior Consulting Pharmacist
San Diego, CA 92123
Medi-Cal Policy Division
714 P Street, Room 1540
Solano County Medical Care Commission
Sacramento, CA 95814
Solano Partnership Health Plan
T: 916/657-0785
360 Campus Lane, Suite 100
F: 916/654-0513
Suisun City, CA 94585
E-mail: vwalker@dhs.ca.gov
Sonoma County Medi-Cal Medi-Cal Drug Utilization Review Board (DUR
Managed care Network Board)
1221 Farmers Lane, Suite 200
Santa Rosa, CA 95404-1705 Timothy E. Albertson, M.D., Ph.D.
University of California-Davis
Sutter Senior Care Pulmonary/Critical Care Medicine
1234 U Street 4301 X Street, Professional Bldg., Room 2120
Sacramento, CA 95818 Sacramento, CA 95817

UCSD Healthcare Craig Jones, M.D.


200 West Arbor Dr. Director, Division of Allergy/Immunology
San Diego, CA 92103-8501 Department of Pediatrics
LA County/USC Medical Center
Universal Care 24725 Avenida Asoleada
1600 E. Signal Hill Street Calabasas, CA 91302
Signal Hill, CA 90806-3682
Janeen G. McBride, R.Ph.
Watts Health Foundation, Inc. Rx America
United Health Plan 1500 South Anaheim Blvd.
3405 West Imperial Highway, Suite 628 Anaheim, CA 92815-0017
Inglewood, CA 90303
Gary M. McCart, Pharm.D.
Western Dental Services University of California, San Francisco
530 South Main Street, 6th Floor 400 Parnassus Ave., Box 312
Orange, CA 92863 San Francisco, CA 94143

Western Health Advantage Kenneth Schell, Pharm.D.


1331 Garden Highway Suite 100 Pharmacy Services
Sacramento, CA 95833-9754 Clinical Operations Manager
Kaiser Permanente
10990 San Diego Mission Road
F. STATE CONTACTS San Diego, CA 92108
State Drug Program Administrator
Stephen M. Stahl, M.D., Ph.D.
J. Kevin Gorospe, Pharm.D. Clinical Neuroscience Research Center
California Department of Health Services 8899 University Center Lane, Ste. 130
Chief, Medi-Cal Pharmaceutical Section San Diego, CA 92122
Medi-Cal Policy Division
714 P Street, Room 1540 Andrew L. Wong, M.D.
Sacramento, CA 95814 Chief of Rheumatology
T: 916/657-4213 University of California - Los Angeles
F: 916/654-0513 14445 Olive View - UCLA Medical Center
E-mail: kgorospe@dhs.ca.gov Sylmar, CA 91342
Internet Address: http://www.dhs.ca.gov

National Pharmaceutical Council California-5


Pharmaceutical Benefits 2002

Prescription Price Updating E-mail address: www.chhs.ca.gov


EDS Federal Corp.
Diana M. Bontá, R.N., Dr.P.H., Director
P. O. Box 13029
Medical Care Services
Sacramento, CA 95813-4029
Department of Health Services
916/636-1000
714 P Street, Room 1253
Medicaid Drug Rebate Contact Sacramento, CA 95814
T: 916/657-1425
Craig Miller
F: 916/657-5183
Chief, Medi-Cal Rebate and Vision Section
E-mail: dbonta@@dhs.ca.gov
Medi-Cal Policy Division
714 P Street, Room 1540
Stan Rosenstein
Sacramento, CA 95814
Deputy Director
T: 916/654-0532
Medical Care Services
F: 916/654-0513
Department of Health Services
E-mail: cmiller2@dhs.ca.gov
714 P Street, Room 1253
Claims Submission Contact Sacramento, CA 95814
T: 916/654-0391
EDS Federal Corp. F: 916/657-1156
P.O. Box 31029 E-mail: srosenst.dhs.ca.gov
Sacramento, CA 95813-4029
916/636-1000 Medi-Cal Contract Drug Advisory Committee
Internet Address: www.medi-cal.ca.gov
Michael B. Huff, M.D.
Medicaid Managed Care Contact 314 West Fourth St.
Oxnard, CA 93030
Ronald Sanui, Pharm D.
Pharmaceutical Consultant II William B. Ness, M.D.
Medi-Cal Managed Care Division 65 North 14th Street
714 P Street, Room 950 San Jose, CA 95112
Sacramento, CA 95814
916/653-1259 Gary M. McCart, Pharm.D.
E-mail: rsanui@dhs.ca.gov University of California
Disease Management Program/Initiative Contact School of Pharmacy
Division of Clinical Pharmacy
Vic Walker, R.Ph., B.C.P.P., 916/657-0785 Box 0622
San Francisco, CA 94143-0622
Mail Order Drug Benefit
State currently has no formal mail order pharmacy Bruce K. Uyeda, Pharm.D.
program for in-state mail order pharmacies. 1076 Mercy Street
Mountain View, CA 94041-1915
Physician-Administered Drug Program Contact
Fulton Lipscomb, M.D. Adrian M. Wong, Pharm.D.
Chief, Medical Policy Unit 17 Warren Drive
Medi-Cal Benefits Branch San Francisco, CA 94131
714 P Street, Room 1640 415/731-6239
Sacramento, CA 95814
T: 916/657-1460 Richard H. White, M.D.
F: 916/657-3457 U.C. California, Davis
Division of General Medicine
Health and Welfare Agency Officials Primary Care Center, Room 3107
Grantland Johnson 2221 Stockton Blvd.
Secretary Sacramento, CA 95817
California Health and Human Services Agency
1600 9th Street, Suite 460
Sacramento, CA 95814 Shirley Ann Floyd
T: 916/654-3454 Blue Cross of California
F: 916/654-3343 131 Chester Ave., Suite A
Bakersfield, CA 93301

6-California National Pharmaceutical Council


Pharmaceutical Benefits 2002

Executive Officers of State Medical and


Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
Executive Vice-President
221 Main Street, 3rd Floor
San Francisco, CA 94105
T: 415/541-0900
F: 415/882-3349
Internet Address: www.cmanet.org

Osteopathic Physicians & Surgeons of California


Gary A. Gramm. D.O.
Executive Director
1900 Point West Way, Suite 188
Sacramento, CA 95815-4703
T: 916/561-0724
F: 916/561-0728
E-mail: opsc@opsc.org

California Pharmacists’ Association


Carlo Michelotti, R.Ph., M.P.H.
Chief Executive Officer
1112 I Street, Suite 300
Sacramento, CA 95814-2865
T: 916/444-7811
F: 916/444-7929
E-mail: cpha@cpha.com
Internet Address: www.calpharm.com

State Board of Pharmacy


Patricia F. Harris
Executive Officer
400 R Street, Suite 4070
Sacramento, CA 95814
T: 916/445-5014
F: 916/327-6308
Internet Address: www.pharmacy.ca.gov

California Healthcare Association


C. Duane Dauner
President
1215 K Street, Suite 800
Sacramento, CA 95814
T: 916/443-7401
F: 916/552-7596
E-mail: info@calhealth.org
Internet Address: www.calhealth.org

National Pharmaceutical Council California-7


Pharmaceutical Benefits 2001

COLORADO

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    

B. EXPENDITURES FOR DRUGS


2000 2001
Expended Recipients Expended Recipients
TOTAL $152,478,786 160,264 $177,115,553 143,169

RECEIVING CASH ASSISTANCE, TOTAL $104,010,530 82,036 $117,978,722 76,243


Aged $34,359,318 19,659 $38,858,494 18,862
Blind/Disabled $63,174,183 29,983 $71,297,760 26,703
Child $2,037,288 17,445 $2,406,437 15,586
Adult $4,439,741 14,949 $5,416,031 15,092

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $16,837,337 45,302 $20,438,343 41,156


Aged $107,937 204 $101,358 129
Blind/Disabled $12,444,445 3,647 $15,354,288 3,802
Child $3,120,175 30,392 $3,695,461 27,041
Adults $1,164,780 11,059 $1,287,236 10,184

TOTAL OTHER EXPENDITURES/RECIPIENTS* $31,630,919 32,926 $38,698,488 25,770

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.

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

National Pharmaceutical Council Colorado-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Colorado Department of Health Care Policy and Formulary: Open formulary.
Financing administers the drug program. Eligibility is
determined by 63 County Departments of Social Services, Prior Authorization: State currently has a formal prior
and the Department. authorization procedure. There is an appeal process and
re-review when appealing coverage of an excluded
D. PROVISIONS RELATING TO DRUGS product and prior authorization decisions.
Benefit Design Prescribing or Dispensing Limitations

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.

Over-the-Counter Product Coverage: Products covered Drug Utilization Review


with restriction (i.e., must be deemed medically
necessary): allergy, asthma, and sinus products; PRODUR system implemented in December 1998. DUR
analgesics; cough and cold preparations; digestive Board meets semiannually.
products; feminine products; topical products; and
smoking deterrent products (prior authorization). Lock-In Review Procedures: The Department receives
computer processed printouts designed to discover over-
Therapeutic Category Coverage: Therapeutic categories utilization of drugs prescribed by physicians, dispensed by
covered: antibiotics; anticoagulants; anticonvulsants; vendors, and received by eligible recipients.
antidepressants; antidiabetic agents; antilipemic agents; Pharmacy Payment and Patient Cost Sharing
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents (given in home); ENT anti- Dispensing fee: $4.00 as of July 1, 2001. Institutional
inflammatory agents; estrogens; hypotensive agents; and pharmacies receive a dispensing fee equal to $1.89.
thyroid agents. Prior authorization required for: anabolic Dispensing physicians shall not receive a dispensing fee
steroids; analgesics, antipyretics, NSAIDs; antihistamine unless their offices or sites of practice are located more
drugs; anti-psychotics (prior authorization required for than 25 miles from the nearest participating pharmacy. In
clozoril); prescribed cough and cold medications; the latter case, physicians receive a fee equal to $1.89.
contraceptives; growth hormones; misc. GI drugs;
sympathominetics (adrenergic); vitamins; acne products; Ingredient Reimbursement Basis: EAC = AWP-13.5% or
leukocyte stimulants; LHRH/GnRH; injectables; plasma WAC (wholesaler acquisition cost) + 18%. AWP-35%
products; Epoetin; fluoride preparations; antisera; for generics. Other: FUL, State Mac, usual and
oxycontin; erectile dysfunction and prescribed smoking customary.
deterrents. Products not covered: anoretics.
Prescription Charge Formula: Benefit drugs shall be
Coverage of Injectables: Injectable medicines reimbursed at the lesser of the Medicaid allowable
reimbursable through the Prescription Drug Program reimbursement charge, or the provider’s usual and
when used in home health care and extended care customary charge or whatever is accepted from any third
facilities, and through physician payment when used in party, discounts, rebates, etc.
physician offices. Prior authorization is required for self-
administration at home. The Medicaid allowable reimbursement charge is the sum
of the ingredient cost of the drug dispensed and the
Vaccines: Vaccines reimbursable as part of the EPSDT provider’s dispensing fee.
Program.
Ingredient cost for retail pharmacies (estimated
Unit Dose: Unit dose packaging not reimbursable. acquisition cost) is the price of the drug actually dispensed

2-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

Basis for inclusion in the high volume estimated


acquisition cost list includes but is not limited to:

National Pharmaceutical Council Colorado-3


Pharmaceutical Benefits 2002

Exceptions to the above are: Community Health Plan of the Rockies


- Shelf package size oral liquid medications, in pint size 400 South Colorado Boulevard Suite 300
only, or smaller package size when not packaged in pint Denver, Colorado 80222
size. 303/355-3220

- 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

4-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Managed Care Contact


Office of Medical Assistance
Lynn Barnard
Colorado Department of Health Care Policy & Financing
Director of Health Care Programs
1575 Sherman Street
Department of Health Care Policy and Financing
Denver, Colorado 80203
1575 Sherman Street, 4th Floor
Denver, CO 80203 Medical Advisory Council
T: 303/866-2445
Donald W. Schiff, M.D.
F: 303/866-2803
600 Front Range Road
Disease Management/Patient Education Littleton, CO 80120
Programs 303/837-2745
Disease/Medical State: Schizophrenia
Molly A. Markert
Program Name: Clients with schizophrenia and
11060 E. Wesley Pl.
comorbidities
Aurora, CO 80014
Program Manager: Specialty Disease Management
303/756-7234
Sponsor: Eli Lilly and Company
Mary Jo Jacobs, M.D.
Disease/Medical State: Asthma
7425 E. Kenyon Ave.
Program Name: Clients with asthma
Denver, CO 80237
Program Manager: National Jewish Hospital
303/694-2878
Sponsor: Novartis and Astra Zeneca
Walter Daniels, D.D.S.
Disease/Medical State: Diabetes
1633 Filmore Street
Program Name: Clients with diabetes
Denver, CO 80206
Program Manager: McKesson
303/388-0989
Sponsor: Eli Lilly and Company
Rodney Fair, O.D.
Disease/Medical State: Neonatal Intensive Care
105 Bridge Street
Program Name: High Risk Infants
Brighton, CO 80601
Program Manager: Clinician Support Technology
303/659-3036
Sponsor: Johnson & Johnson
Douglas Clinkscales
Disease/Medical State: Breast and Cervical Cancer
Denver Health and Hospitals
Program Name: Breast and Cervical Cancer Longitudinal
777 Bannock Street
Study
Denver, CO 80204
Sponsor: Astra Zeneca
303/426-7253
Disease/Medical State: Case Management
Cathy Corcoran
Sponsor: Pfizer, Abbott, and Astra Zeneca
15920 W. 66th Place
Golden, CO 80403
Disease/Medical State: Telemedicine
303/861-6256
Sponsor: GlaxoSmithKline
Disease Management/Patient Education Contact Ernestine Kotthoff-Burrell
6098 S. Iola Ct.
Lynn Barnard, 303/866-2445 Englewood, CO 80111
303/270-8974
Mail Order Pharmacy Program
None
Physician-Administered Drug Program Contact
Patti Campbell, 303/866-5459
Health Care Policy & Financing Department
Officials
Richard Allen, Executive Director
Vivianne Chavmont, Director Health Plan & Medical
Services

National Pharmaceutical Council Colorado-5


Pharmaceutical Benefits 2002

Carol Bartley Val Kalnins, R.Ph., Executive Director


Denver VNA 6825 E. Tennessee Avenue
3801 E. Florida Ave., Suite 800 Denver, CO 80224-1662
Denver, CO 80201 T: 303/756-3069
303/753-7312 F: 303/756-3649
E-mail: val@copharm.org
Mary Ellen Kuhlman, MSW Internet address: www.copharm.org
St. Mary’s Hospital & Medical Center
P.O. Box 1628 Colorado Society of Osteopathic Medicine
Grand Junction, CO 81502 Kathleen Brennan
970/244-2273 Executive Director
650 South Cherry Street, Suite 440
Dan Stenerson Denver, CO 80246
Shalom Park T: 303/322-1752
14800 E. Belleview F: 303/332-1956
Aurora, CO 80015 E-mail: coloradodo@aol.com
303/680-5000 Internet address: www.coloradodo.org

Mark Kunart, D.O. Colorado State Board of Pharmacy


17200 E. Iliff Avenue Susan L. Warren
Aurora, CO 80013 Program Administration
303/755-4111 1560 Broadway, Suite 1310
Denver, CO 80202-5146
Robert Slay T: 303/894-7750
Jefferson Co. CCB F: 303/894-7750
7456 W. 5th Avenue E-mail: pharmacy@dora.state.co.us/pharmacy
Lakewood, CO 80226 Internet address: www.coloradodo.org
303/233-3363 x366
Colorado Health and Hospital Association
Department Contact Larry H. Wall
Richard Allen, Director President
Health Plans and Medical Services 7335 East Orchard Road, Suite 100
303/866-6092 Greenwood Village, CO 80111-2512
T: 720/489-4630
Legislative Liaison F: 720/489-9400
Dean Woodward Internet address: www.cha.com
Department of Health Care Policy and Financing
303/866-2708
Executive Officers of State Medical and
Pharmaceutical Societies
Colorado Medical Society
Sandra L. Maloney
Executive Director
7351 Lowry Boulevard.
Denver, CO 80230
T: 720/859-10013
F: 303/771-8659
E-mail: sandi_maloney@cms.org
Internet address: www.cms.org

Colorado Pharmacists Society

6-Colorado National Pharmaceutical Council


Pharmaceutical Benefits 2002

CONNECTICUT

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $264,641,409 113,089 $304,470,534 116,755

RECEIVING CASH ASSISTANCE, TOTAL $77,985,386 29,535 $85,509,574 29,004


Aged $13,736,629 6,606 $14,661,696 6,146
Blind/Disabled $63,581,603 17,784 $70,113,706 17,814
Child $158,664 2,592 $176,052 2,598
Adult $508,490 2,553 $558,120 2,446

MEDICALLY NEEDY, TOTAL $79,159,403 29,860 $89,643,018 29,417


Aged $19,167,645 10,198 $21,970,885 10,353
Blind/Disabled $59,237,780 18,385 $67,436,637 18,548
Child $123,249 399 $91,458 283
Adult $630,729 878 $144,038 233

POVERTY RELATED, TOTAL $2,122,228 5,968 $3,750,393 5,721


Aged $221,813 250 $644,493 700
Blind/Disabled $818,286 475 $2,152,958 1,089
Child $1,005,370 3,966 $877,998 2,974
Adult $76,759 1,277 $74,944 958

TOTAL OTHER EXPENDITURES/RECIPIENTS* $105,374,392 47,726 $125,567,549 52,613

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

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

National Pharmaceutical Council Connecticut-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization

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.

2-Connecticut National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE Commissioner


Department of Social Services
Connecticut has approximately 290,000 Medicaid recipients 25 Sigourney St.
enrolled in managed care. Pharmaceutical benefits received Hartford, CT 06016-5033
through the managed care plan. T: 860/424-5008
F: 860/566-2022
Managed Care Organizations E-mail: pat.wilson-coker@po.state.ct.us
Anthem Blue Cross/Blue Shield of CT
Blue Care Family Plan Rita Pacheco, Deputy Commissioner
Deborah Hine, Director 860/424-5055
Medicaid Managed Care
370 Bassett Road Michael Starkowski, Deputy Commissioner
North Haven, CT 06473-4201 860/424-5053
203/985-6130
David Parrella, Director
Community Health Network of CT Medical Care Administration
Sylvia Kelly, CEO 860/424-5177
290 Pratt - 2nd Floor
Meriden, CT 06450 Rose Ciarcia Director
203/237-4000 Managed Care
860-424-5139
Health Net Healthy Options
Janice Perkins, Vice President Michelle Parsons, Manager
Government Relations and Programs Alternate Care Unit
One Far Mill Crossing, Box 904 860/424-5177
Shelton, CT 06484-0944
203/225-8630 Marcia Mains, Director
Medical Operations
First Choice of CT 860/424-5219
Preferred One
Tejas Patel, Director Evelyn Dudley
23 Maiden Lane Pharmacy Program Manager
North Haven, CT 06473 860/424-5654
203/239-7444 Ext. 664 DUR Contact

F. STATE CONTACTS James Zakszewski, R.Ph.


Pharmacy Consultant
Medicaid Drug Program Administrator Department of Social Services
Evelyn A. Dudley 25 Sigourney Street
Pharmacy Program Manager Hartford, CT 06106
Department of Social Services, Medical Operations T: 860/424-5150
25 Sigourney Street F: 860/424-5206
Hartford, CT 06106 E-mail: james.zakszewski@po.state.ct.us
T: 860/424-5654 Connecticut DUR Board
F: 860/424-5206
E-mail: evelyn.dudley@po.state.ct.us Kenneth Fisher, R.Ph.
Internet address: www.ctmedicalassistanceprogram.com Brooks Pharmacy

Arturo Morales, M.D.


St. Francis Hospital

Lori Jane Duntz Lord, R.Ph.


Greenville Drug
Dennis J. Chapron, R.Ph.
Department of Social Services Administrative Pharmokinetics Lab
Officials
Keith Lyke, R.Ph.
Patricia A. Wilson-Coker Pelton’s Pharmacy

National Pharmaceutical Council Connecticut-3


Pharmaceutical Benefits 2002

Physician-Administered Drug Program Contact


Frederick N. Rowland, M.D.
Zanita McKinney, Medical Policy
St. Francis Hospital and Medical Center
25 Sigourney Street
Hartford, CT 06106
Richard Gannon, Pharm.D.
860/424-535
Hartford Hospital
State Pharmacy Commission
Kathryn Mashey, DPM
William Summa, P.D., Chairman
Community Health Services
Executive Officers of State Medical and
Michael Moore, R.Ph. Pharmaceutical Societies
Hebrew Home Hospital
State Medical Society
Prescription Price Updating Timothy B. Norbeck, Executive Director
160 St. Ronan Street
Ellen Arce, R.Ph.
New Haven, CT 06511-2390
Pharmacy Manager
T: 203/865-0587
Electronic Data Systems
F: 203/865-4997
100 Stanley Street
E-mail: tnorbeck@csms.org
New Britain, CT 06053
Internet address: www.csms.org
860/832-5858
Medicaid Drug Rebate Contacts Connecticut Pharmacists Association
Margherita R. Guiliano, R.Ph. Executive V.P.
Mark Heushkel (Audits)
35 Cold Spring Road, Suite 124
Lead Planning Analyst - Pharmacy
Rocky Hill, CT 06067-3161
Department of Social Services
T: 860/563-4619
Medical Operations
F: 860/257-8241
25 Sigourney Street
E-mail: mguiliano@ctpharmacists.org
Hartford, CT 06106
Internet address: www.ctpharmacists.org
T: 860/424-5347
F: 860/424-5206
Connecticut Osteopathic Medical Society
E-mail: mark.heushkel@po.state.ct.us
Donald Halpin, Executive Director
P.O. Box 487
Ellen Arce, R.Ph. (Rebate & Disputes)
Winchester, MA 01800-0487
860/832-5858
T: 781/721-9900
Claims Submission Contact F: 781/721-4400
E-mail: don@northeastosteo.org
Kevin Walsh
Internet address: www.northeastosteo.org
Electronic Data Systems
100 Stanley Street
Pharmacy Commission & Drug Control Division
New Britain, CT 06053
Michelle Sylvestre, R.Ph.
860/832-5858
Board Administrator
Medicaid Managed Care Contact State Office Building
165 Capitol Avenue, Room 147
Rose Ciarcia
Hartford, CT 06106
Department of Social Services
T: 860/713-6070
25 Sigourney St.
F: 860/713-7242
Hartford, CT 06106
E-mail: michelle.sylvestre@po.state.ct.us
T: 860/424-5139
Internet address: www.ctdrugcontrol.com/rxcommission.htm
E-mail: rose.ciarcia@po.state.ct.us
Mail Order Pharmacy Program Connecticut Hospital Association, Inc.
Jennifer Jackson
None
President and CEO
110 Barnes Road
Elderly Drug Coverage Program Contact P.O. Box 90
Evelyn Dudley Wallingford, CT 06492-0090
860/424-5654 T: 203/265-7611
F: 203/284-9318

4-Connecticut National Pharmaceutical Council


Pharmaceutical Benefits 2002

Internet address: www.chime.org

National Pharmaceutical Council Connecticut-5


Pharmaceutical Benefits 2002

6-Connecticut National Pharmaceutical Council


Pharmaceutical Benefits 2002

1
DELAWARE

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $66,263,771 78,167 $81,623,058 85,351

RECEIVING CASH ASSISTANCE, TOTAL $40,920,160 53,640 $52,023,939 62,035


Aged $4,873,491 2,464 $5,833,794 2,470
Blind/Disabled $22,570,175 9,405 $27,480,662 9,724
Child $4,927,265 26,644 $7,259,311 31,503
Adult $8,549,229 15,127 $11,450,172 18,338

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $1,369,908 4,901 $1,423,154 3,654


Aged $180,455 147 $145,083 132
Blind/Disabled $399,640 286 $533,696 282
Child $715,522 4,084 $718,597 3,103
Adults $74,291 384 $25,778 137

TOTAL OTHER EXPENDITURES/RECIPIENTS* $23,973,703 19,626 $28,175,965 19,662


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

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

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

National Pharmaceutical Council Delaware-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescribing or Dispensing Limitations


Prescription Refills: Prescription blank has space for
Division of Social Services, Department of Health and physician to authorize renewals.
Social Services, through three county offices of the State
agency. Monthly Quantity Limit: Greater of 34-day supply or 100
dosing units.
D. PROVISIONS RELATING TO DRUGS
Benefit Design Monthly Dollar Limits: None.
Drug Utilization Review
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe PRODUR system implemented in August 1994.
combinations used for insulin; blood glucose test strips; Pharmacy Payment and Patient Cost Sharing
urine ketone test strips; and total parenteral nutrition.
Products not covered: cosmetics; fertility drugs; Dispensing Fee: $3.65.
experimental drugs; and interdialytic parenteral nutrition.
Ingredient Reimbursement Basis: EAC = AWP-12.9%.
Over-the-Counter Product Coverage: Products covered:
allergy, asthma and sinus products; analgesics; cough and Prescription Charge Formula: Payment is based on
cold preparations; digestive products (non-H2 antagonist); AWP-12.9% or maximum allowable cost (MAC) plus a
digestive products (H2 antagonists); and smoking dispensing fee, or the usual and customary cost to the
deterrent products. Products covered with restriction: general public, whichever is lower.
feminine products (antifungals) and topical products (anti-
infectants). Maximum Allowable Cost: State imposes Federal Upper
Limits as well as state-specific limits on generic drugs.
Therapeutic Category Coverage: Therapeutic categories Override requires completion of an FDA Med-Watch
covered: anabolic steroids; analgesics, antipyretics, form.
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; Incentive Fee: None.
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; Patient Cost Sharing: None.
prescribed cold medications; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive agents; misc. Cognitive Services: Does not pay for cognitive services.
GI drugs; prescribed smoking deterrents;
sympathominetics (adrenergic); and thyroid agents. Prior E. USE OF MANAGED CARE
authorization required for: growth hormones; regranex
zyvox; and soma accutane cipro. Products not covered: Approximately 83,500 Medicaid recipients were enrolled
anoretics. in MCOs in FY 2001. Recipients receive pharmaceutical
benefits through the State.
Coverage of Injectables: Injectable medicines
Managed Care Organizations
reimbursable through the Prescription Drug Program and
physician payment when used in physician offices. DelawareCare
Reimbursable only through the Prescription Drug Program 2751 Centerville Road, Suite 400
when used in home health care and extended care Wilmington, DE 19808
facilities. 215/937-8285

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.

Prior Authorization: State currently has a formal prior


authorization procedure.

2-Delaware National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Dover, DE 19901


Carl Mulveny
State Drug Program Administrator 1941 Limestone Rd.
Philip Soulé Wilmington, DE 19808
Deputy Director/Medicaid
Dept. of Health and Social Services John Barron
1901 N. Dupont Highway 4735 Ogletown-Stanton Road
New Castle, DE 19720 Suite 3201
T: 302/255-9501 Newark, DE 19713
F: 302/255-4425 Prescription Price Updating
Internet address:
http://www.state.de.us/govern/agencies/dhss Cynthia Denemark, 302/453-8453
Prior Authorization Contact Medicaid Drug Rebate Contacts
Cynthia Denemark, R.Ph. Lynnessa Reynoso, Rebate Analyst
Pharmacist Consultant EDS
EDS 248 Chapman Road, Suite 100
248 Chapman Road, Suite 100 Newark, DE 19702
Newark, DE 19702-9720 T: 302/453-8453
T: 302/453-8453 F: 302/454-7603
F: 302/454-7603 Claims Submission Contact
E-mail: cynthia.denemark@eds.com
Robert Curnutt
DUR Contact System Manager
Cynthia Denemark, 302/453-8453 EDS
248 Chapman Rd
DUR Board Newark, DE 19702
Calvin Freedman, R.Ph. T: 302/453-8453
302 Lark Drive F: 302/454-7603
Newark, DE 19713-1216
Medicaid Managed Care Contact
Marvin H. Dorph, M.D.
614 Loveville Road Glyne Williams
Unit E4H Coffee Run Condo Division of Social Services
Hockessin, DE 19707 P.O. Box 906
New Castle, DE 19720
Daniel M. Hauser, Pharm.D. T: 302/577-4900
325 W. Broadstair F: 302/577-4405
Dover, DE 19904
Micheal Glacken
Physician-Administered Drug Program Contact
500 West 10th Street
Wilmington, DE 19801 Cynthia Denemark, 302/453-8453
Mail Order Pharmacy Benefit
Richard Steele
2617 Epping Rd. None
Wilmington, DE 19810

Teresa Corbo
114 Vincent Circle
Middletown, DE 19709

Sharon Wisneski, R.N., M.S.


336 Pine Valley Road

National Pharmaceutical Council Delaware-3


Pharmaceutical Benefits 2002

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

4-Delaware National Pharmaceutical Council


Pharmaceutical Benefits 2002

Ulder Jane Tillman, M.D. Osteopathic Medical Society


Director, DPH Edward Sobel, D.O.
Jesse Cooper Building Executive Director
417 Federal and Water Streets P.O. Box 8177
Dover, DE 19901 Talleyville, DE 19803-8177
T: 302/764-1198
Yrene E. Waldron F: 302/764-1322
Executive Director E-mail: info@deosteopathic.org
DE Health Care Facilities Association Internet address: www.deosteopathic.org
Two Mill Rd., Suite 200
Wilmington, DE 19806 State Board of Pharmacy
David W. Dryden, R.Ph., J.D.
Anne M. Allen Executive Secretary
Medical Society of Delaware P.O. Box 637
1925 Lovering Avenue Dover, DE 19901
Wilmington, DE 19806 302/739-4798
E-mail: gbunting@state.de.us
Theodore Gregory Internet address: www.professionallicensing.state.de.us
Mental Health Consumer Coalition
100 W. 10th Street Delaware Healthcare Association
Community Services Building, Suite 303 Joseph M. Letnaunchyn
Wilmington, DE 19801 President & CEO
1280 South Governors Avenue
Ellen M. Steele Dover, DE 19904-4802
2863 Kenton Road T: 302/674-2853
Dover, DE 19904 F: 302/734-2731
E-mail: joelet@deha.org
Kim L. Carpenter, M.D. Internet address: www.deha.org
MSB Bldg, Level II
7th & Clayton Streets
Wilmington, DE 19805

Executive Officers of State Medical and


Pharmaceutical Societies
Medical Society of Delaware
Mark Meister, Sr.
Executive Director
131 Continental Drive, Suite 405
Wilmington, DE 19713
T: 302/658-7596
F: 302/658-9669
E-mail: mama@medsocdel.org
Internet address: www.medsocdel.org

Delaware Pharmacists Society


Pat Carroll-Grant, R.Ph.
Executive Director
P.O. Box 454
Smyrna, DE 19977-0454
T: 302/659-3088
F: 302/659-3089
Internet address: www.depharmacy.org/index.htm

National Pharmaceutical Council Delaware-5


Pharmaceutical Benefits 2002

6-Delaware National Pharmaceutical Council


Pharmaceutical Benefits 2002

DISTRICT OF COLUMBIA 1

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $55,092,178 38,129 $62,292,004 35,324

CATEGORICALLY NEEDY CASH TOTAL $38,607,849 24,754 $42,750,082 22,033


Aged $3,403,484 2,385 $3,745,744 2,262
Blind/Disabled $33,339,739 14,921 $37,256,814 14,440
Child $440,863 3,146 $358,540 2,063
Adult $1,423,763 4,302 $1,388,984 3,268

CATEGORICALLY NEEDY NON-CASH TOTAL $6,862,242 5,037 $7,930,965 4,980


Aged $1,476,093 835 $1,637,536 819
Blind/Disabled $4,724,198 2,015 $5,639,520 2,399
Child $116,837 1,114 $128,355 853
Adult $545,114 1,073 $525,554 909

MEDICALLY NEEDY TOTAL $6,667,998 5,177 $8,495,578 5,135


Aged $2,199,308 1,344 $2,772,481 1,513
Blind/Disabled $4,237,256 1,626 $5,511,608 1,858
Child $199,741 2,015 $195,736 1,575
Adult $31,693 192 $15,753 189

TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,954,089 3,161 $3,115,379 3,176

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

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


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

National Pharmaceutical Council District of Columbia-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Ingredient Reimbursement Basis: AWP-10%.

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.

Over-the-counter Product Coverage: Products covered: E. USE OF MANAGED CARE


oral analgesics; oral antacids; contraceptive foams and
jellies; prenatal vitamin formulations; geriatric vitamin Recipients enrolled in managed care receive
formulations for recipients 65 and over; and multivitamin pharmaceutical benefits through managed care plans.
formulations for children 7 years of age and over.
Managed Care Organizations
Coverage of Injectables: Injectable medicines
Advantage Health Plan, Inc.
reimbursable when used in physicians offices, home
P.O. Box 9596
health care, and extended care facilities.
Washington, DC 20016
202/686-8555
Vaccines: Vaccines reimbursable at cost as part of the
EPSDT service. American Preferred Provider Plan Mid-Atlantic, Inc.
1501 M Street, NW, Suite 500
Unit Dose: Unit dose packaging not reimbursable Washington, DC 20002
Formulary/Prior Authorization 202/408-0460

Formulary: Open formulary D.C. Chartered Health Plan


820 First Street, NE, Suite LL100
Prescribing or Dispensing Limitations Washington, DC 20002
202/408-4710
Monthly Quantity Limit: In general, amounts dispensed
are to be limited to quantities sufficient to treat an episode Capitol Community Health Plan
of illness. Maintenance drugs such as thyroid, digitalis, 750 First Street, NE, Suite 1120
etc. may be dispensed in amounts up to a 30-day supply Washington, DC 20002
with 3 refills that must be dispensed within 4 months. 202/408-0460
Antibiotic medications used in treatment of acute
infections are not to be dispensed in excess of a 10-day
supply. Birth control tablets may be dispensed in 3-cycle
units with a maximum of 3 refills within one year.
Monthly Dollar Limits: $1,500 limit. Physicians are to
request prior authorization for prescriptions that exceed
this amount.
Drug Utilization Review

PRODUR system implemented in September 1996.


Pharmacy Payment and Patient Cost Sharing

Dispensing Fee: $3.75.

2-District of Columbia National Pharmaceutical Council


Pharmaceutical Benefits 2002

George Washington University Health Plan Medicaid Drug Rebate Contacts


4550 Montgomery Avenue
Technical: Ken Boni, 202/965-7400
Bethesda, MD 20814
301/941-2044
Policy: Donna Bovell, R.Ph., 202/442-5988
Health Right, Inc.
DUR: Donna Bovell, R.Ph., 202/442-5988
3020 14th Street, NW
Washington, DC 20009 Physician-Administered Drug Program Contact
202/518-2370
Donna Bovell, R.Ph., 202/442-5988
Prudential Health Care Plan Department of Human Services Officials
2800 N. Charles Street
Baltimore, MD 21218 James A. Buford
410/554-7224 Director
Department of Health
825 North Capitol Street, NE
F. STATE CONTACTS Fourth Floor
State Drug Program Administrator Washington, DC 20002
T: 202/442-5999
Donna Bovell, R.Ph. F: 202/442-4788
Pharmacist Consultant E-mail: james.buford@dc.gov
Medical Assistance Administration
Department of Health Wanda Tucker
825 North Capitol Street, NE Interim Director
Fifth Floor Medical Assistance Administration
Washington, DC 20002 Department of Health
T: 202/442-5988 825 North Capitol Street, NE
F: 202/442-4790 Fifth Floor
E-mail: donna.bovell@dcgov.org Washington, DC 20002
District of Columbia DUR Board T: 202/442-5988
F: 202/442-4790
Christopher Keeyes, Pharm.D. (Chair) E-mail: wanda.tucker@dc.gov
President, Clinical Pharmacy Associates Internet address: www.dchealth.dc.gov
11710 Beltsville Drive, Suite 510
Calverton, MD 20705 Executive Officers of District Medical and
301/572-1616 Pharmaceutical Societies
Medical Society of the District of Columbia
Martin Dillard, M.D. (Vice Chair) K. Edward Shanbacker
Assistant Dean for Clinical Affairs 2215 M St., NW, Suite 200
Chief, Division of Nephrology Washington, DC 20037-2059
Howard University Hospital T: 202/466-1800
2041 Georgia Avenue, NW, Suite 5C02 F: 202/452-1542
Washington, DC 20060 E-mail: shanbacker@msdc.org
202/865-1191 Internet address: www.msdc.org
Howard Robinson, R.Ph. Washington D.C. Pharmacy Association
Manager, Central Pharmacy Herbert Kwash, R.Ph., President
Greater Community Hospital 6406 Georgia Ave, NW
1310 Southern Avenue, SE Washington, DC 20012-2960
Washington, DC 20032 T: 202/829-1515
F: 202/829-1515
Dr. Kim Bullock
Providence Hospital
Emergency Room
1150 Varuum St., NE
Washington, DC 20017
202/269-7863
Osteopathic Association of the District of Columbia

National Pharmaceutical Council District of Columbia-3


Pharmaceutical Benefits 2002

Roy Heaton, D.O., President


2517 North Glebe Road
Arlington, VA 22207
T: 703/522-8404
F: 703/522-2692

DC Board of Pharmacy
Graphelia Ramseur
Health Licensing Specialist
825 North Capitol Street, NE, Room 224
Washington, DC 20002
T: 202/442-4776
F: 202/442-9431
E-mail: gramseur@dchealth .com
Internet address: www.dchealth.dc.gov

District of Columbia Hospital Association


Robert Malson, President
1250 Eye Street, NW, Suite 700
Washington, DC 20005-3980
T: 202/682-1581
F: 202/371-8151
E-mail: rmalson@dcha.org
Internet address: www.dcha.org

4-District of Columbia National Pharmaceutical Council


Pharmaceutical Benefits 2002

FLORIDA

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  

B. EXPENDITURES FOR DRUGS


2001 2002
Expenditures Recipients Expenditures Recipients

TOTAL $1,474,041,051 1,109,511 $1,714,883,612 1,179,944

RECEIVING CASH ASSISTANCE TOTAL $902,864,131 501,647 $1,026,862,696 576,092


Aged $151,665,321 77,328 $170,850,446 79,748
Blind/Disabled $655,894,629 226,562 $750,274,442 235,685
Child $40,614,696 168,664 $46,013,540 170,004
Adult $54,689,485 89,093 $59,724,268 90,655

MEDICALLY NEEDY, TOTAL $83,614,245 28,388 $118,805,473 33,216


Aged $52,764 16 $31,545 21
Blind/Disabled $69,638,383 13,733 $120,427,359 16,970
Child $2,869,193 3,007 $2,360,440 2,997
Adult $11,053,905 11,632 $15,986,129 13,228

POVERTY RELATED, TOTAL $288,039,981 359,849 $336,992,042 397,152


Aged $100,027,087 50,977 $100,463,428 56,777
Blind/Disabled $132,695,788 42,558 $145,453,276 41,099
Child $46,875,856 203,778 $60,847,477 230,119
Adult $8,441,250 62,536 $10,227,861 69,157

TOTAL OTHER EXPENDITURE/RECIPIENTS $199,522,694 159,627 $232,223,401 173,484

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

National Pharmaceutical Council Florida-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization

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

2-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council Florida-3


Pharmaceutical Benefits 2002

Personal Health Plan Agency for Health Care Administration Officials


Contact: Debi L. Gavras
Rhonda Meadows, M.D.
Dr. Jeff Davis, D.O. (Interim)
Secretary
324 Datura Street, Suite 401
Agency for Health Care Administration
West Palm Beach, FL 33401
2727 MahanDrive, MS 1
561/659-1270 ext. 5885
Tallahassee, FL 32308
T: 850/922-3809
Physicians Healthcare Plans, Inc.
F: 850/488-0043
Contact: Peter Jimenez
E-mail: AHCAcontact@fdhc.state.fl.us
2333 Ponce de Leon Blvd. Ste 303
Coral Gables, FL 33134
Bob Sharpe
305/441-9400 ext. 125
Deputy Secretary
Agency for Health Care Administration
Preferred Medical Plan, Inc.
2727 Mahan Drive, MS 8
Contact: Tamara Meyerson
Tallahassee, FL 32308
4950 SW 8th Street
T: 850/488-3560
Coral Gables, FL 33134
F: 850/488-2520
305/445-8373
E-mail: AHCAcontact@fdhc.state.fl.us
St. Augustine Health Care, Inc. Prior Authorization Contact
Contact: Mary Lynn Leach
Jerry F. Wells
Mail: P.O. Box 23160
Pharmacy Program Manager
Location: 4300 NW 89th Blvd.
Agency for Health Care Administration
Gainesville, FL 32606
2727 Mahan Drive, MS 38
352/337-8650
Tallahassee, FL 32308
T: 850/487-4441
Stay Well Health Plan
F: 850/922-0685
Contact: Nancy Gareau
E-mail: wellsj@fdhc.state.fl.us
6800 N. Dale Mabry Hwy., Ste. 209-211
Tampa, FL 33614 DUR Contact
813/290-6283
Jerry F. Wells
United Healthcare of Florida, Inc. Pharmacy Program Manager
Contact: Linna Van Nette 850/487-4441
800 North Magnolia Ave., Suite 600 Medicaid DUR Board
Orlando, FL 32803
407/872-1000 Bryan Bognar, M.D.
17515 Mallard Court
United ElderCare Plan Lutz, FL 33549
800 North Magnolia Ave., Suite 600
Orlando, FL 32803 Leanne Lai, Ph.D.
800/643-5337 3200 South University Drive
Ft. Lauderdale, FL 33328

F. STATE CONTACTS David Levine, DPM, D.O.


111 West Broward Blvd
State Drug Program Administrator
Ft. Lauderdale, FL 33312
George Kitchens
Chief, Pharmacy Bureau Earlene Lipowski, Ph.D.
Agency for Health Care Administration JHMHC
2727 Mahan Drive, MS 38 Box 100496
Tallahassee, FL 32308 Gainesville, FL 32610
T: 850/487-4441
F: 850/922-0685 Larry Mattingly, D.O.
E-mail: kitcheng@fdhc.state.fl.us 2233 Park Ave, Suite 303
Internet address: www.fdhc.state.fl.us Orange Park, FL 32073

Jeane McCarthy, M.D., Ph.D.

4-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2002

880-6th Street South Medicaid Drug Rebate Contacts


St. Petersburg, FL 33701
Jason Ottinger
Agency for Health Care Administration
Richard Roberts, Pharm.D.
2727 Mahan Drive
5219 Magnolia Oaks Lane
Tallahassee, FL 32308
Jacksonville, FL 32210
T: 850/922-7794
Prescribing Pattern Review Panel F: 850/922-0685
E-mail: ottingej@fdhc.state.fl.us
Cynthia Griffin, Pharm.D.
C/o Humana Claims Submission Contact
76 S. Laura Street
Kevin Whittington
Jacksonville, FL 32209
Clinical Program Coordinator
ACS
Mary Stelnicki, R.Ph.
2308 Killearn Center Blvd.
5320 N.E. 31st Avenue
Tallahassee, FL 32308
Ft. Lauderdale, FL 33308
850/201-1418
Stephen Clark, M.D. Medicaid Managed Care Contact
3901 University Blvd.
Elizabeth Dudek
S. Suite 215
Agency for Health Care Administration
Jacksonville, FL 32216
2727 Mahan Drive, BLD 1, Rm 323
Tallahassee, FL 32308
James D. Ruskiv, D.M.D., M.D., FACC
T: 850/922-6830
P.O. Box 100416
F: 850/414-5418
Gainesville, FL 32610
Mail Order Pharmacy Program
Walter Flesner, D.O.
20537 N.E. Sixth Court State has a mail order pharmacy benefit under its diabetes
Miami, FL 33179 demonstration waiver.

Daryl D. Wier, M.D. Disease Management Program/Initiative Contact


1181 Orange Avenue
Winter Park, FL 32789 Hemophilia:
Michael L. Ansel
George Thomas, M.D. Accordant Health Services
316 Manatee Ave. West 5509-A West Friendly Avenue, Ste 101
Bradenton, FL 34205 Greensboro, NC 27410
T: 336/855-5870 ext.134
Bob Windom, M.D. F: 336/852-7413
5450 Eagle Point Circle E-mail: mansel@accordant.com
Sarasota, FL 34231
Prescription Price Updating George E. Hurrell, Jr.
Director, Disease Management
First DataBank Caremark Inc.
1111 Bayhill Drive, Suite 350 1127 Bryn Mawr Avenue
San Bruno, CA 94066 Redlands, CA 92374
T: 650/588-5454 T: 909/799-4160
F: 650/827-4578 F: 909/7998-4335
E-mail: george.hurrell@mdmnetwork.com

National Pharmaceutical Council Florida-5


Pharmaceutical Benefits 2002

AIDS: Florida Pharmacy Association


Michael Jackson, R.Ph.
Peter D. Reis
Executive Direct
Director of Business Development
610 North Adams Street
AIDS Healthcare Foundation
Tallahassee, FL 32301-1114
6255 West Sunset Blvd, 16th Fl.
T: 850/222-2400
Los Angeles, CA 90028
F: 850/561-6758
T: 213/860-5200
E-mail : fpa@pharmview.com
F: 213/860-5235
Internet address: www.pharmview.com
E-mail: pdreisjr@aol.com
Florida Osteopathic Medical Association
S. Shai Gold,
Joel B. Rose, D.O.
Director, Business and Proposal Development Center
President
The South Florida Community Care Network
The Hull Building
1801 NW 9th Avenue, Ste 700
2007 Apalachee Parkway
Miami, FL 33136
Tallahassee, FL 32301
T: 305/585-5187
T: 850/878-7364
F: 305/585-3815
F: 850/942-7538
E-mail: umimbdc@compusource.net
E-mail: admin@foma.org
Internet address: www.foma.org
Plans exist for disease management programs for End-
Stage Renal Disease (ESRD) and congestive heart failure.
State Board of Pharmacy
Contact: David Rogers
Vacant
Program Administrator
Executive Director
Agency for Health Care Administration
4052 Bald Cypress Way
2727 Mahan Drive
Tallahassee, FL 32399-3254
Tallahassee, FL 32308
T: 850/245-4292
T: 850/487-4642
F: 850/413-6982
F: 850/410-1676
E-mail: mqa_pharmacy@doh.state.fl.us
Physician-Administered Drug Program Internet address: www.doh.state.fl.us/mga
Laura Rutledge
Florida Hospital Association
850/488-4481
Wayne N. Smith
Executive Officers of State Medical and President
Pharmaceutical Societies 306 East College Avenue
Tallahassee, FL 32301-1522
Florida Medical Association, Inc. T: 850/222-9800
Robert E. Cline, M.D. F: 850/561-6230
President E-mail: wayne@fha.org
113 East College Avenue Internet address: www.fha.org
P.O. Box 10269
Tallahassee, FL 32302
T: 850/224-6496
F: 850/222-8030
Internet address: www.fmaonline.org

6-Florida National Pharmaceutical Council


Pharmaceutical Benefits 2002

GEORGIA

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $580,612,920 847,730 $655,515,772 856,797

RECEIVING CASH ASSISTANCE, TOTAL $366,686,830 298,096 $422,797,389 368,161


Aged $48,636,401 33,486 $49,961,732 31,775
Blind/Disabled $291,064,893 157,467 $323,103,058 156,568
Child $13,292,609 72,236 $22,633,229 112,507
Adults $13,692,927 34,907 $27,099,370 67,311

MEDICALLY NEEDY, TOTAL $14,032,902 8,110 $15,484,179 8,446


Aged $5,217,528 3,517 $5,802,403 3,606
Blind/Disabled $8,802,364 4,565 $9,681,639 4,837
Child $12,940 27 $137 3
Adults $70 1 $0 0

POVERTY RELATED, TOTAL $57,728,991 325,482 $63,048,028 309,147


Aged $3,340,565 2,468 $3,524,685 2,335
Blind/Disabled $2,999,264 2,015 $3,102,251 2,047
Child $40,209,249 244,977 $44,949,926 230,198
Adults $11,179,913 76,022 $11,471,166 74,567

TOTAL OTHER EXPENDITURES/RECIPIENTS* $142,164,197 216,042 $154,186,176 171,043

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data are preliminary and subject to change.
Source: CMS, MSIS Report, FY 2000 and FY 2001.

National Pharmaceutical Council Georgia-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Closed formulary with restrictions on use
Department of Community Health, Division of Medicaid (quantity level limits), PA, preferred products, and
physician profiling.
D. PROVISIONS RELATING TO DRUGS
Benefit Design Prior Authorization: State currently has a formal prior
authorization procedure
Drug Benefit Product Coverage: Products covered:
prescribed insulin and disposable needles and syringe Prescribing or Dispensing Limitations:
combinations used for insulin. Products covered with
restrictions: blood glucose test strips (Roche products Prescription Refill Limit: Maximum of five refills for
only); urine ketone test strips (Roche products only); total adults, six for children. May be overridden at POS by the
parenteral nutrition (21 and younger) and interdialytic pharmacist for certain maintenance drugs.
parenteral nutrition (21 and younger). Products requiring
prior authorization: Marinol; Epoetin; interferons; Monthly Quantity Limit: Physicians are encouraged to
lactulose; neupogen; top.vit.A derivatives; toradol; prescribe a 31-day supply. Some exceptions exist.
Regranex; Viagra; PPIs; Lamisil; Sporanox; Botox;
Oxycontin; brand-names and multi-source. Products not Monthly Dollar Limit: $2,999.99 requires an override;
covered: cosmetics; fertility drugs; experimental drugs; >$9,999.99 requires paper claim and a copy of the
prescription vitamins and minerals (except for prenatal prescription.
and fluorides not in combination with other vitamins);
barbituates (except Seconal); DESI drugs; and Miralax; Drug Utilization Review
and smoking cessation products.
On-line PRODUR system implemented in October 2000.
Over-the-Counter Product Coverage: Products covered: State has a 20 member DUR Board (4 meetings per year).
analgesics (Ibuprofen suspension) covered with restriction
for ages less than 21; cough and cold preparations; topical Pharmacy Payment and Patient Cost Sharing
products; PIN-X; NIX; OTC iron and multivitamins; Dispensing Fee: $4.63, effective 7/1/98.
klout; and meclizine. Products not covered: allergy,
asthma, and sinus products; digestive products; feminine Ingredient Reimbursement Basis: EAC = AWP - 10% or
products; and smoking deterrent products. MFN price.
Therapeutic Category Coverage: Therapeutic categories Prescription Charge Formula: Lower of average
covered: antibiotics; anticoagulants; anticonvulsants; wholesale price (AWP) minus 10% plus dispensing fee,
antidepressants; antidiabetic agents; antihistamines; MAC plus fee, or usual and customary.
antilipemic agents; antipsychotics; cardiac drugs;
chemotherapy agents; prescribed cold medications (partial Maximum Allowable Cost: State imposes a combination
coverage); contraceptives; ENT anti-inflammatory agents; of Federal Upper Limits and State- Specific Limits on
estrogens; hypotensive agents; misc. GI drugs; generic drugs. Override requires Prior Approval.
sympathominetics (andrenergic); and thyroid agents. Approximately 800 drugs on the State-specific MAC list.
Prior authorization required for: anabolic steroids;
analgesics, antipyretics, NSAIDS for single source; Incentive Fee: $0.50 for generic drug.
anxiolytics, sedatives, and hypnotics; growth hormones;
and immunoglobulins. Therapeutic categories not
Patient Cost Sharing: $0.50 per prescription for generics
covered: anoretics and prescribed smoking deterrents.
or preferred drugs. $0.50 - $3.00 for non-preferred and
brand drugs, dependent on the cost of the drug.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
Cognitive Services: Does not pay for cognitive services.
when used in home health care and extended care
facilities, and through physician payment when used in
physicians offices.
E. USE OF MANAGED CARE

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.

Unit Dose: Unit dose packaging reimbursable.

2-Georgia National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Riverdale, GA 30296


State Drug Program Administrator J. Russell May, Pharm.D. , Chairperson
Lori S. Garner, R.Ph., M.B.A., M.H.S. Director of Pharmacy Services
Director, Pharmacy Services Department of Pharmacy
Department of Community Health-Medicaid Division Medical College of Georgia
2 Peachtree Street, NW, 37th Floor Hospital and Clinics
Atlanta, GA 30303-3159 1120 15th Street
T: 404/656-4044 Augusta, GA 30912-5600
F: 404/656-8366
E-mail: lgarner@dch.state.ga.us Harry Strothers III, M.D., M.M.M.
Internet Address: http://www.dch.state.ga.us Professor, Family Medicine
Morehouse School of Medicine
Department of Community Health Department of Family Medicine
Gary Redding, Commissioner 505 Fairburn Rd. S.W.
Department of Community Health Atlanta, GA 30331
2 Peachtree Street, NW, Suite 4043
Atlanta, GA 30303-3159 Ronald M. Barnes, M.S., R.Ph.
T: 404/656-4507 6025 Coventry Circle
F: 404/651-6880 Alpharetta, GA 30004
E-mail: gredding@dma.state.ga.us
L. Dianne Bradford, Ph.D.
Mark Trail, Medicaid Director Morehouse School of Medicine
Department of Community Health Departments of Psychiatry and Medicine
2 Peachtree Street, NW, Suite 4043 720 Westview Drive, SW
Atlanta, GA 30303-3159 Atlanta, GA 30310-1495
T: 404/656-4496
F: 404/651-6880 Stacy Ivin Burke, Pharm.D.
E-mail: mtrail@dma.state.ga.us Publix Pharmacy
2095 Highway 211
Prior Authorization Contact Braselton, GA 30517
Jean Cox, R.Ph.
Drug Utilization Review/Prior Approval Daniel Gallina, M.D.
DCH/Division of Medical Assistance Emory University School of Medicine
2 Peachtree Street, 37th floor Grady Health System
Atlanta, GA 30303-3159 Diabetes Unit
T: 404/657-7241 69 Butler Street
F: 404/656-8366 Atlanta, GA 30303-3033
E-mail: jcox@dch.state.ga.us
Louis Wayne Goolsby, M.D.
DUR Contact Senior Vice President for Medical Affairs
Jean Cox, 404/657-7241 Medical Center of Central Georgia
777 Hemlock Street #146
Medicaid DUR Board Macon, GA 31201
John Stephen Antalis, M.D.
Dalton Family Practice, P.C. Phyllis A. Johnson, R.N., Ph.D.
1114 Professional Blvd. 1010 Forest Overlook Trail, SW
Dalton, GA 30720 Atlanta, GA 30331

Frank W. Brown, M.D., M.B.A.


Wesley Woods Center
1841 Clifton Road, NE
Atlanta, GA 30329

Catherine E. Burley, M.D.


7365 Old National Hwy, Suite A

National Pharmaceutical Council Georgia-3


Pharmaceutical Benefits 2002

Robyn Anderson Lorys, Pharm.D. Medicaid Drug Rebate Contact


2430 Laurelwood Road Patricia Zeigler Jeter, M.P.A., R.Ph.
Atlanta, GA 30360 Pharmacist
Pharmacy Services Unit, Program Policy Section
Calvin W. McLarin, M.D. Division of Medical Assistance
Metropolitan Atlanta Cardiology Consultants 2 Peachtree Street, NW 37th Floor
999 Peachtree Street, NE Atlanta, GA 30303
Suite 850 T: 404/657-9181
Atlanta, GA 30309 F: 404/656-8366
E-mail: pjeter@dch.state.ga.us
Mathew Perri III, R.Ph., Ph.D.
Claims Submission Contact
Department of Clinical and Administrative Sciences
Dustin Gruhlke
University of Georgia College of Pharmacy
Account Manager
DW Brooks Drive, Room 250G
Express Scripts, Inc.
Athens Georgia 30602
6625 W. 78th St., BL-0420
Bllomington, MN 55439
Cynthia O’Steen-Piela, R.Ph.
T: 952/837-7741
District Manager
F: 952/837-7741
Wal-Mart Pharmacy
E-mail: dustin.gruhlke@express-scripts.com
1350 Arborwood Ridge
Bishop, Georgia 30621 Medicaid Managed Care Contact
Kathy Driggers
Kimberly Rogan, R.Ph.
Director, Managed Care
District Manager, South Region
Department of Community Health
Ekcerd Drugs
2 Peachtree Street, NW
3549 Chamblee Tucker Road
Atlanta, Georgia 30303
Tucker, GA 30341
T: 404/657-7793
F: 404/656-8366
Joseph Rosenfeld, M.D.
E-mail: kdriggers@dch.state.ga.us
Snapfinger Woods Pediatric
5008 Snapfinger Woods Drive Disease Management Program/Initiative Contact
Decatur, GA 30035 Charmaine Heard, M.D.
Medical Director
William Dennis Taylor, M.D. Department of Community Health
Green Acres Nursing Home 2 Peachtree Street, NW, 37th Floor
313 Allen Memorial Drive Atlanta, Georgia 30303
Milledgeville, GA 31061 T: 404/463-7638
F: 404/656-8366
Cynthia Wainscott E-mail: cheard@dch.state.ga.us
2274 Camden Drive
Marietta, GA 30064 Mail Order Pharmacy Benefits
None
Andrew D. Weinberg, M.D., FACP Physician-Administered Drug Program Contact
1647 Brookhaven Close, NE Margie Preston, R.N.
Atlanta, GA 30319 2 Peachtree Street, N.E.
Atlanta, Georgia 30303
Prescription Price Updating 404/656-3961
Andrew Shim, Pharm.D.
Clinical Program Manager
Express Scripts, Inc.
6625 W. 78th Street, BL0420
Bloomington, MN 55439
T: 952/837-5326
F: 952/837-7184
E-mail: andrew.shim@express-scripts.com

4-Georgia National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medical Assistance Advisory Committee Mercer University


Representatives from each of the following groups: 593 Cantebury Lane
Medical Association of Georgia Winder, GA 30680
Georgia Pharmaceutical Association
Atlanta Medical Association Ellen Whipple Guthrie, Pharm.D.
Georgia Health Care Association Pharmacy Manager
Georgia Hospital Association The Shepard Center
Georgia Dental Association 2020 Peachtree Rd., NW
Georgia Osteopathic Medical Association Atlanta, GA 30309
National Pharmaceutical Association
Timara Faulkner Rembert, Pharm.D.
Pharmacy Advisory Committee
87 Buckeye Loop
Ifeanyi J. Anikpe, Pharm.D.
Midland, GA 31820
Washington Road Pharmacy
3518 Washington Road Executive Officers of State Medical and
East Point, GA 30344 Pharmaceutical Societies
Medical Association of Georgia
Anthony Compton, Pharm.D. David Cook, Executive Director
Pharmacy Manager 1330 W. Peachtree Street, NW, Suite 500
Saint Joseph’s Hospital of Atlanta Atlant, GA 30309
2783 Harvest Drive T: 404/876-7535
Conyers, GA 30013 F: 404/881-5021
Internet address: www.mag.org
Amanda R. Gaddy, R.Ph.
Kroger Georgia Pharmaceutical Association
131 Windsong Drive Oren “Buddy” Harden, Jr.
Stockbridge, GA 30281 Chief Executive Officer
50 Lenox Pointe, NE
Ted M. Hunt, R.Ph. Atlanta, GA 30324-3170
General Manger T: 404/231-5074
PharMerica F: 404/237-8435
1100 Wilson Way, Suite 500 Internet address: www.gpha.org
Smyrna, GA 30082
Osteopathic Medical Association
Leslie M. Litton Sheila J. Smith, D.O.
Executive Director President
Kaiser Permanente 2037 Grayson Highway, Suite 200
9 Piedmont Center Grayson, GA 30017
3495 Piedmont Rd. NE T: 770/493-9278
Atlanta, GA 30082 F: 770/908-3210
E-mail: www.goma.org
Scott Moody, Pharm.D.
Regional Manager, Pro State Board of Pharmacy
Glaxo Wellcome, Inc. Anita O. Martin
9306 Fall Court West Executive Director
Brentwood, TN 37027 237 Coliseum Drive
Macon, GA 31217-3858
Malcolm “Mickey” Tatum, R.Ph. T: 478/207-1686
Dinglewood Pharmacy F: 404/656-0513
1819 Wynnton Road Internet address: www.sos.state.ga.us/plb, pharmacy
Columbus, GA 31902

Homer L. Whelchel, R.Ph.


President, CEO
Berrien Health Center
P.O. Box 866
Nashville, GA 31639-0866
Julie M. Wickman, Pharm.D. Georgia State Medical Association

National Pharmaceutical Council Georgia-5


Pharmaceutical Benefits 2002

Katherine Daniels
Executive Director
Morehouse School of Medicine
720 Westview Drive, SW
Atlanta, GA 30310-1495
T: 404/752-1564
F: 404/752-1024
Internet address: www.gastatemedicalassoc.org

Georgia Hospital Association


Joseph A. Parker
President
1675 Terrell Mill Road
Marietta, GA 30067
T: 770/249-4522
F: 770/955-5801
Internet address: www.gha.org

6-Georgia National Pharmaceutical Council


Pharmaceutical Benefits 2002

HAWAII

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $44,849,669 35,687 $74,869,859

RECEIVING CASH ASSISTANCE TOTAL $26,683,919 19,797


Aged $7,181,063 7,581
Blind/Disabled $19,457,302 11,436
Child $10,145 364
Adult $35,409 416

MEDICALLY NEEDY, TOTAL $2,533,810 1,915


Aged $1,799,925 1,555
Blind/Disabled $733,885 360
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $15,209,816 12,118


Aged $6,660,312 6,911
Blind/Disabled $8,481,521 4,460
Child $9,495 192
Adult $58,488 555

TOTAL OTHER EXPENDITURES/RECIPIENTS* $422,119 1,857

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Note: Hawaii estimates 2002 drug expenditures to be $80 million.

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

National Pharmaceutical Council Hawaii-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescribing or Dispensing Limitations


Monthly Quantity Limit: Physicians are encouraged to
Hawaii Department of Human Services through its Med- prescribe a 30-day supply or 100 units.
Quest Division and four county branch offices.
Drug Utilization Review
D. PROVISIONS RELATING TO DRUGS
Benefit Design PRODUR system implemented in September 1997. State
currently has a DUR board with a quarterly review.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Pharmacy Payment and Patient Cost Sharing
combinations used for insulin; blood glucose test strips; Dispensing Fee: $4.67, effective May 9, 1990.
and urine ketone test strips. Products requiring prior
authorization: total parenteral nutrition (for home Ingredient Reimbursement Basis: EAC = AWP-10.5%.
infusion); interdialytic parenteral nutrition (for home
infusion); Clorazil; Procardia XL; Norvasc; brand Prescription Charge Formula: Payment for prescription
products on FUL price list; and Betaseron. Products not and OTC drugs listed in the formulary is limited to the
covered: cosmetics; fertility drugs; and experimental state or federally established MAC price, or Estimated
drugs. Acquisition Cost (EAC) or AWP-10.5% when equal to
average selling price plus dispensing fee, or billed
Over-the-Counter Product Coverage: Limited coverage amount, whichever is lowest.
for allergy, asthma and sinus products; analgesics; cough
and cold preparations; digestive products; and topical Maximum Allowable Cost: State imposed Federal Upper
products. Products not covered: smoking deterrent Limits and State-specific limits on generic drugs. Override
products. requires “Medically Necessary” as “Brand Medically
Necessary”.
Therapeutic Category Coverage: Products covered:
antibiotics; anticoagulants; anticonvulsants; anti- Incentive Fee: None.
depressants; antidiabetic agents; antilipemic agents;
anxiolytics; sedatives; and hypnotics; cardiac drugs; Patient Cost Sharing: No copayment.
contraceptives; estrogens; hypotensive agents; misc. GI
drugs; sympathominetics (adrenergic); and thyroid agents Cognitive Services: Does not pay for cognitive services.
Prior authorization required for: anabolic steroids;
analgesics, antysyretics, and single source NSAIDs;
E. USE OF MANAGED CARE
anorectics; non-sedating antihistamine drugs; atypical
anti-psychotics; chemotherapy agents; prescribed cold
Approximately 135,000 Medicaid recipients were enrolled
medications; proton pump inhibitors; and growth
in MCOs in FY 2002. Recipients receive pharmaceutical
hormones. Products not covered: prescribed smoking
benefits through State/managed care plans or both. State
deterrents.
has specific guidelines for the pharmacy benefit for
Medicaid recipients enrolled in managed care plans.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Managed Care Organizations
when used in home health care, extended care facilities, AlohaCare, Inc.
and physicians offices. Mr. John McComas
1357 Kapiolani Blvd., Suite 1250
Vaccines: Vaccines reimbursable as part of EPSDT Honolulu, HI 96814
service, CHIP, and covered by the Vaccines for Children 808/973-1650
Program.
Hawaii Medical Service Association (HMSA)
Unit Dose: Unit dose packaging reimbursable Andreas Carvalho, Director
QUEST Administration
Formulary/Prior Authorization
818 Keeaumoku Street
Formulary: Open formulary. Honolulu, HI 96808
808/948-5250
Prior Authorization: State currently has a formal prior
authorization procedure. A fair hearing may be requested
for appeal of prior authorization decisions.
Kaiser Foundation Health Plan, Inc.

2-Hawaii National Pharmaceutical Council


Pharmaceutical Benefits 2002

Ms. Virginia Vierra 808/377-5485


1441 Kapliolani Blvd, Suite 1600
Brian Matsuura (Medical Services Rep.)
Honolulu, HI 96814
DHS/MQD/MSB
808/944-0261
P.O. Box 700190
Kapolei, HI 96709-0190
Behavioral Health Services
808/692-8065
Community Care Services (CCS)
Sharon Yoshiura or Carolyn Gire Joy Higa, R.Ph. (Long Term Care),Chair
810 N. Vineyard Blvd. DHS/MQD/MSB
Honolulu, HI 96817 P.O. Box 700190
T: 808/948-5379 Kapolei, HI 96709-0190
F: 808/948-6588 808/692-8065
Jerry Smead, R.Ph. (Ambulatory Care)
F. STATE CONTACTS Kaiser Parmanente Hawaii Region
Medicaid Drug Program Administrator 201 Hamakua Drive, Building B
Lynn Donovan, R.Ph. Kailua, HI 96734
Pharmacy Consultant 808/432-3454
Med-Quest Division Kerry Kitsu, R.Ph. (Community, chain)
P.O. Box 700190 DHS/MQD/MSB
Kapolei, HI 96709-0190 P.O. Box 700190
T: 808/692-8116 Kapolei, HI 96709-0190
F: 808/692-8131 808/692-8065
Prior Authorization Contact Carl Mudrick, R.Ph. (Community, independent)
Lynn S. Donovan, R.Ph. 750 Palani Avenue
808/692-8116 Honolulu. HI 96816
808/739-1188
DUR Contact
Kathleen Kang-Kaulupali Prescription Price Updating
DUR Coordinator First Data Bank
Med-Quest Division 111 Bayhill Dr.
P.O. Box 700190 San Bruno, CA 94066
601 Kamokila Blvd., Room 506 B 800/633-3453
Kapolei, HI 96709-0190
T: 808/692-8065 Medicaid Drug Rebate Contacts
F: 808/692-8131 Technical: Lynn Donovan, 808/692-8116
Policy: Lynn Donovan, 808/692-8116
Medicaid DUR Board Audits: Lynn Donovan, 808/692-8116
Myron Shirasu, M.D. (Internal Medicine) DUR: Kathleen Kang-Kaulupali, 808/692-8065
321 North Kuakini Street #200
Honolulu, HI 96817 Claims Submission Contact
808/523-8611 Med. - Supplies:
ACS
Gregory E.M. Yuen, M.D. (Psychiatry) P.O. Box 1220
1188 Bishop Street, Suite 806 Honolulu, HI 96807-1220
Honolulu, HI 96813 808/952-5570
808/599-5050 Drugs:
Linda Tom MD (Geriatric Medicine), Vice-Chair
347 N. Kuakini Street, HPM-9
Honolulu, HI 96817
808/523-8461

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

National Pharmaceutical Council Hawaii-3


Pharmaceutical Benefits 2002

T: 800/358-2381 State Board of Pharmacy


F: 770/730-5198 Lee Ann Teshima
E-mail: heather.bodiford@acs-inc.com Executive Officer
P. O. Box 3469
Disease Management/Patient Education Contact
Honolulu, HI 96801
Susan Oh
T: 808/586-2694
Clinical Services Manager
F: 808/586-2689
ACS
E-mail: pharmacy@dcca.state.hi.us
T: 800/358-2381
Internet address: www.state.hi.us/dcca/pvl
E-mail: susan.oh@acs-inc.com
Mail Order Pharmacy Benefit Healthcare Association of Hawaii
None Richard E. Meiers
President/CEO
Department of Human Services Officials
932 Ward Avenue
Lillian Koller
Suite 430
Director
Honolulu, HI 96814-2126
Department of Human Services
T: 808/521-8961
P.O. Box 339
F: 808/599-2879
Honolulu, HI 96809-0339
E-mail: postmaster@hah.org
T: 808/586-4997
Internet address: www.hah.org
F: 808/586-4890
E-mail: Lillian.b.koller@hawaii.gov

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

Hawaii Pharmacist Association


Les Krenk
President
P. O. Box 1198
Honolulu, HI 96807-1198
T: 808/877-6222
F: 808/432-5535
E-mail: tkiammc@aol.com
Association of Osteopathic Physicians and Surgeons
Brenda Dela Cruz
545 Ohohia Street
Honolulu, HI 96819
T: 808/831-3000
F: 808/834-5763

4-Hawaii National Pharmaceutical Council


Pharmaceutical Benefits 2002

IDAHO

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $83,525,730 92,776 $105,473,425 112,357

RECEIVING CASH ASSISTANCE, TOTAL $52,792,616 20,936 $64,871,126 22,489


Aged $4,481,474 2,040 $4,947,969 2,016
Blind/Disabled $48,041,510 17,913 $59,411,640 19,271
Child $164,562 799 $280,234 963
Adult $105,070 184 $231,283 239

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $6,389,472 42,534 $10,152,018 55,312


Aged $44,337 52 $139,939 93
Blind/Disabled $190,496 126 $160,823 132
Child $5,335,356 36,583 $8,806,102 48,702
Adult $819,283 5,773 $1,045,154 6,385

TOTAL OTHER EXPENDITURES/RECIPIENTS* $24,343,642 29,306 $30,450,281 34,556

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

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

National Pharmaceutical Council Idaho-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION committee. Written “notice of appeal” required for fair


hearing.
Division of Medicaid
Idaho Department of Health & Welfare Prescribing or Dispensing Limitations
By the State Department of Health and Welfare through Monthly Quantity Limit: Prescription drugs are limited to
seven regional offices, each serves five or more of the a 34-day supply. The following drugs are limited to a 100-
State’s 44 counties. day supply: Digoxin, thyroids, prenatal vitamins,
nitroglycerin, fluoride, fluoride and vitamin combinations,
D. PROVISIONS RELATING TO DRUGS non-legend oral iron salts and 3 cycles of birth control.

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.

Unit Dose: Unit dose packaging reimbursable when used


in unit dose systems.
Formulary Authorization
Formulary: Open formulary.
Prior Authorization: State currently has a formal prior
authorization procedure and a prior authorization

2-Idaho National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Division of Medicaid


Bureau of Care Management
Medicaid Drug Program Administrator 3380 Americana Terrace, Suite 140
Shawna Kittridge, R.Ph., M.H.S. Boise, ID 83720-0036
Medicaid Drug Program Supervisor 208/364-1832
Department of Health and Welfare E-mail: jeffreyc@idwh.state.id.us
Division of Medicaid Bureau of Care Management HR
3380 Americana Terrace, Suite 140 Claims Submission Contact
Boise, ID 83720-0036 EDS
T: 208/364-1956 P.O. Box 23
F: 208/364-1864 Boise, ID 83707
E-mail: kttrids@idhw.state.id.us T: 208/395-2000
Internet Address: F: 208/395-2030
www.state.id.us/dhw/medicaid/providers/pharmacy.htm
Prior Authorization Contact Medicaid Managed Care Contact
Shawna Kittridge, R.Ph., M.H.S., 208/364-1956 Robin Pewtress
Alternate Care Coordinator
DUR Contact P.O. Box 83720
Tamara Eide, Pharm.D., BCPS, FASHP Boise, ID 83720
Pharmacy Service Specialist T: 208/364-1892
Department of Health and Welfare F: 208/364-1911
Division of Medicaid E-mail: pewtresr@idhw.state.id.us
Bureau of Care Management
3380 Americana Terrace, Suite 140 Mail Order Pharmacy Program
Boise, ID 83720-0036 State currently has a mail order pharmacy program.
208/364-1821 Pharmacy must be a registered Idaho Medicaid provider.
E-mail: eidet@idhw.state.id.us
Physician-Administered Drug Program Contact
Robbie Charlton
Medicaid DUR Board Medicaid Policy
Board Members: PO Box 83720
Gary Wilburn, R.Ph. Boise, ID 83720-0036
Don Smith, R.Ph. Health and Welfare Department Officials
Kent Jensen, R.Ph. Karl Kurtz, Director
Joseph Steiner, Pharm. D. Dept. of Health & Welfare
Nancy Mann, M.D. 450 West State Street
E. Gregory Thompson, M.D. PO Box 83720
Robert Ting, M.D. Boise, Idaho 83720-0036
T: 208/334-5500
Staff: F: 208/334-6558
Tamara Eide, Pharm. D., Dept. Contact E-mail: dhwinfo@idhw.state.id.us
Vaughn Culbertson, Pharm.D. Project Dir.
Bureau of Medicaid Care Mgmt.
Prescription Price Updating Ike Gayfield, Bureau Chief
Kaydeen Burkett, R.Ph. Randy May, Interim Medicaid Administration
Pharmacy Services Specialist Shawna Kittridge, R.Ph., Pharmacy Services Supervisor
Department of Health and Welfare Tom Young, M.D., Medical Director
Division of Medicaid
Bureau of Care Management
3380 Americana Terrace, Suite 140
Boise, ID 83720-0036
208/364-1826 Title XIX Medical Care Advisory Committee
E-mail: burkett@idhw.state.id.us JoAn Condie
Idaho State Pharmacy Association
Medicaid Drug Rebate Contact
Carl Jefferey, Pharm. D. Greg Dickerson
Pharmacy Services Specialist Mental Health Providers Association
Department of Health and Welfare

National Pharmaceutical Council Idaho-3


Pharmaceutical Benefits 2002

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

Gene Wiggers (Chairperson)


AARP

Executive Officers of State Medical and


Pharmaceutical Societies
Idaho Medical Association
Robert Seehusen, CEO
305 West Jefferson
Boise, ID 83701
T: 208/344-7888
F: 208/344-7903
E-mail: mail@imed.org
Internet address: www.imed.org

Idaho State Pharmacy Association


JoAn Condie
Executive Director
P.O. Box 140117
Boise, ID 83714-0117
T: 208/424-1107
F: 208/376-3131

4-Idaho National Pharmaceutical Council


Pharmaceutical Benefits 2002

1
ILLINOIS

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $847,001,431 1,013,254 $975,308,665 1,068,512

RECEIVING CASH ASSISTANCE TOTAL $331,464,185 314,029 $330,554,700 241,558


Aged $36,629,569 19,225 $39,705,433 19,211
Blind/Disabled $261,163,109 122,778 $270,172,401 120,775
Child $13,779,760 116,293 $9,671,068 71,477
Adult $19,891,747 55,733 $11,005,798 30,095

MEDICALLY NEEDY, TOTAL $402,152,932 254,191 $458,851,724 294,439


Aged $119,518,205 58,482 $128,714,145 61,241
Blind/Disabled $236,268,215 84,298 $270,986,820 93,060
Child $512,937 846 $620,921 783
Adult $45,853,575 110,565 $58,529,838 139,355

POVERTY RELATED, TOTAL $68,711,632 362,584 $84,313,807 456,812


Aged $5,525,333 3,869 $3,621,230 2,432
Blind/Disabled $11,633,989 5,521 $9,303,294 3,666
Child $46,879,148 313,744 $64,770,113 404,559
Adult $4,673,126 39,414 $6,619,170 46,155

OTHER EXPENDITURES/RECIPIENTS* $44,672,682 82,486 $101,588,434 75,703

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

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

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.

National Pharmaceutical Council Illinois-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure and a Committee on Drugs and
Illinois Department of Public Aid, Division of Medical Therapeutics. Recipient must file an appeal with their
Assistance. local office in order to appeal prior authorization
decisions. To appeal the coverage of an excluded product,
D. PROVISIONS RELATING TO DRUGS the recipient can request the opportunity to appear before
the Committee on Drugs and Therapeutics.
Benefit Design
Prescribing or Dispensing Limitations
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Prescription Refill Limit: Maximum of eleven refills.
combinations used for insulin; blood glucose test strips;
and urine ketone test strips. Prior authorization required: Monthly Quantity Limit: As medically appropriate. Also
syringe combinations used for insulin. Products covered edit for maximum daily quantities.
with restrictions: total parenteral nutrition and interdialytic Drug Utilization Review
parenteral nutrition. Products not covered: cosmetics; PRODUR system implemented in January 1993. State
DESI-ineffectives; fertility drugs; and experimental drugs. currently has a DUR board which meets as needed.

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.

2-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2002

Managed Care Organizations 650/588-5454


Amerigroup Illinois
Medicaid Drug Rebate Contact
211 Wacker Drive
Brandley Wallner
Suite 1350
Manager
Chicago, IL 60606-3101
Illinois Department of Public Aid
2200 Churchill Road
United Health Care of IL
Springfield, IL 62704
233 N. Michigan Ave. 8th Fl-12th Fl.
217/785-6114
Chicago, IL 60601
E-mail: cpa_webmaster@state.il.us
Harmony Health Plan of Illinois Medicaid Managed Care Contact
125 South Wacker Drive Bureau of Managed Care
Suite 2900 Illinois Department of Public Aid
Chicago, IL 60606-4402 201 S. Grand Avenue East
Springfield, Illinois 62763
Harmony Health Plan T: 217/524-7478
23 Public Square F: 217/524-7535
Belleville, IL 62220 E-mail:dpa_webmaster@state.il.us
Mail Order Pharmacy Benefit
Humana Health Plan
None
30 South Wacker Drive
Suite 3100 Elderly Expanded Drug Coverage Program
Chicago, IL 60606 Susan Coombe, Supervisor
Circuit Breaker Program
Family Health Network Illinois Department of Revenue
910 West Van Buren 101 W. Jefferson - Level 3- 250
6th Floor Springfield, Illinois 62794
Chicago, IL 60607-3523 217/785-2097
Physician-Administered Drug Program Contact
F. STATE CONTACTS Cheryl Bechner
217/782-5565
State Drug Program Administrator
Marvin L. Hazelwood, Manager Illinois Medicaid Agency Officials
Pharmacy and Ancillary Services Programs Barry Maram, Director
Illinois Department of Public Aid Illinois Department of Public Aid
Division of Medical Assistance 201 South Grand Avenue, East, Third Floor
1001 N. Walnut St. Springfield, IL 62794
Springfield, IL 62702 T: 217/782-1200
T: 217/524-5565 F: 217/524-7120
F: 217/524-7194 E-mail: directordpa@mail.idpa.state.il.us
E-mail: dpa_webmaster@state.il.us
Internet address: http://www.state.il.us/dpa/
Prior Authorization Contact
Pharmacy Unit Staff
217/782-5565
DUR Contact
Marvin L. Hazelwood
217/524-5565

A. George Hovanec, Administrator


Division of Medicaid Programs
Illinois Department of Public Aid
Prescription Price Updating 201 South Grand Avenue, East, Third Floor
First DataBank Springfield, IL 62763-0001
111 Bayhill Dr. T: 217/782-2570
San Bruno, CA 94066 F: 217/524-7979

National Pharmaceutical Council Illinois-3


Pharmaceutical Benefits 2002

Title XIX Medical Care Advisory Committees Highland Park, IL 60035


State Medical Advisory Committee 708/433-3900
Arthur Traugott, M.D.
32207 Weisiger Way Richard P. Snodgrass, M.D.
Urbana, IL 61801 550 30th Avenue
Moline, IL 61265
Committee on Drugs and Therapeutics 309/764-1910
Marshall Blankenship, M.D., Chairman
1555 Astor Avenue IDPA Representative
Chicago, IL 60610 Marvin Hazelwood
708/636-3757 Illinois Department of Public Aid
1001 N. Walnut St.
Nicholas C. Bellios, M.D. Springfield, IL 62702
2504 Washington 217/524-7112
Waukegan, IL 60085
708/249-3660 Illinois State Medical Society
Kenneth E. Ryan
Armand Littman, M.D. Director, Department of Economics
Medical Services 20 N. Michigan Avenue, Suite 700
Hines VA Hospital Chicago, IL 60602
Hines, IL 60141 312/782-1654
708/216-2006
IDPH Representative:
Vincent A. Costanzo, Jr., M.D. Ron Gottrich, R.Ph
7501 South Stony Island Avenue Illinois Department of Public Health
Chicago, IL 60649 525 W. Jefferson
312/995-1075 Springfield, IL 62761
217/782-7532
Theodore M. Kanellakes, M.D.
229 N. Hammes Avenue
Executive Officers of State Medical and
Joliet, IL 60435
Pharmaceutical Societies
815/744-2300
Illinois State Medical Society
William E. Kobler, M.D.
Patrick R. Staunton, M.D.
President
156 N. Oak Park Avenue
20 N. Michigan Avenue, Suite 700
Oak Park, IL 60301
Chicago, IL 60602
708/696-5887
T: 312/782-1654
F: 312/782-2023
Board of Trustees
E-mail: info@isms.org
Phillip D. Boren, M.D.
Internet address: www.isms.org
Doctor's Clinic
S. Plum Street
Carmi, IL 62821
618/382-4193

Illinois Pharmacists Association


Joan E. Cummings, M.D.
Terri McEntaffer, R.Ph., CAE
Extended Care
Executive Director
181 Hines VA Hospital
204 West Cook
Building 1, Room C-124D
Springfield, IL 62704-2526
Hines, IL 60141
T: 217/522-7300
708/343-7200 ext. 5057
F: 217/522-7349
E-mail: terrim@ipha.org
David B. Littman, M.D.
Internet address: www.ipha.org
1030 Old Elm Road

4-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2002

Illinois Osteopathic Medical Society


Gary Knepp
President
142 East Ontario Avenue, Suite 1023
Chicago, IL 60611-2854
T: 312/202-8174
F: 312/202-8224
E-mail: ioms@ioms.org
Internet address: www.ioms.org

State Board of Pharmacy


Judy Cullen
Pharmacy Coordinator
Illinois Department of Professional Regulation
Pharmacy Section
320 West Washington Street, 3rd Floor
Springfield, IL 62786
T: 217/782-8556
F: 217/782-7645
Internet address: www.dpr.state.il.us

Illinois Hospital and Health Systems Association


Kenneth C. Robbins
President
Center for Health Affairs
1151 East Warrenville Road
P.O. Box 3015
Naperville, IL 60566-7015
T: 630/505-7777
F: 630/505-9457
Internet address: www.ihatoday.org

National Pharmaceutical Council Illinois-5


Pharmaceutical Benefits 2002

6-Illinois National Pharmaceutical Council


Pharmaceutical Benefits 2002

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $464,982,829 420,041 $562,120,344 464,879

RECEIVING CASH ASSISTANCE, TOTAL $228,983,212 167,338 $277,174,243 188,399


Aged $41,456,711 16,201 $47,951,486 16,531
Blind/Disabled $161,118,015 53,734 $190,763,506 56,296
Child $10,263,863 58,420 $15,067,039 69,054
Adult $16,144,623 38,983 $23,392,212 46,518

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $35,072,606 130,043 $48,080,747 146,488


Aged $337,019 397 $304,966 378
Blind/Disabled $475,865 543 $535,916 566
Child $33,151,471 120,008 $46,038,486 136,278
Adult $1,108,251 9,095 $1,201,379 9,266

TOTAL OTHER EXPENDITURES/RECIPENTS* $200,927,011 122,660 $236,865,354 129,992

*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.

National Pharmaceutical Council Indiana-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION 1. Federal MAC, if applicable, plus a dispensing fee.


2. State MAC, if applicable, plus a dispensing fee.
Office of Medicaid Policy and Planning
3. EAC plus a dispensing fee.
D. PROVISIONS RELATING TO DRUGS
4. Pharmacy’s usual and customary charge to the
Benefit Design general public.

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.

Therapeutic Category Coverage: All coverage in Cognitive Services: None.


accordance with OBRA ’90 & ’93.
E. USE OF MANAGED CARE
Coverage of Injectables: Covered.
Approximately 105,000 Medicaid recipients were enrolled
Vaccines: Vaccines reimbursable as part of the EPSDT in MCOs in FY 2001. Recipients receive pharmaceutical
service, the Children Health Insurance Program, and the benefits through managed care plans.
Vaccines for Children Program.
Managed Care Organizations
Unit Dose: In accordance with OBRA 1990 Harmony Health Management, Inc.
Requirements. MCFA policy only. 504 Broadway, Suite 200
Gary, IN 46404-4300
Formulary/Prior Authorization
Managed Health Services
Formulary: Preferred Drug List 1099 N. Meridian Street, Suite 400
Indianapolis, IN 46204
Prior Authorization: State has a prior authorization
program with formal appeal process. MDwise
1099 N. Meridian Street, Suite 320
Prescribing or Dispensing Limitations Indianapolis, IN 46204

Monthly Quantity Limit: 34-day supply for maintenance


drugs. F. STATE CONTACTS
Drug Utilization Review State Drug Program*
Marc Shirley, R.Ph.
PRODUR system implemented in March 1996. State Pharmacy Program Director
currently has a DUR Board with a monthly review. Office of Medicaid Policy and Planning
Pharmacy Payment and Patient Cost Sharing Room W382
Indiana State Government Center South
Dispensing Fee: $4.90, effective 05/30/02. 402 W. Washington Street
Indianapolis, IN 46204-2739
Ingredient Reimbursement Basis: T: 317/232-4343
F: 317/232-7382
EAC = Brand: AWP-13.5% E-mail: mshirley@fssa.state.in.us
Generic: AWP-20% *Do not contact state staff with requests for survey
information. All industry information requests and
Legend Drug Reimbursement Methodology: inquiries by or on behalf of pharmaceutical
manufacturers must be directed via e-mail to:
Lower/Lowest of: ACS

2-Indiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

David George F: 317/232-7382


david.george@acs-inc.com
Mail Order Pharmacy Program
No Phone Surveys Will Be Accepted! None
Physician-Administered Drug Program Contact
DUR Contact
Karen Clifton ACS
DUR Board Secretary david.george@acs-inc.com
Office of Medicaid Policy & Planning
Room W382, Indiana Sate Government Center South, 402 Administration Officials
Melanie Bella
West Washington St.
Assistant Secretary
Indianapolis, IN 46204
Medicaid Policy & Planning
T: 317/232-4391
Indiana Family & Social Services Administration
F: 317/232-7382
402 W. Washington Street, Room W382
E-mail: kclifton@fssa.state.in.us
Indianapolis, IN 46204
Medicaid DUR Board T: 317/233-4455
Physicians F: 317/232-7382
Neil Irick, M.D.
Patricia Treadwell, M.D. John Barth
John J. Wernert, M.D. Managed Care Director
Philip N. Eskew, Jr., M.D. 317/233-4697

Pharmacists Pat Nolting, Director


Paula Ceh, Pharm.D. Medicaid Program Operations – Acute Care
Brian Musial, R.Ph. 317/232-4318
Thomas A. Smith, P.D., M.S.
G. Thomas Wilson, B.S. Pharm., J.D. Medicaid Advisory Committee
John B. DeLap
2365 Chestnut Street
Health Care Economist
Columbus, IN 47201
Marko Mychaskiw, R.Ph., Ph.D.
Deborah A. Freund
Pharmacologist
1327 East First Street
Terry Lindstrom, Ph.D.
Bloomington, IN 47402
Representative from HMO
Eleanor DeArman Kinney
Vicki Perry
5140 Reed Road
Prescription Pricing Updating Indianapolis, IN 46254
First DataBank
1111 Bay Hill Drive
San Bruno, CA 94066
650/588-5454
Medicaid Drug Rebate Contacts
ACS
david.george@acs-inc.com
Claims Submission Contact
ACS
david.george@acs-inc.com

Medicaid Managed Care Contact


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

National Pharmaceutical Council Indiana-3


Pharmaceutical Benefits 2002

Kayla Templin West Rep. William Crawford


1014 N. Arsenal Avenue PO Box 18446
Indianapolis, IN 46201 Indianapolis, IN 46218-0446

Edward A. White, D.O. Rep. Jeffrey K. Espich


410 North Main Street 1250 W. Hancock Street, Box 158
Princeton, IN 47670-1516 Uniondale, IN 46791

Beverly Richards, D.N.S., R.N. Vickie Trout


Indiana St. Nurses Association Division of Mental Health
2915 North High School Road 402 W. Washington - W 353
Indianapolis, IN 46224-2969 Indianapolis, IN 46204

David Giles, M.D. David Harris


6934 Hillsdale Court 125 East 48th Street
Indianapolis, IN 46250 Indianapolis, IN 46205

L. Richard Gohman Donald Mulligan, Sr.


One American Sq. - Suite 1100 6185 Broughton
Indianapolis, IN 46204 Portage, IN 46368

Polly E. Hendricks, O.D. Barry Delks


3222 Oceanline E. Drive 21 Peregrine Court
Indianapolis, IN 46214 West Lafayette, IN 47906

James F. Jones, M.S. Lula E. Baxter


101 W. Ohio Street - Suite 610 9710 East 38th Street
Indianapolis, IN 46204 Indianapolis, IN 46236

Mike Weber R. Stanley Wilson, M.D.


Indiana Health Care Association 3 Hazelwood Drive
One N. Capital, Suite 1115 Vinciennes, IN 47591
Indianapolis, IN 46204
Paul Schneider, Ph.D.
Anna Schenk, Pres., ILPNA 6320 Latona Court
1501 W. 500 North Indianapolis, IN 46278
Marion, IN 47952
Robert S. Mandresh, D.P.M.
Paul C. Johnson, D.D.S. 3351 N. Meridian #101
8240 Naab Road Indianapolis, IN 46208
Indianapolis, IN 46260
Chip Garver
Robin Taylor, R.Ph., President 101 West Ohio, Suite 560
Healthcare Prescription Svs, Inc. Indianapolis, IN 46204
3830 E. Southport Road, Suite C
Indianapolis, IN 46237 Michael Sullivan
Ind. Assn. For Home Care, Inc.
Greg Wilson, M.D. 8888 Keystone Crossing
Developmental Pediatrics Suite 1000
702 Barnhill Dr., Room 1601 Indianapolis, IN 46202
Indianapolis, IN 46202
Louis Cantor, M.D.
Sen. Marvin Riegsecker 702 Rotary Circle
801 S. 6th Street Indianapolis, IN 46202
Goshen, IN 46526

4-Indiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

Joe D. Hunt, Director


Bureau of Policy Development
State Department of Health
1330 W. Michigan Street
Indianapolis, IN 46202

Executive Officers of State Medical and


Pharmaceutical Societies
Indiana State Medical Association
Richard R. King, J.D.
Executive Director
322 Canal Walk, Canal Level
Indianapolis, IN 46202-3268
T: 317/261-2060
F: 317/261-2076
E-mail: rking@ismanet.org
Internet address: www.ismanet.org

Indiana Pharmacists Alliance


Lawrence J. Sage
Executive Vice President
729 N. Pennsylvania, Suite 1171
Indianapolis, IN 46204-1171
T: 317/634-4968
F: 317/632-1219
Email: inpharm@indianapharmacists.org
Internet address: www.indianapharmacists.org

Indiana Osteopathic Association


Terry Iwasko, D.O.
President
3520 Guion Road, Suite 202
Indianapolis, IN 46222-1672
T: 317/926-3009
F: 317/926-3984
Email: info@inosteo.org
Internet address: www.inosteo.org

State Board of Pharmacy


Joshua Bolin
Director
402 W. Washington Street, Room 041
Indianapolis, IN 46204-2739
T: 317/234-2067
F: 317/233-4236
Email: hpb4@hpb.state.in.us
Internet address: www.in.gov/hpb/boards/isbp

Indiana Hospital and Health Association


Kenneth G. Stella
President
One American Square
P.O. Box 82063
Indianapolis, IN 46282
T: 317/633-4870
F: 317/633-4875
Internet address: www.inha.org

National Pharmaceutical Council Indiana-5


Pharmaceutical Benefits 2002

6-Indiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

IOWA

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $193,832,443 212,178 $230,430,967 221,691

RECEIVING CASH ASSISTANCE TOTAL $100,555,605 103,217 $114,379,584 106,099


Aged $13,767,752 7,089 $14,750,173 6,734
Blind/Disabled $71,452,959 32,561 $81,135,611 32,484
Child $6,199,907 37,726 $7,586,771 39,126
Adult $9,134,987 25,841 $10,907,029 27,755

MEDICALLY NEEDY, TOTAL $11,931,960 6,673 $13,202,042 6,191


Aged $4,201,568 2,643 $3,922,542 2,287
Blind/Disabled $6,624,010 2,352 $7,976,548 2,034
Child $224,083 272 $154,791 278
Adult $882,299 1,406 $1,148,161 1,592

POVERTY RELATED, TOTAL $7,214,153 42,643 $8,996,176 46,728


Aged $586,638 1,037 $513,385 843
Blind/Disabled $791,858 896 $740,862 756
Child $4,928,129 33,469 $6,629,188 37,819
Adult $907,528 7,241 $1,112,741 7,310

TOTAL OTHER EXPENDITURES/RECIPIENTS* $74,130,725 59,645 $93,853,165 62,673

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

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

National Pharmaceutical Council Iowa-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION − Pseudoephedrine Hydrochloride: 30/60 mg Tablets;


30mg/5mg Liquid
State Department of Human Services, Bureau of Long − Salicylic Acid Liquid 17%
Term Care. − Senokot: 326 mg/tsp Granules for children aged 20
and under; 187 mg Tablets for children aged 20 and
D. PROVISIONS RELATING TO DRUGS under
− Sodium Chloride Solution 0.9% for inhalation, with
Benefit Design metered dispensing valve 90 ml, 240 ml
Drug Benefit Product Coverage: Products covered: − Tolnaftate 1% Cream, Solution, Powder
prescribed insulin. Products covered requiring prior − Nonprescription multiple vitamin and mineral
authorization: PPIs; dipyridamole; epoetin; filgrastim; products specifically formulated and recommended for
vitamins and minerals; ergotamine derivatives; narcotic use as a dietary supplement during pregnancy and
agonist-antagonist nasal sprays; isotretinoin; oral lactation
antifungals; non-parenteral vasopressin derivatives; and − With prior authorization, nonprescription multiple
Serotonin 5-HT1 receptor agonists. Products not covered: vitamins and minerals under the conditions specified
fertility drugs; experimental drugs; cosmetics; disposable in subparagraph 78.1(2) “a” (3)
needles and syringe combinations for insulin; blood − Insulin
glucose test strips; urine ketone test strips; total parenteral − Oral solid forms of the above-covered items shall be
nutrition; and interdialytic parenteral nutrition. prescribed and dispensed in a minimum quantity of
100 units per prescription or the currently available
Over-the-Counter Product Coverage: Products covered consumer package size except when dispensed via a
with restriction (selected products): allergy, asthma and unit dose system. When used for maintenance therapy,
sinus products; analgesics; cough and cold preparations; all of the above-listed items may be prescribed and
and topical products. Products not covered: digestive dispensed in 90-day quantities
products (non-H2 antagonists and H2 antagonists);
feminine products; and smoking deterrent products.
Therapeutic Category Coverage: Therapeutic categories
The Iowa Department of Human Services adopted an covered: anabolic steroids; antibiotics; anticoagulants;
administrative rule that permits coverage for these non- anticonvulsants; antidepressants; antidiabetic agents;
prescription drugs: antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents;
− Aspirin: 325/650 mg Tabs; 81mg Chewable; Aspirin prescribed cold medications; contraceptives; ENT anti-
Enteric Coated: 325/650mg Tabs; 81mg Chewable; inflammatory agents; estrogens; hypotensive agents;
Aspirin Tablets Buffered, 325 mg sympathominetics (adrenergic); and thyroid agents. Prior
− Acetaminophen: 325/500mg Tablets; 120mg/5ml and authorization required for: analgesics, antipyretics,
160mg/5mL Elixir; 100 mg/ml Solution; 120mg NSAIDs; amphetamines; antihistamine drugs; growth
Suppositories hormones; and misc. GI drugs. Therapeutic categories not
− Bacitracin Ointment 500 units/gm covered: anorectics; prescribed smoking deterrents; drugs
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion, for strictly cosmetic purposes and hair growth; fertility
Cream, Gel drugs; and drugs without signed Medicaid rebate
− Chlorpheniramine Maleate Tablets 4 mg agreements.
− Diphenhydramine Hydrochloride: 25 mg Capsules;
6.25mg/5mL and 12.5mg/5ml Liquid Coverage of Injectables: Injectable medicines
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml reimbursable through the Prescription Drug Program and
Elixir; 75 mg/0.6 ml Drops physician payment when used in physicians offices.
− Ferrous Gluconate: 300/325mg Tablets; 300mg/5ml
Elixir Vaccines: Vaccines reimbursable as part of the EPSDT
− Ferrous Fumarate Tablets 300 mg, 325 mg service and the Vaccines for Children Program.
− Guafenesin 100 mg/5 ml with Dextromethorphan 10
mg/5 ml liquid Unit Dose: Unit dose packaging reimbursable.
− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg
− Miconazole Nitrate: Topical and Vaginal Cream 2%,
Vaginal Suppositories, 100mg
− Nicotinic Acid (Niacin) Tablets: 25/50/100/250/500
mg
− Pediatric Oral Electrolyte Solutions
− Permethrin Liquid 1%

2-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2002

Formulary/Prior Authorization 4201 Westown Parkway, Suite 325


Formulary: No formulary. West DesMoines, IA 50266-6270
515/327-2004
Prior Authorization: State currently has a formal prior
authorization procedure. State appeals and a fair hearing Coventry Health Care of Iowa
procedure required for appeal of prior authorization Jennifer Goodell
decisions and coverage of an excluded product. Account Manager
4600 Westown Parkway, Suite 301
Prescribing and Dispensing Limitations: Des Moines, IA 50266
Prescribing or Dispensing Limitations: Maximum 30 day 515/225-1234
supply except select maintenance drugs (90 days)
Iowa Health Solutions
including oral contraceptives, cardiac drugs, hypotensive
Bob Wilcox
agents, antidiabetic agents, diuretics, anticonvulsants and
Vice President
thyroid/antithyroid agents.
2550 Middle Road, Suite 405
Drug Utilization Review Bettendorf, IA 52722
PRODUR system implemented in July 1997. State 319/359-8999
currently has a DUR Board with a monthly review.
Pharmacy Payment and Patient Cost Sharing F. STATE CONTACTS
Dispensing Fee: $5.17, effective 7/1/00. State Drug Program Administrator
Susan L. Parker, Pharm.D.
Ingredient Reimbursement Basis: EAC = AWP-10%. Pharmacy Consultant
Division of Medical Services
Prescription Charge Formula: Payment will be based on Bureau of Long Term Care
the pharmacist's usual, customary and reasonable charge, Hoover State Office Bldg.
but payment may not exceed EAC plus a dispensing fee. Des Moines, IA 50319
T: 515/281-3002
Maximum Allowable Cost: State imposes Federal Upper F: 515/281-8512
Limits as well as state-specific limits on generic drugs. E-mail: sparker2@dhs.state.ia.us
Override requires “Brand Medically Necessary,”
Prior Authorization Contact
completion of a Med watch form, and prior authorization.
Randy Brentnall, R.Ph.
ACS
Incentive Fee: None.
P.O. Box 14422
Des Moines, IA 50306-3422
Patient Cost Sharing: Copayment of $1.00 for branded
T: 515/327-0950 ext. 1322
and generic (federal exclusions) products.
F: 515/327-0945
Cognitive Services: Does not pay for cognitive services. DUR Contact
Julie Kuhle, R.Ph.
DUR Coordinator
E. USE OF MANAGED CARE Iowa Pharmacy Association
8515 Douglas Ave, Suite 16
Approximately 110,000 Medicaid beneficiaries are Des Moines, IA 50322
enrolled in managed care organizations. Iowa Medicaid T: 515/270-0713
recipients enrolled in managed care receive F: 515/270-2979
pharmaceutical benefits through the State.

Managed Care Organizations


John Deere Health Care, Inc.
Kristine Klaver
1300 River Drive, Suite 200
Moline, IL 61265-1368
309/765-1482

Timothy J. Gibson
Area Manager, Central Iowa

National Pharmaceutical Council Iowa-3


Pharmaceutical Benefits 2002

Medicaid DUR Board Physician-Administered Drug Program Contact


Ralph Stanifer, M.D. Sherry Swanson
Ilyenn Wiesley, R.Ph. ACS
Sharon Meyer, Pharm.D., M.S. P.O. Box 14422
Ronald Miller, M.D., M.B.A. Des Moines, IA 50306-3422
Bruce Alexander, R.Ph., Pharm. D. T: 515/327-0950 ext. 1107
Sandi Birchem, D.O. F: 515/327-0945
George Kappos, M.D.
Iowa Pharmacy Association Medicaid Pharmacy
Dan Murphy, R.Ph.
Advisory Committee
Julie Kuhle, R.Ph., Project Coordinator
Tim Becker (Chair)
Nancy Bell, R.Ph.
Mason City, IA
Janalyn Phillips, R.Ph.
641/422-6100
Susan Parker, Pharm.D.
Prescription Price Updating David Brotherson (Vice Chair)
Sherry Swanson Davenport, IA
Deputy Account Manager 563/388-1887
ACS
P. O. Box 14422 Hal Jackson
Des Moines, IA 50306-3422 Winterset, IA
T: 515/327-0950 ext. 1107 515/462-2479
F: 515/327-0945
Russ Wiesley
Medicaid Drug Rebate Contacts
Waukee, IA
Technical: Rocco Russo, 515/327-0950 ext. 1114
515/987-8111
Audits: Rocco Russo, 515/327-0950 ext. 1114
DUR: Julie Kuhle 515/270-0713
Matthew Shivers
PA: Randy Brentnall, 515/327-0950 ext. 1322
Burlington, IA
Claims Submission Contact 319/753-0112
Mindy Ruby
Claims Manager Jerry Hartleip
ACS Waterloo, IA
P. O. Box 14422 319/234-1589
Des Moines, IA 50306-3422
T: 515/327-0950 ext. 1108 Mary Tasler
F: 515/327-0945 LaPorte City, IA
319/272-5700
Medicaid Managed Care Contact
Dennis Janssen
Joe Mahrenholz
MHC Program Manager
Panora, IA
Bureau of Managed Care and Clinical Services
641/755-3052
Hoover Building, 5th Floor
T: 515/281-8747
Marilyn Aldrich
F: 515/281-8512
DSM
E-mail: djansse@dhs.state.ia.us
515/255-8642
Mail Order Pharmacy Program
Larry Costello
State currently has a mail order pharmacy program. Mason City, IA
Participating pharmacies must be enrolled as an Iowa 641/424-1343
Medicaid provider.
Wally Tschopp
Hartley, IA
712/728-2165

Joe Cunningham
Waukon, IA
563/568-6315

4-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2002

Robert Dean Title XIX Medical Assistance Advisory Council


Sioux City, IA College of Medicine
712/252-2761 Stacey T. Cyphert, Ph.D.
Assistant Vice President-Statewide Health Services
Sue Testroet Senior Assistant Director of University Hospitals and
Bettendorf, IA Clinics
563/324-5004 The University of Iowa
Iowa City, IA 52242-1009
Sally Horst
Maquoketa, IA House of Representatives
563/652-5611 Andra Attenberry
1034 Sherman Avenue
Dennis Killion Manchester, IA 52057
Red Oak, IA
712/623-3370 Brad Hansen
1015 Shoal Pointe Dr.
Steve Firman Carter Lake, IA 51510
Cedar Falls, IA
319/352-4440 Iowa Nurses Association
Linda Goeldner
Leman Olson 1501 42nd Street, Suite 471
Mason City, IA West Des Moines, IA 50266
641/422-7917
Iowa Medical Society
David Gavin Angela Dorsey
Indianola, IA Manager of Legislative Affairs
515/961-2191 1001 Grand Avenue
West Des Moines, IA 50265
Alan Shepley
Mount Vernon, IA Opticians Assn. of Iowa
319/895-6248 Vacant

Matt Osterhaus Iowa Senate


Maquoketa, IA Sen. Maggie Tinsman
563/652-5611 3541 E. Kimberly Road
Davenport, IA 52807
Gene Lutz
Altoona, IA Senator Jack Holveck
515/967-4213 2007 47th Street
Des Moines, IA 50310
Cora Lynn Becker
West Des Moines, IA Iowa Dept. of Public Health
515/360-0065 Anne Kinzel
State Planning Grant Project Director
Jim Wallace Lucas State Office Bldg., 5th Floor
Davenport, IA DesMoines, IA 50319-0075

Iowa Human Services Department Officials Public Representatives


Sally Titus Cunningham, Interim Director Vacant
Dept. of Human Services
Hoover State Office Bldg., 5th Floor Mary Ann Weber
Des Moines, IA 50319-0014 565 Greenwood Court
T: 515/281-5452 Dubuque, IA 52001
F: 515/281-7791
E-mail: scunnin@dhs.state.ia.us Orvil Nelson
1534 Second Street
Boone, IA 50036

National Pharmaceutical Council Iowa-5


Pharmaceutical Benefits 2002

Jodi Tomlonovic George W. Appleby


Executive Director Carney, Appleby, Neilson and Skinner PLC
Family Planning Council of Iowa 303 Locust Street, 400 Homestead Building
108 Third Street, Suite 220 Des Moines, IA 50309
Des Moines, IA 50309
Iowa Osteopathic Medical Association
Iowa Speech & Hearing Association Leah McWilliams
Barbara Vogen Executive Director
Central Rehabilitation, Ltd. 950 12th St.
950 Office Park Road, Suite 100 Des Moines, IA 50309-1001
West Des Moines, IA 50265
Iowa Optometric Association
Iowa Hospital Association Gary Ellis
Tracy Warner 1454 30th Street, Suite 204
100 E. Grand Avenue, Suite 100 West Des Moines, IA 50266-1312
Des Moines, IA 50309-1835
Iowa Podiatric Medical Association
Iowa Health Care Association Dr. Richard Spencer
Steve Ackerson Spencer Foot & Ankle Clinics
Executive Director 110 East McLane
6750 Westown Parkway, Suite 100 Osceola, IA 50213
West Des Moines, IA 50266-7726
Iowa Psychological Society
Iowa Assn. for Home Care Mark Peltan, Ph.D.
Larry L. Breeding Mercy Medical Center-North Iowa
Executive Director 1000 4th Street, SW
1520 High Street, Suite 203-B Mason City, IA 50401-2921
Des Moines, IA 50309
Iowa Association of Hearing Health Professionals
Iowa Chiropractic Society Bev Thomas
Dr. Terry Burk Executive Director
P.O. Box 370 1001 Office Park Road, Suite 105
Huxley, IA 50124 West DesMoines, IA 50265

Iowa Pharmacy Association Alliance for the Mentally Ill of Iowa


Jerry Karbeling Margaret Stout
8515 Douglas, Suite 16 5911 Meredith Drive, Suite E
Des Moines, IA 50322 Urbandale, IA 50322

Iowa Assn. of Homes and Services for the Aging


Dana Petrowsky
President
1701 48th Street, Suite 203
West Des Moines, IA 50266-6723

Iowa Association of Community Providers


Michelle Wray
Abbe Inc.
800 First Street, NW
Cedar Rapids, IA 52405

Iowa Dental Association


Larry Carl
Executive Director
505 5th Avenue, Suite 333
Des Moines, IA 50309

Iowa Council of Health Care Centers

6-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2002

Iowa Psychiatric Society Iowa Chapter-Am. Academy of Pediatrics


Karen Loihl Rizwan Z. Shah, M.D.
2643 Beaver, Suite 338 Children’s Health Center
Des Moines, IA 50310 1212 Pleasant Street
Des Moines, IA 50309
Iowa Governor’s Developmental Disabilities Council
Executive Officers of State Medical and
Rick Shannon
Pharmaceutical Societies
617 E. 2nd Street
Iowa Medical Society
Des Moines, IA 50309
Michael Abrams
Executive Vice President
Iowa Academy of Family Physicians
1000 Grand Avenue West
Dr. Dave Carlyle
Des Moines, IA 50265
1215 Duff Avenue
T: 515/223-1401
Ames, IA 50010
F: 515/223-0590
E-mail: mambrams@iowamedical.org
Iowa Physical Therapy Association
Internet addresss: www.iowamedical.org
Michael Mandel
1228 8th Street, Suite 106
Iowa Pharmacy Association
West Des Moines, IA 50265-2624
Thomas R. Temple, R.Ph., M.S.
Executive Vice President & CEO
Iowa Physician Assistant Society
8515 Douglas, Suite 16
Michael Farley
Des Moines, IA 50322-2927
4524 Boulevard Pl.
T: 515/270-0713
Des Moines, IA 50311
F: 515/270-2979
E-mail: ipa@iarx.org
Iowa Association of Nurse Practitioners
Internet address: www.iarx.org
Wanda Marshall
Children’s Health Center
Iowa Osteopathic Medical Association
1212 Pleasant Avenue, Suite 300
Leah McWilliams
Des Moines, IA 50309
Executive Director
950 12th St.
Iowa Association of Rural Health Clinics
Des Moines, IA 50309-1001
Ed Friedmann
T: 515/283-0002
1013 1st Street, Box C
F: 515/283-0355
Redfield, IA 50233
E-mail: leah@ioma.org
Internet address: www.ioma.org
Iowa Occupational Therapy Association
Angela Hansen-Abbas
State Board of Pharmacy Examiners
161 315th St.
Lloyd K. Jessen
Perry, IA 50220
Executive Secretary/Director
400 SW 8th St., Suite E
The ARC of Iowa
Des Moines, IA 50309-4688
Vacant
T: 515/281-5944
F: 515/281-4609
Des Moines University-Osteopathic Medical Center
E-mail: debbie.jorgenson@ibpe.state.ia.us
Howard S. Teitelbaum, D.O., Ph.D., M.P.H.
Internet address: www.state.ia.us/ibpe
Dean of OMS
3200 Grand Avenue
The Association of Iowa Hospitals and Health Systems
Des Moines, IA 50312
J. Kirk Norris
President
Iowa Chapter-Nat’l. Association of Social Workers
100 East Grand Avenue
Jay J. Cayner, A.C.S.W., L.I.S.W.
Suite 100
Assistant Hospital Director and Director, Social, Patient,
Des Moines, IA 50309-1835
and Family Services
T: 515/288-1955
University of Iowa Hospitals and Clinics
F: 515/283-9366
200 Hawkins Drive
E-mail: norrisk@ihaonline.org
Iowa City, IA 52242

National Pharmaceutical Council Iowa-7


Pharmaceutical Benefits 2002

8-Iowa National Pharmaceutical Council


Pharmaceutical Benefits 2002

KANSAS

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $167,216,488 158,334 $189,290,260 158,515

RECEIVING CASH ASSISTANCE TOTAL $75,748,711 56,573 $85,089,631 58,792


Aged $8,192,697 4,381 $8,618,107 4,187
Blind/Disabled $61,896,472 29,392 $70,087,687 29,828
Child $2,367,507 13,048 $2,774,647 14,115
Adult $3,292,035 9,752 $3,609,190 10,662

MEDICALLY NEEDY, TOTAL $12,935,273 7,207 $11,665,933 8,314


Aged $4,876,847 3,850 $2,421,349 1,362
Blind/Disabled $7,987,152 3,102 $8,335,032 2,898
Child $53,732 166 $331,900 1,946
Adult $17,542 89 $577,652 2,108

POVERTY RELATED, TOTAL $9,870,105 53,581 $10,333,897 49,242


Aged $553,577 569 $484,846 470
Blind/Disabled $1,225,234 772 $1,460,600 867
Child $7,271,974 44,984 $7,711,591 41,266
Adult $819,320 7,256 $676,860 6,639

TOTAL OTHER EXPENDITURES/RECIPIENTS* $68,662,399 40,973 $82,200,799 42,167

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

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

National Pharmaceutical Council Kansas-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure. The individual appealing may
State Department of Social and Rehabilitation Services. request an administrative hearing to appeal a prior
authorization hearing by sending a request in writing to:
D. PROVISIONS RELATING TO DRUGS
Administrative Hearing Office
Benefit Design 610 S.W. 10th Ave, 2nd Floor
Drug Benefit Product Coverage: Products covered: Topeka, KS 66612-1616
prescribed insulin: Products covered under DME: Prescribing or Dispensing Limitations
disposable needles and syringe combinations used for
insulin; blood glucose test strips; urine ketone test strips; Monthly Prescription Limit: 5 single source
and total parenteral nutrition. Products covered with scripts/month.
restriction: interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; experimental drugs; Prescription Refill Limit: As authorized by the prescriber
DESI drugs; and drugs not rebated by the manufacturer. and allowed by statute up to a one-year period from the
date of issuance of the prescription for non-controlled
Over-the-Counter Product Coverage: Products covered: drugs. No early refills (<75% Rx utilized).
analgesics (for adults); digestive products (H2 antagonist);
and antifungals. Products covered with restrictions: cough Monthly Quantity Limit: 31-day supply.
and cold preparations (for children), smoking deterrent
products (limited time period). Products not covered: Other: Narcotics, Viagra, Ketorolac, Toradol and
allergy, asthma and sinus products; digestive products Relenza have other specific limits.
(non-H2 antagonists); feminine products; topical products; Drug Utilization Review
and nutritional supplements.
PRODUR system implemented in November 1996. State
Therapeutic Category Coverage: Therapeutic categories currently has a DUR Board that meets every two months.
covered: anabolic steroids; analgesics (for children), Pharmacy Payment and Patient Cost Sharing
antipyretics (for children), NSAIDs; antibiotics;
anticoagulants; anticonvulsants; antidepressants; Dispensing Fee: $3.40, effective 7/1/02.
antidiabetic agents; antihistamine drugs; anti-psychotics Ingredient Reimbursement Basis: EAC Brand, = AWP -
antilipemic agents; cardiac drugs; chemotherapy agents; 13%. Generics, AWP-27%. #IV fluids, AWP-
contraceptives; ENT anti-inflammatory agents; estrogens; 50%.#Blood fraction products, AWP-30%.
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); and thyroid agents. Partial coverage for: Prescription Charge Formula: Pharmacies are
prescribed cold medications; prescribed smoking reimbursed the lesser of usual and customary, MAC,
deterrents. Prior authorization required for: anxiolytics, FUL, or acquisition cost (EAC) plus a dispensing fee.
sedatives, and hypnotics; anorectics; growth hormones;
triptans; nasal steroids; PPIs, statins; H2 antagonists; and Maximum Allowable Cost: State imposes Federal Upper
non-preferred drugs. Limits as well as State-specific maximum allowable cost
(MAC) limits on generic drugs.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program when Incentive Fee: None.
used in home health care and extended care facilities, and
through physician payment program when used in Patient Cost Sharing: A recipient copay charge of $3.00
physician offices. (effective 7/02) applies to each new and refill prescription
not specifically exempted under Federal regulations.
Vaccines: Vaccines reimbursed as part of the Children
Health Insurance Program and the Vaccines for Children Cognitive Services: Does not pay for cognitive services.
Program.
E. USE OF MANAGED CARE
Unit Dose: Unit dose packaging not reimbursable.
Approximately 44,500 Medicaid Recipients were
Formulary/Prior Authorization
enrolled in MCOs in FY 2001. Recipients receive
Formulary: State currently maintains a closed formulary pharmaceutical benefits through both the state and
with a Preferred Drug List (PDL). Prior authorization managed care plans.
required for non-PDL products.
Managed Care Organizations
First Guard

2-Kansas National Pharmaceutical Council


Pharmaceutical Benefits 2002

3801 Blue Pkwy Topeka, KS 66612-1570


Kansas City, MO 64130 T: 785/296-3667
F: 785/296-4813
F. STATE CONTACTS E-mail: DJZ.B@srskansas.org
State Drug Program Administrator Mail Order Pharmacy Program
Mary H. Obley, Pharmacist None
Health Care Policy Division Social and Rehabilitation Services Department
Department of Social and Rehabilitation Services Officials
915 SW Harrison, Rm. 651-S Janet Schalansky
Topeka, KS 66612-1570 Secretary
T: 785/296-8406 Department of Social and Rehabilitation Services
F: 785/296-4813 Docking State Office Bldg.
E-mail: mho@srskansas.org 915 SW Harrison
Internet Address: www.srskansas.org Topeka, KS 66612-1570
Prior Authorization Contact T: 785/296-3271
Mary H. Obley, Pharmacist F: 785/296-2173
785/296-8406 E-mail: JKS@srskansas.org
DUR Contact Medical Care Advisory Committee Contact
Mary H. Obley Pharmacist Robert Day, Ph.D.
785/296-8406 Commissioner
DUR Board Adult and Medical Services
Michael Burke, M.D., Ph.D. Dept. of Social and Rehabilitation Services
Barry Sarvis, R.Ph. 915 SW Harrison
Jim Bachus, R.Ph. Topeka, KS 66612-1570
John Lowdermilk, R.Ph. T: 785/296-3981
Linda Frey, R.N. F: 785/296-4813
Brenda Shewe, M.D. E-mail: rmd@srskansas.org
John Whitehead, D.O. Executive Officers of State Medical and
Prescription Price Updating Pharmaceutical Societies
Mary H.Obley, Pharmacists Kansas Medical Society
785/296-8406 Karen Hagen
President
Medicaid Drug Rebate Contacts 623 SW 10th Avenue
Policy: Mary H. Obley, Pharmacist Topeka, KS 66612
785/296-8406 T: 785/235-2383
F: 785/235-5114
Technical: Vick Schmidt, Pharmacist E-mail: karenhagen@comcast.net
Drug Rebate Internet address: www.kmsonline.org
EDS
360 SW Topeka Boulevard
Suite 204
Topeka, KS 66611
785/274-5937
Claims Submission Contact
EDS
360 SW Topeka Boulevard
Suite 204
Topeka, KS 66611 Kansas Pharmacists Association
785/274-5939 Robert R. Williams, M.S., CAE
Executive Director
Medicaid Managed Care Contact 1020 SW Fairlawn Road
Debra Bachmann, R.N. IV Topeka, KS 66604-2275
Manager, Health Wave XIX T: 785/228-2327
Health Care Policy Division, Kansas Dept. of SRS F: 785/228-9147
915 SW Harrison, Rm. 651-S E-mail: info@kansaspharmacy.org

National Pharmaceutical Council Kansas-3


Pharmaceutical Benefits 2002

Internet address: www.kansaspharmacy.org

Kansas Association of Osteopathic Medicine


Harold Riehm, CAE
Executive Director
1260 SW Topeka Boulevard
Topeka, KS 66612
T: 785/234-5563
F: 785/234-5564
E-mail: kansasdo@aol.com

State Board of Pharmacy


Susan Linn
Executive Director
Landon State Office Building
900 Jackson, Room 513
Topeka, KS 66612
T: 785/296-4056
F: 785/296-8420
E-mail: pharmacy@ink.org
Internet address: www.accesskansas.org

Kansas Hospital Association


Thomas Sipe
President
215 Southeast Eighth Street
Topeka, KS 66603
785/276-3116
E-mail: cyelkin@kha-net.org
Internet address: www.kha.org

4-Kansas National Pharmaceutical Council


Pharmaceutical Benefits 2002

KENTUCKY

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $465,178,958 427,514 $598,093,343 475,365

RECEIVING CASH ASSISTANCE, TOTAL $326,458,102 213,429 $424,804,782 235,058


Aged $30,876,495 17,219 $37,547,483 16,692
Blind / Disabled $274,483,368 131,650 $355,245,438 137,989
Child $8,650,123 42,996 $12,748,175 51,834
Adult $12,448,116 21,564 $19,263,686 28,543

MEDICALLY NEEDY, TOTAL $17,528,881 29,057 $19,756,137 24,343


Aged $4,268,258 1,966 $4,859,165 2,018
Blind / Disabled $3,233,791 1,685 $3,736,659 1,645
Child $2,948,612 14,111 $3,032,751 11,256
Adult $7,078,220 11,295 $8,127,562 9,424

POVERTY RELATED, TOTAL $25,437,087 130,605 $40,038,880 160,513


Aged $554,301 583 $557,666 595
Blind / Disabled $994,423 786 $1,299,771 941
Child $21,676,976 112,649 $35,140,791 140,715
Adult $2,211,387 16,587 $3,040,652 18,262

TOTAL OTHER EXPENDITURES/RECIPIENTS* $95,754,888 54,423 $113,493,544 55,451

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

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

National Pharmaceutical Council Kentucky-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Closed Formulary. The Kentucky Medicaid
Department for Medicaid Services, within the Cabinet for Program maintains a closed formulary of approximately
Health Services. 96,800 drugs and covers all rebated products. The State
manages the formulary through a variety of techniques
D. PROVISIONS RELATING TO DRUGS including the exclusion of products based on contracting
Benefit Design issues, restrictions on use, prior authorization, algorithms,
and preferred products.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; syringe combinations used for insulin. Prior Authorization: State currently has a prior
Products covered with restrictions (i.e., require prior authorization procedure. A formal appeals process is
authorization): total parenteral nutrition; and interdialytic available if a request is denied.
parenteral nutrition. Products not covered: cosmetics;
fertility drugs; experimental drugs; disposable needles Prescribing or Dispensing Limitations
used for insulin; blood glucose test strips; and urine Prescription Refill Limit: (1) No prescriptions may be
ketone test strips. refilled more than 5 times or more than 6 months after the
prescription is written. (2) After initial filling, one
Over-the-Counter Product Coverage: Products covered dispensing fee per 30-day period for designated
with restrictions (i.e., require prior authorization): allergy, maintenance drugs.
asthma and sinus products; analgesics; cough and cold
preparations; digestive products (H2 and non-H2 Monthly Quantity Limit: For designated classes of
antagonists); feminine products and topical products. maintenance drugs, refills of the original prescription and
Products not covered: smoking deterrent products. subsequent prescriptions for these drugs must be
prescribed and dispensed in quantities of not less than a
Therapeutic Category Coverage: Therapeutic categories 30 day supply unless the prescriber requests an exception
covered: antibiotics; anticoagulants; anticonvulsants; to his policy.
antidepressants; antidiabetic agents; cardiac drugs; Drug Utilization Review
contraceptives; ENT anti-inflammatory agents; estrogens;
sympathominetics (adrenergic); and thyroid agents. Prior PRODUR system implemented in 1987. State currently
authorization required for: anabolic steroids; analgesics, has a DUR Board with a quarterly review.
antipyretics, NSAIDs; anoretics; antihistamine drugs; Pharmacy Payment and Patient Cost Sharing
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; chemotherapy agents; prescribed cold Dispensing Fee: $4.51, effective 1/16/01.
medications; growth hormones; hypotensive agents; misc.
GI drugs; and topical steroids. Therapeutic categories not Ingredient Reimbursement Basis: EAC = AWP-12%.
covered: prescribed smoking deterrents; agents for
cosmetic purposes or hair growth and agents to promote Prescription Charge Formula: Reimbursement consists of
fertility. the lowest of: (1) the usual and customary charge; (2) the
FMAC, if any, plus a dispensing fee; or (3) the EAC plus
Coverage of Injectables: Injectable medicines a dispensing fee.
reimbursable through the Prescription Drug Program
when used in home health care and extended care facilities Maximum Allowable Cost: State imposes Federal Upper
and through both the Prescription Drug Program and Limits on generic drugs. Override requires “Brand
physician payment when used in physician offices. Necessary,” “Brand Medically Necessary,” or Prior
Reimbursement is limited to antineoplastic drugs with “J” Authorization.
codes in physician offices, several antibiotics, Depo-
Provera for birth control. Incentive Fee: None.

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.

Unit Dose: Unit dose packaging reimbursable.

2-Kentucky National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE Drug Management Review Advisory Board

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

National Pharmaceutical Council Kentucky-3


Pharmaceutical Benefits 2002

Claims Submission Contact Leslie H. Rogers


Unisys Provider Services 109 Daniel Drive
P.O. Box 2100 Hazard, KY 41701
Frankfort, KY 40602 William T. Watkins, M.D.
T: 502/226-1140 125 Volunteer Drive
F: 502/226-1860 Somerset, KY 42501
606/679-2169
Medicaid Managed Care Contact
Lorraine Dumas Frank A. Butler, Hospital Director
Department of Medicaid Services University of Kentucky Hospital
CHR Building, 6 E-C 800 Rose Street
275 E. Main St Lexington, KY 40536-0084
Frankfort, KY 40621 606/323-5767
T: 502/564-4923
F: 502/564-0223 Faye Hensley, R.N.
E-mail: Lorraine.Dumas@mail.state.ky.us P.O. Box 85
Manchester, KY 40962
Mail Order Pharmacy Program
Sate currently has a mail order pharmacy program. Mail
Bettie Speicher Weyler
order pharmacy program is open to all Medicaid
3420 Grandview Avenue
recipients. Must use a pharmacy that participates in the
Louisville, KY 40207
Kentucky Medicaid Program.
502/893-4964
Physician-Administered Drug Program Contact
Barbara Utter Bob Gray
275 East Main Street 2504 Duke Drive, Apt. 24
Frankfort, KY 40621 Owensboro, KY 42301
502/564-2687 502/685-2976
Department for Medicaid Services Officials Donnie Wilhite
Marcia R. Morgan, Secretary 106 Creekstone Court
Cabinet for Human Resources Frankfort, KY 40601
CHR Building, 5 W-A 502/223-1052
275 East Main Street
Frankfort, KY 40621 Betty Rose Boyd
502/564-7130 Apt. #19, Highland Heights
State Advisory Council on Medical Assistance Prestonsburg, KY 41653
Chester L. Parker, Pharm.D., R.Ph. 606/886-0343
2086 Old Nassau
Lexington, KY 40504 Marianne Keller
606/277-5723 The Good Samaritan Center
106177 Watterson Terrace
Chester A. Nava, Jr., D.P.M. Jeffersontown, KY 40299
110 North Hubbards Lane 502/267-7403
Louisville, KY 40207-3903
502/897-2047 Patricia Conner-Young
10409 Christina Court
Carol J. Braun, D.D.S. Louisville, KY 40223
2816 Veach Road 502/5835034
Owensboro, KY 42303
502/683-7114 Nancy Durham
8900 Hawley-Gibson
James A. Burcham Crestwood, KY 40014
P.O. Box 20 502/241-9072
Burlington, KY 41005 Vicki Prichard
606/431-2244 222 Ft. Mitchell Avenue
Fr. Mitchell, KY 41011
606/344-0277

4-Kentucky National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

Kentucky Pharmacists Association


Mike Mayes, FACHE
Executive Director
1228 U.S. Highway 127 South
Frankfort, KY 40601
T: 502/227-2302
F: 502/227-2854
Internet address: www.kphanet.org

State Board of Pharmacy


Michael A. Mone
Executive Director
23 Millcreek Park
Frankfort, KY 40601-9230
T: 502/573-1580
F: 502/573-1582
Internet address: www.state.ky.us/boards/pharmacy

Kentucky Society of Health-System Pharmacists


Dwaine K. Green
Executive Vice President
One Quality Street
Lexington, KY 40507-1428
E-mail: dgree1@uky.edu
Internet address: www.kshp.org

Kentucky Osteopathic Medical Association


Tom Underwood
Executive Director
1501 Twilight Trail
Frankfort, KY 40601
T: 502/223-5322
F: 502/223-4937
Internet address: www.koma.org

Kentucky Hospital Association


Michael T. Rust
President
2501 Nelson Miller Parkway
Louisville, KY 40223
T: 502/992-4380
F: 502/426-6226
Internet address: www.kyha.com

National Pharmaceutical Council Kentucky-5


Pharmaceutical Benefits 2002

6-Kentucky National Pharmaceutical Council


Pharmaceutical Benefits 2002

LOUISIANA

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $476,400,908 581,356 $547,731,897 594,364

RECEIVING CASH ASSISTANCE, TOTAL $310,302,551 260,107 $351,387,693 259,405


Aged $86,327,808 43,091 $91,902,271 41,683
Blind/Disabled $196,365,331 114,002 $227,169,789 114,935
Child $13,267,175 68,187 $15,071,139 64,596
Adult $14,342,237 34,827 $17,244,494 38,191

MEDICALLY NEEDY, TOTAL $5,713,428 4,553 $7,085,668 5,470


Aged $2,409,629 1,079 $2,977,860 1,238
Blind/Disabled $2,006,295 1,160 $2,574,449 1,411
Child $54,995 252 $61,884 215
Adult $1,242,509 2,062 $1,471,475 2,606

POVERTY RELATED, TOTAL $45,860,182 206,436 $67,020,934 260,160


Aged $1,826,705 1,452 $1,987,183 1,371
Blind/Disabled $1,475,603 1,122 $1,481,920 1,336
Child $38,639,381 176,609 $59,094,838 228,683
Adult $3,918,493 27,253 $4,456,993 28,770

TOTAL OTHER EXPENDITURES/RECIPIENTS* $114,524,747 110,260 $122,237,602 69,329

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

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

National Pharmaceutical Council Louisiana-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION be either 30-day supply or 100 unit doses, whichever is


greater. Monthly limit of 8 prescriptions per recipient.
Department of Health and Hospitals.
Other: Viagra and other drugs to treat impotence are
D. PROVISIONS RELATING TO DRUGS limited to a quantity of 6 pills per month.

Benefit Design Drug Utilization Review

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:

1. AWP minus 13.5% for independent pharmacies and


Therapeutic Category Coverage: All except cosmetics,
AWP minus 15% for chain pharmacies plus a
cough and cold preparations, DESI drugs and
dispensing fee for single source products or multiple
experimental drugs. Prior authorization required for:
source products with no maximum allowable cost
analgesics, antipyretics, and NSAIDs; antibiotics;
limitations or when physician authorizes “Brand
anticoagulants; anti-depressants; antidiabetic agents;
Medically Necessary” for a brand name product
antihistamines; antilipemic agents; cardiac drugs;
which has a state MAC or FUL.
contraceptives; ENT anti-inflammatory agents; estrogens;
growth hormones; hypotensive agents; and misc. GI 2. Louisiana Maximum Allowable Costs (LMAC) or the
drugs. Federal Upper Limit plus the dispensing fee.
3. AWP for multi-source drugs when lower than FUL or
Coverage of Injectables: Injectable medicines
LMAC.
reimbursable when used in physician offices, home health
care, and extended care facilities. 4. The provider’s usual and customary charge to other
payors.
Vaccines: Vaccines reimbursable at cost as part of
EPSDT service and Vaccines for Children Program. Maximum Allowable Cost: State imposes Federal Upper
Limits as well as State-specific limits on generic drugs.
Unit Dose: Unit dose packaging reimbursable. Approximately 800 drugs are listed on the State-specific
MAC list. Override requires “Brand Necessary” or
Formulary/Prior Authorization “Brand Medically Necessary.”
Formulary: Open formulary. General restrictions include
prior authorization, preferred products, and physician Incentive Fee: None.
profiling.
Patient Cost Sharing: $ 0.50 - $3.00 copayment
Prior Authorization: State currently has a formal prior depending of the cost of the prescription, effective
authorization procedure but no method of appealing a 7/13/95.
prior authorization decision.
Cognitive Services: Does not pay for cognitive services
Prescribing or Dispensing Limitations
Prescription Refill Limit: Permitted as indicated by E. USE OF MANAGED CARE
physician within 6 months and not to exceed 5 refills.
Does not use MCOs to deliver services to Medicaid
Monthly Quantity Limit: New prescription must be issued recipients.
for drugs given on a continuing basis, after 5 refills or
after 6 months. Maximum quantity for prescriptions shall

2-Louisiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS W. Merwin McMahen, P.D.


Donna White, P.D.
State Drug Program Administrator Johnny Johnston, M.D.
Mary J. Terrebonne, P.D.
Pharmacy Program Director DUR Board
Department of Health & Hospitals Edwin Adams
1201 Capital Access Road, 6th Floor 120 Dove Drive
P.O. Box 91030 West Monroe, LA 71291
Baton Rouge, LA 70821 318/343-3562
T: 225/342-9768
F: 225/342-1980 Ken Ardoin, Senior Manager
E-mail: mterrebo@dhh.state.la.us State Government Relations
Internet Address: www.lamedicaid.com Pfizer, Inc.
7 Village Circle, Suite 400
Department of Health and Hospital Westlake, TX 76262
Administration Officials 817/491-8410
Ben A. Bearden, Director
Bureau of Health Services Financing Brad Belding, P.D.
Department of Health and Hospitals Director of Pharmacy
P.O. Box 91030 Thibodaux Hospital
Baton Rouge, LA 70821 402 Easy Street
T: 225/342-3891 Thibodaux, LA 70301
F: 225/342-9508 504/493-4786
E-mail: bbearden@dhhmail.dhh-state.la.us
Sylvia Heidingsfelder, M.D.
David W. Hood, Secretary 5805 Highland Road
Department of Health and Hospitals Baton Rouge, LA 70808
P.O. Box 629, Bin #2 225/358-1069
Baton Rouge, LA 70821
T: 225/342-9500 Susan Hinton, Pharm.D.
F: 225/342-9508 7680 Dune Drive
E-mail: bgulotta@dhh.state.la.us New Orleans, LA 70128
DUR Contact 504/483-7570
Mary J. Terrebonne, P.D., 225/342-9768
Richard Soileau
DUR Committee 401 ½ St Peters Street
Region I: New Iberia, LA 70560
Lisa Chetta, P.D. 337/365-6721
Donald Fellows, P.D.
Donna Robinson, P.D. Paul Staab, M.D.
Paul Staab, M.D. 5216 Lapalco Boulevard
Marrero, LA 70072
Region II: 504/348-4357
Leslie Day, P.D.
Blake Pitre, P.D. Charmaine Venters, M.D.
Don Ramirez, P.D. Earl K. Long Hospital
Charles Raborn, M.D. 5825 Airline Highway
Baton Rouge, LA 70805
Region III: 225/358-1063
John Baker, P.D.
Shawn McGee, P.D.
Joseph Vizena, P.D.
(Physician member vacancy)

Prescription Price Updating


Maggie Vick
Region IV: Unisys
Paul Chachere, P.D. 8591 United Plaza Boulevard, Suite 300
Baton Rouge, LA 70809

National Pharmaceutical Council Louisiana-3


Pharmaceutical Benefits 2002

T:225/237-3251 Ralph D. Balentine


F: 225/237-3334 Marcia Daigle
E-mail: margaret.vick@unisys.com Partricia DeMichele
Medicaid Drug Rebate Contacts Medicaid Pharmaceutical and Therapeutics
Technical: Timothy Williams, 225/342-5194 Committee
Policy: Mary J. Terrebonne, 225/342-9768 Mr. Joe Adams
Disputes: Katie Landry, 225/342-0427 2005 Scotchpine Lane
Mandeville, LA 70448
Claims Submission Contact
985/624-8510
Doug Hasty
Project Manager
State Representative Rodney Alexander
Unisys
320 6th Street
8591 United Plaza Blvd., Suite 300
Jonesboro, LA 71251-0665
Baton Rouge, LA 70809
318/259-8694
T: 225/237-3391
F: 225/237-3334
Dr. Donnie Batie
E-mail:doug.hasty@unisys.com
8333 Goodwood Blvd.
Mail Order Pharmacy Program Baton Rouge, LA 70806
State has a mail order pharmacy program for asthma and 225/929-7882
diabetic patients.
Mr. Ben Bearden
Medical Managed Care Contact
P.O. Box 91030
Mary J. Terrebonne, P.D., 225/342-9768
Baton Rouge, LA 70821-9030
Physician-Administered Drug Program Contact 225/342-3891
Kandis McDaniel
504/342-0127 Dr. Vincent Culotta
4228 Houma Blvd.
Medical Care Advisory Committee Metairie, LA 70006
Sandra C. Adams (Chairperson) 504/883-3773
Mary Joseph
Rep. Rodney M. Alexander Dr. Richard Doskey
Sen. John L. “Jay” Dardenne, Jr. 9605 Jefferson Highway
Sen. J. “Tom” Schedler River Ridge, LA 70123
Rep. Jerry L. “Luke” LeBlane 504/738-1604
Mary Tonore
Robert D. Horneman Dr. Blackwell B. Evans, Jr.
Amelia Lafont 1430 Tulane Avenue
Linda Welch New Orleans, LA 70112
Willa Rawls 504/988-6800
Kay Marcel
Daily Dupre, Jr. Dr. Conchetta Fulton
Francine Boyles 7325 Palmetto
Brenda Armstrong New Orleans, LA 70125
Mary Scott 504/483-7402
Paul Hildreth Mr. David Hood
June Peach P. O. Box 629
Dr. Keith M. Perrin Baton Rouge, LA 70821-0629
Greg Scott 225/342-9509
Dr. Leonard Weather, Jr. Dr. Ernest Kinchen
Dr. Donnie Batie 850 North Pierce
Sean Prados Lafayette, LA 70501
Dr. Floys A. Buras 337/233-2116
Richard “Andy” Soileau
Dr. Robert L. Marier Dr. Michael Kudla
Jennifer Canaday 2770 2nd Avenue #203
Wanda Ellis Lake Charles, LA 70601
Tawna Pounders 337/477-7871
Warren Hebert

4-Louisiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

Executive Vice President


Dr. W. Chapman Lee 6767 Perkins Road
5825 Airline Highway Baton Rouge, LA 70808
Baton Rouge, LA 70805 T: 225/763-8500
225/358-1078 F: 225/763-6122
E-mail:executive@lsms.org
Dr. Brobson Lutz Internet Address:www.lsms.org
2622 Jena Street
New Orleans, LA 70115 Louisiana Osteopathic Medical Association (Inactive)
504/865-0361 Nancy Bellemare, D.O.
President
Dr. Catherine A. McDonald 215 Friedrichs Avenue
1105 S. College Road, Ste. A Metairie, LA 70005-4516
Lafayette, LA 70503 Internet Address: www.loma-net.org
337/232-9113
State Board of Pharmacy
Mr. Marty McKay Malcolm J. Broussard
74 Foxfire Lane Executive Director
Alexandria, LA 71302 5615 Corporate Boulevard, Suite 8E
318/776-5646 Baton Rouge, LA 70808-2537
225/925-6496
Dr. Phillip J. Medon Internet Address: www.labp.com
700 University Avenue
Monroe, LA 71209 Louisiana State Pharmacists Association
318/342-3800 Doug Cheramie
Executive Director
Dr. John B. Pope 4744 Jamestown, Suite 101
1501 Kings Highway Building 7-B
Shreveport, LA 71130 Baton Rouge, LA 70808
318/675-5811 T: 225/926-2666
F: 225/926-1020
Carolyn Tackett E-mail: lpa2000@tlxnet.net
P.O. Box 485 Internet Address:www.louisianapharmacists.org
Hammond, LA 70404
985/230-0160 Louisiana Society of Health-System Pharmacists
Mathew Thomas
Dr. Henderson Tilton President
200 Henry Clay Avenue 8550 United Plaza Boulevard, Suite 1001
New Orleans, LA 70118 Baton Rouge, LA 70809
504/891-8851 T :225/922-4520
F :225/922-4611
Dr. Leonard Weather E-mail : lshp@pncpa.com
7820 Chef Menteur Highway Internet Address :www.lshp.org
New Orleans, LA 70126
504/241-0413

Louisiana Hospital Association


Dr. Lolie C. Yu Lynn B. Nicholsl
1542 Tulane Avenue President & CEO
New Orleans, LA 70112 9521 Brookline Avenue
504/896-9740 Baton Rouge, LA 70898-0720
T: 504/928-0026
Executive Officers of State Medical and F: 225/923-1004
Pharmaceutical Societies Internet Address: www.laha.org
Louisiana State Medical Society
Dave L. Tarver

National Pharmaceutical Council Louisiana-5


Pharmaceutical Benefits 2002

6-Louisiana National Pharmaceutical Council


Pharmaceutical Benefits 2002

MAINE

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       ^ ^ 
^ Routine dental services; other categories eligible for non-routine dental service only.

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $175,938,952 148,049 $191,785,942

RECEIVING CASH ASSISTANCE, TOTAL $89,612,435 57,012


Aged $10,108,338 4,821
Blind/Disabled $70,104,828 27,532
Child $2,867,751 14,684
Adults $6,531,518 9,975

MEDICALLY NEEDY, TOTAL $2,944,061 1,177


Aged $1,907,252 773
Blind/Disabled $981,506 328
Child $27,186 50
Adults $28,117 26

POVERTY RELATED, TOTAL $36,155,591 39,151


Aged $9,941,001 5,457
Blind/Disabled $20,666,793 7,804
Child $5,142,738 23,386
Adult $405,059 2,504

TOTAL OTHER EXPENDITURES/RECIPIENTS* $47,226,865 50,709

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

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

National Pharmaceutical Council Maine-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


State Department of Human Services, Bureau of Medical Formulary: Closed formulary. Restrictions on use, prior
Services. authorization, and preferred products.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a formal prior
authorization procedure. Prior authorization may be
Benefit Design obtained in the case of necessary exceptions. State has no
Drug Benefit Product Coverage: Products covered: formal prior authorization committee.
prescribed insulin; disposable needles and syringe
combinations used for insulin (not covered for nursing Prescribing or Dispensing Limitations
home patients). Covered as DME: blood glucose test
strips (with HbA1e values); urine ketone test strips. Monthly Quantity Limit: 34 day for brand-name drugs and
Products not covered: cosmetics; fertility drugs; 90 days for generic drugs per month.
experimental drugs; total parenteral nutrition; interdialytic
parenteral nutrition (part of procedure);vitamin and Prescription Refill Limit: maximum of 11 refills per
vitamin preparations (except pregnancy); and injectables prescription.
when oral medication is available for equally effective
treatment. Drug Utilization Review

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.

Unit Dose: Unit dose packaging not reimbursable.

2-Maine National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE John Grotton, R.Ph.


Goold Health Systems
About 100,000 Medicaid recipients are enrolled in P.O. Box 708
managed care. Medicaid recipients enrolled in managed Augusta, ME 04332
care receive pharmaceutical benefits through the State. 207/622-7153

F. STATE CONTACTS Cheryl Blaisdell, R.Ph.


94 Marston Road
State Drug Program Administrator Waterville, ME 04901
Vacant
Director of Pharmacy Paula Knight, R.Ph.
Department of Human Services 31 Birch Circle
Bureau of Medical Services Sidney, ME 04330
442 Civic Center Drive 207/547-3681
Augusta, ME 04333-0011
T: 207/287-4018 Stephen McPike, R.Ph.
F: 207/287-8601 15 Wildwood Lane
E-mail: ed.bauer@state.me.us Gray, ME 04039
Internet address: 207822-7627
http://www.state.me.us/dhs/welcome_to_dhs.htm
Michael Ouellette, R.
4235 Bassett Road
Prior Authorization Contact
Winslow, ME 04901
Director of Pharmacy 207/281-2727
207/287-4018
Robert Weiss, M.D.
Pharmacy Advisory Group 2 Great Falls Plaza
Auburn, ME 04210
Alroy Chow, M.D.
Tim Clifford, M.D.
Jabbar Fazeli, M.D.
Edward Ervin, M.D.
100 Campus Avenue
Jabbar Fazeli, M.D.
Lewiston, ME 04240
Thomas Hayward, M.D.
Lawrence Losey, M.D.
Non-voting:
James Raczek. M.D.
John Grotton, R.Ph. Joe Bruno (President)
Paula Knight, R.Ph. Goold Health Systems
Dennis Lyons, R.Ph. P.O. Box 708
Steve McPike, R.Ph. Augusta, ME 04332
Gary Roy, R.Ph. 207/622-7153

DUR Contact Dennis G. Lyons, R.Ph.


255 Bear Hill Rd., 2nd Fl.
Director of Pharmacy Waltham, MA 02451
207/287-4018
Prescription Price Updating
Maine DUR Board
Medispan
Timothy Clifford, M.D.
Pharmacy Consultant
Medicaid Drug Rebate Contacts
P.O. Box 708
Augusta, ME 04332 Technical: Rossi Rowe, 207/287-1838
207/622-7153 Policy: Chris Zukas-Lessard, 207/287-2674
Rebates: Rossi Rowe, 207/287-1838
William Alto, M.D. Audits: Vacant
Maine Dartmouth Family Practice
4 Sheridan Drive
Fairfield, ME 04937
207/861-5000

National Pharmaceutical Council Maine-3


Pharmaceutical Benefits 2002

Claims Submission Contact Medical Assistance Advisory Committee


Marcia Pykare Robert Philbrook
Manager of Data Processing MAC c/o BMS
Goold Health Systems 11 State House Station
P.O. Box 1090 Augusta, ME 04333-0011
Augusta, ME 04332-1090
T: 207/622-7153
F: 207/623-5125 Executive Officers of State Medical and
Internet address: www.ghsinc.com/intro.html Pharmaceutical Societies
Maine Medical Association
Medicaid Managed Care Contact Gordon Smith, Esq.
Executive Vice President
Brenda McCormick
Frank O. Stred Building
Department of Human Services
P. O. Box 190
Bureau of Medical Services
Manchester, ME 04351-0190
11 State House Station
T: 207/622-3374
Augusta, ME 04333-0011
F: 207/622-3332
T: 207/287-8820
E-mail: info@mainemed.com
F: 207/287-1864
Internet address: www.mainemed.com
Mail Order Pharmacy Program
Maine Pharmacy Association
None Lisa Asali, R.Ph., President
725 Main Street
Elderly Expanded Drug Coverage Program South Portland, ME 04106
T: 207/722-7235
Paula Knight, R. Ph. F: 207/772-0920
Maine Drugs for the Elderly and Disabled Program E-mail: lasali@hannaford.com
T: 207/287-1818 Internet address: www.mparx.com
F: 207/287-8601
Internet address : Maine Osteopathic Association
www.state.me.us/sos/cec/rc/apa/10/chaps10.htm Kellie Miller, M.S.
Executive Director
Disease Management Program/Initiative Contact 693 Western Avenue, #1
Director of Pharmacy Manchester, ME 04351
207/287-4018 T: 207/623-1101
F: 207/623-4228
Human Services Department Officials E-mail: kmiller@mainedo.org
Internet address: www.mainedo.org
Eugene Gessow, Director
Bureau of Medical Services Maine Board of Pharmacy
Department of Human Services Geraldine “Jeri” Betts, Board Administrator
State House Station II 35 State House Station
Augusta,ME 04333-0011 Augusta, ME 04333
T:207/287-2674 T: 207/624-8620
F: 207/287-2675 F: 207/624-8637
E-mail: gene.gessow@state.me.us E-mail: jeri.l.betts@state.me.us
Internet address: www.state.me.us/prf/olr/
Jan Yorks
Drug Program Coordinator Maine Society of Health-System Pharmacists
Medical Claims Review Ann Marco, President
207/287-1818 800/291-8121
E-mail: nhlfan@megalink.net
Mark Fecteau, Director Internet address: www.meshp.org
Medicaid Surveillance/Utilization Review
207/624-5220

4-Maine National Pharmaceutical Council


Pharmaceutical Benefits 2002

Maine Hospital Association


Steve Michaud
President
33 Fuller Road
Augusta, ME 04330
T: 207/622-4794
F: 207/622-3073
E-mail: smichaud@themha.org
Internet address: www.themha.org

Maine Health Care Association


Richard A. Erb
President and CEO
317 State Street
Augusta, ME 04330
T: 207/623-1146
F: 207/623-4080
E-mail: rerb@mehca.org
Internet address: www.mehca.org

National Pharmaceutical Council Maine-5


Pharmaceutical Benefits 2002

6-Maine National Pharmaceutical Council


Pharmaceutical Benefits 2002

MARYLAND

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $374,121,433 409,511 $244,203,084

RECEIVING CASH ASSISTANCE, TOTAL $223,765,324 145,724


Aged $26,694,367 15,553
Blind / Disabled $175,619,643 66,765
Child $8,062,216 41,683
Adult $13,389,098 21,723

MEDICALLY NEEDY, TOTAL $80,436,582 51,985


Aged $41,479,224 18,560
Blind / Disabled $30,498,787 12,449
Child $3,749,506 11,759
Adult $4,709,065 9,217

POVERTY RELATED, TOTAL $47,673,288 163,568


Aged $8,791,420 6,633
Blind / Disabled $11,713,692 4,779
Child $24,239,865 130,271
Adult $2,928,311 21,885

TOTAL OTHER EXPENDITURES/RECIPIENTS* $22,246,239 48,234

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

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

National Pharmaceutical Council Maryland - 1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


State Department of Health and Mental Hygiene. Formulary: Open formulary.
D. PROVISIONS RELATING TO DRUGS Prior Authorization: State currently has a Prior
Authorization procedure. A general appeals procedure is
Benefit Design available for appeal of prior authorization decisions.

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.

Unit Dose: Unit dose packaging not reimbursable.

2-Maryland National Pharmaceutical Council


Pharmaceutical Benefits 2002

Maximum Allowable Cost: State imposes Federal Upper F. STATE CONTACTS


Limits as well as State-specific limits on generic drugs.
Approximately 1,000 drugs are listed on the State-specific
MAC list. Override requires “Brand Medically State Drug Program Administrator
Necessary” and a reason. Mr. Frank Tetkoski
Incentive Fee: None. Pharmacy Services Manager
DHMH, Office of Health Services
Patient Cost Sharing: Copayment = $1.00. Does not Division of Pharmacy and Clinic Services
apply to managed care, family planning, nursing home 201 West Preston Street, Room 205
residents or recipients under 21 years old. Baltimore, MD 21201
T: 410/767-1455
Cognitive Services: Does not pay for cognitive services. F: 410/333-7049
E-mail: tetkoskif@dhmh.state.md.us
E. USE OF MANAGED CARE
Prior Authorization Contact
Approximately 400,000 Medicaid recipients were
Tuong Nguyen, P.D.
enrolled in MCOs in FY 2001. Recipients receive
Pharmacist Consultant
pharmaceutical benefits through the State and managed
DHMH-Office of Health Services
care plans.
Division of Pharmacy and Clinical Services
201 W. Preston St., Rm. 132
Managed Care Organizations Baltimore, MD 21201
T: 410/787-1455
United Healthcare F: 410/333-7049
6300 Security Boulevard E-mail: nguyent@dhmh.md.us
Baltimore, MD 21207

FreeState Health Plan DUR Contact


Blue Cross Blue Shield
Judy Geisler, P.D.
10455 Mill Run Circle
Pharmacist Consultant
Owings Mills, MD 21117-5559
DHMH-Office of Health Services
Division of Pharmacy and Clinical Services
Helix Family Choice, Inc.
201 W. Preston Street
8094 Sandpiper Circle
Baltimore, MD 21201
Baltimore, MD 21236
T: 410/767-1455
F: 410/333-7049
Jai Medical Systems, Inc.
E-mail: GeislerJ@dhmh.state.md.us
5010 York Road
Baltimore, MD 21212
DUR Board
Maryland Physicians Care MCO Deneen Pieri, M.D.
7106 Ambassador Road John Boronow, M.D.
Suite 100 Michelle A. Forrest-Smith, Pharm.D.
Baltimore, MD 21244 Myron Miller, M.D. (Chair)
Lori Fantry, M.D., M.P.H.
Prime Health Corporation Vincent Ferrari, R.Ph.
9602-C M.L.K., Jr. Hwy Steve A. Anifowshe, R.Ph.
Lanham, MD 20706 Elliot S. Gottlieb, R.Ph.
Bernard J. Lechman, R.Ph.
Priority Partners MCO
The Candler Building
111 Market Place Prescription Price Updating
Baltimore, MD 21202 First DataBank
1111 Bayhill Dr.
Ameri Group San Bruno, CA 94066
857 Elkridge Landing Road, #300 T: 415/588-5454
Linthicum, MD 21040 F: 415/827-4578

National Pharmaceutical Council Maryland-3


Pharmaceutical Benefits 2002

Medicaid Drug Rebate Contacts Debbie I. Chang


Deputy Secretary
Technical: Ed Ellis, 410/767-1455
Health Care Financing
Policy: Jeffrey Gruel, 410/767-1455
Department of Health and Mental Hygiene
Audits: Kenneth Smoot, 410/767-5186
201 W. Preston Street
Disputes: Katherine Novak, 410/582-9305
Baltimore, MD 21201
T: 410/767-4664
Claims Submission Contact F: 410/333-7687
E-mail: Dchang@dhmh.md.state.us
First Health
Division of Claims Processing Susan Tucker
James Demery Executive Director
Manager, Pharmacy Services Office of Health Services
201 W. Preston St. 201 W. Preston Street
Baltimore, MD 21201 Baltimore, MD 21201
T: 410/767-6028
F: 410/333-7186 Shelby Boggs
E-mail: DemeryJ@dhmh.state.md.us Director of Healthcare and Acute Care
Office of Health Services
Medicare Managed Care Contact 201 W. Preston Street
Baltimore, MD 21201
Jim Gardner
Chief Jeffrey Gruel
Division of Health Choice Management Chief
Office of Health Services Division of Pharmacy and Clinic Services
201 W. Preston St. Office of Health Services
Baltimore, MD 21201 201 W. Preston Street
410/767-1482 Baltimore, MD 21201
410/767-1455
Mail Order Pharmacy Benefit
None Leslie S. Lyles
Deputy Director
Expanded Drug Coverage Program Program Operations
Office of Operations and Eligibility
Paul Roeger 201 W. Preston Street
Manager, Pharmacy Assistance Program Baltimore, MD 21201
Medical Care Operations and Eligibility 410/767-5161
201 W. Preston St
Baltimore, MD 21201 Paul Roeger
T: 410/767-5394 Program Manager
F: 410/333-5027 Pharmacy Assistance Program
E-mail: Roegerp@dhmh.state.md.us PO Box 386
Baltimore, MD 21203
Physician-Administered Drug Program Contact 410/767-5392

Edward Watters, M.D. Medical Assistance Staff Committee Members


201 W. Preston Street
Baltimore, MD 21201 Judy Geisler, P.D.
410/767-1482 Division of Pharmacy and Clinic Services
201 W. Preston Street
Health and Mental Hygiene Department Officials Baltimore, MD 21201

Nelson J. Sabatini Mr. Frank Tetkoski, P.D., Manager, Pharmacy Services


Secretary Division of Pharmacy and Clinic Services
Department of Health and Mental Hygiene 201 W. Preston Street, Room 205
201 W. Preston Street Baltimore, MD 21201
Baltimore, MD 21201
T: 410/225-6500
F: 410/161-6489
E-mail: nsabatini@dhmh.state.md.us

4-Maryland National Pharmaceutical Council


Pharmaceutical Benefits 2002

Tuong Nguyen, P.D. The Maryland Hospital Association, Inc.


Division of Pharmacy and Clinic Services Calvin M. Pierson, President
201 W. Preston St. 1301 York Road, Suite 800
Baltimore, MD 21201 Lutherville, MD 21093-6087
T: 410/321-6200
F: 410/379-8239
Executive Officers of State Medical and Internet Address: www.mhaonline.org
Pharmaceutical Societies
Medical/Chirurgical Faculty of Maryland Health Facilities Association of Maryland
T. Michael Preston Adele Wilzack, President
Executive Director 7060 Oakland Mills Road, Suite M
1211 Cathedral Street Columbia, MD 21046
Baltimore, MD 21201 T: 410/792-4390
T: 410/539-0872 T: 301/490-8413
F: 410/547-0915 F : 410/792-4617
E-mail: mpreston@medchi.org E-mail: awilzack@hfam.org
Internet Address: www.medchi.org Internet Address: www.hfam.org

Maryland Osteopathic Association, Inc.


John Kylan Lynch, D.O.
President
3603 Southside Drive
Phoenix, MD 21131
T: 410/683-8100
F :410/683-8200
E-mail : lynchj@ninds.nih.gov
Internet Address: www.maops.com

Maryland Pharmacists Association


Howard Schiff
Executive Director
650 West Lombard Street
Baltimore, MD 21201-1572
T: 410/727-0746
F: 410/727-2253
Internet Address: users.erols.com/mpha/index.html

Maryland Society of Health-System Pharmacists


David A. Kotzin, President
8480-M Baltimore National Pike, Ste. 250
Ellicott City, MD 21042
T: 410/465-9975
F: 410/465-7073
E-mail: dkotzin@gbmc.org
Internet Address: www.mshp.org

State Board of Pharmacy


LaVerne G. Naesea
Executive Director
4201 Patterson Avenue
Baltimore, MD 21215-2299
T: 410/764-4794
F: 410/358-6207
E-mail: mdbop@dhmh.state.md.us
Internet Address: www.dhmh.state.md.us/pharmacyboard

National Pharmaceutical Council Maryland-5


Pharmaceutical Benefits 2002

6-Maryland National Pharmaceutical Council


Pharmaceutical Benefits 2002

MASSACHUSETTS

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $682,519,910 666,627 $797,859,072

RECEIVING CASH ASSISTANCE TOTAL $350,268,440 237,277


Aged $39,048,243 27,870
Blind/Disabled $290,432,382 129,552
Child $7,752,715 52,864
Adult $13,035,100 26,991

MEDICALLY NEEDY, TOTAL $30,341,383 16,713


Aged $11,516,242 8,076
Blind/Disabled $18,825,141 8,637
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $183,962,431 232,935


Aged $52,662,378 29,640
Blind/Disabled $101,474,974 39,208
Child $26,676,016 155,560
Adult $3,149,063 8,527

TOTAL OTHER EXPENDITURES/RECIPIENTS* $117,947,656 179,702

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

Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY2001.

National Pharmaceutical Council Massachusetts-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Formulary: Open Formulary
Executive Offices of Health and Human Services,
Division of Medical Assistance. Prior Authorization: State currently has a prior
authorization procedure. A fair hearing process by the
D. PROVISIONS RELATING TO DRUGS recipient on an individual basis is required for appealing a
prior authorization decision.
Benefit Design
Prescribing or Dispensing Limitations
Drug Benefit Product Coverage: Products covered Prescription Refill Limit: Prescription may be refilled, as
(except in LTC facilities): prescribed insulin; disposable authorized, with a limit of up to 5 refills from the filling
needles and syringe combinations used for insulin; blood of the original prescription
glucose test strips; urine ketone test strips. Products
covered with restrictions: total parenteral nutrition. Ritalin Monthly Quantity Limit: Schedule II and III drugs are
and amphetamines are limited to treatment of limited to a 30-day supply, except Ritalin and Dexedrine,
hyperkinesis for children under age 17, except by prior which may be dispensed up to a 60-day supply.
authorization; and ADD by prior authorization (not Monthly Dollar Limits: None.
covered for appetite control). Products not covered:
cosmetics; fertility drugs; experimental drugs; Drug Utilization Review
interdialytic parenteral nutrition; DESI drugs; legend
vitamins not on Drug List, non-legend drugs not on Drug PRODUR system implemented in October 1995. State
List; propoxyphene-containing products and products currently has a DUR Board with a quarterly review.
rated by the FDA as less-than-effective.
Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Products covered Dispensing Fee: Brand: $3.50; Generic: $5.00, effective
with restrictions (limited OTC list-generics only): allergy, 11/1/02.
asthma and sinus products; analgesics; digestive products;
feminine products and topical products. Products covered Ingredient Reimbursement Basis: EAC = WAC + 5%.
with restrictions: cough and cold preparations (only in
LTC facilities). Products not covered: smoking deterrent
Prescription Charge Formula: Payment shall be for the
products.
lowest of:
Therapeutic Category Coverage: Therapeutic categories
1. EAC plus dispensing fee;
covered: anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; 2. The usual and customary charge defined as the
antilipemic agents; anti-psychotics; anxiolytics, sedatives, lowest price charged or accepted by a provider for
and hypnotics; cardiac drugs; chemotherapy agents; any payor; or
contraceptives; ENT anti-inflammatory agents; estrogens;
3. FULP plus a dispensing fee.
hypotensive agents; sympathominetics (adrenergic); and
thyroid agents. Prior authorization required for: growth
Maximum Allowable Cost: State imposes Federal Upper
hormones; biotech drugs. Partial coverage: analgesics,
Limits as well as State-specific limits on generic drugs.
antipyretics, and NSAIDs (PA required); antihistamines;
Override requires “Dispense as Written,” and/or “Brand
and misc. GI drugs (PA required). Therapeutic categories
Medically Necessary” plus prior approval.
not covered: anoretics; prescribed cold medicines;
prescribed smoking deterrents; weight loss or gain
medications; and medications to treat sexual dysfunction. Patient Cost Sharing: Copayment = $2.00 with the
following exceptions:
Coverage of Injectables: Injectable medicines − Institutionalized patients
reimbursable through the Prescription Drug Program
when used in home health care and extended care − Children under age 19
facilities and through both the Prescription Drug Program − Pregnant and postpartum women
and physician payment when used in physician offices.
− Hospice care
Vaccines: Vaccines reimbursable as part of the EPSDT − Family planning items
service if not provided by the Department of Public
Health. Incentive Fee: None.

Unit Dose: Unit dose packaging not reimbursable. Cognitive Services: Does not pay for cognitive services.

2-Massachusetts National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE Medicaid Drug Rebate Contacts


Approximately 616,000 Medicaid recipients were Martha Kessenich
enrolled in MCOs in FY 2000. Recipients receive Rebate Analyst
pharmaceutical benefits through managed care plans. ACS State Health Care
365 North Ridge Road
Managed Care Organization Atlanta, GA 30350
800/358-2381
Primary Care Clinician Plan 340,690
Boston Medical Center HealthNet Plan 105,923 Claims Submission Contact
Fallon Community Health Plan 9,488
Neighborhood Health Plan 100,410 ACS State Health Care
Network Health 49,391 365 North Ridge Road
Atlanta, GA 30350
F. STATE CONTACTS 800/358-2381

State Drug Program Administrator Medicaid Managed Care Contact

Paul L. Jeffrey Kate Willrich-Nordahl, Director


Director of Pharmacy MCO Program
Division of Medical Assistance Division of Medical Assistance
600 Washington Street, 5th Floor 600 Washington Street
Boston, MA 02111 Boston, MA 02111
T: 617/210-5319 T: 617/210-5466
F: 617/210-5865 F: 617/210-5003
E-mail: jeffrey@nt.state.ma.us E-mail: kwillrich@nt.dma.state.us
Internet Address: www.state.ma.us/dma
Mail Order Pharmacy Benefit
Prior Authorization Contact None
Paul L. Jeffrey
617/210-5319 Disease Management Program/Initiative Contact
N/A
DUR Contact
Paul L. Jeffrey Elderly Expanded Drug Coverage Program
617/210-5319 Contact
David Morales
Medicaid DUR Board Executive Office of Elder Affairs
Spencer Wilking, MD (Chairman) One Ashburton Place, Room 517
C. Michael Bliss, MD Boston, MA 02108
Sarah Cheeseman, MD T: 617/727-7750
Thomas Hewitt, MD F: 617/727-9368
Anne Marie McCloskey, R.Ph. E-mail: david.morales@state.ma.us
Leo McKenna, R.Ph.
Dave Morgan, R.Ph. Executive Offices of Health and Human Services
Robert Portney, MD Ronald Preston, Secretary
James Scanlon, R.Ph. Executive Office of Health and Human Services
David Kosegarten, Ph.D. One Ashburton Place, Room 1109
Gerry Longnecker, Pharm.D. Boston, MA 02108
T: 617/727-0077
Prescription Price Updating F: 617/727-5134
First Data Bank E-mail: ronald.preston@state.ma.us
111 Bayhill Drive, Suite 350 Internet address: www.masscares.org
San Bruno, CA 94066
650/588-5454

National Pharmaceutical Council Massachusetts-3


Pharmaceutical Benefits 2002

Wendy Warring, Commissioner Massachusetts Hospital Association


Division of Medical Assistance Ronald M. Hollander
600 Washington Street President
Boston, MA 02111 Five New England Executive Park
T: 617/210-5690 Burlington, MA 01803
F: 617/210-5000 617/272-8000
E-mail: wwarring@nt.dma.state.ma.us Internet address: www.mhaliuk.org
Internet address: www.state.ma.us/dma
Massachusetts Extended Care Federation
Executive Officers of State Medical and Abraham E. Morse
Pharmaceutical Societies President
2310 Washington Street, Suite 300
Massachusetts Medical Society
Newton, MA 02462
Charles A. Welch, M.D.
T: 617/558-0202
President F : 617/558-3546
860 Winter Street E-mail: amorse@mecf.org
Waltham Woods Corporate Center
Internet address: www.mecf.org
Waltham, MA 02451-1411
781/893-4610
E-mail: president@massmed.org
Internet address: www.massmed.org

Massachusetts Pharmacists Association


Alan J. Shubin, R.Ph.
President
681 Main Street, Suite 3-32
Waltham, MA 02451
T: 781/736-0101
F: 781/736-0080
Internet address: www.maspharmacists.org

Massachusetts Osteopathic Society, Inc.


Ron Jolda, D.O.
President
49 Wawela Road
Webster, MA 01570
508/949-2985
E-mail: rjolda@pdmg.com
Internet address: www.northeastosteo.org/MOS_HP.htm

Massachusetts Board of Registration in Pharmacy


Charles R. Young
Executive Director
239 Causeway Street, Suite 500
Boston, MA 02114
617/727-9953
E-mail: charles.r.young@state.ma.us
Internet address: www.state.ma.us/reg/boards/ph

Massachusetts Society of Health-Systems Pharmacists


Alana Arnold Boermeester
President
681 Main Street, Suite 3-32
Waltham, MA 02451
T: 781/894-9300
F: 781/894-9393
Internet address: www.mashp.org

4-Massachusetts National Pharmaceutical Council


Pharmaceutical Benefits 2002

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $374,334,359 435,654 $584,670,445

RECEIVING CASH ASSISTANCE TOTAL $157,228,868 156,791


Aged $22,910,676 16,186
Blind/Disabled $128,621,561 102,171
Child $2,108,586 18,695
Adult $3,588,045 19,735

MEDICALLY NEEDY, TOTAL $25,686,605 40,549


Aged $6,580,156 4,681
Blind/Disabled $12,066,396 5,606
Child $1,828,824 8,882
Adult $5,211,229 21,380

POVERTY RELATED, TOTAL $19,770,950 85,801


Aged $1,349,453 1,217
Blind/Disabled $9,758,682 4,342
Child $7,116,143 62,329
Adult $1,546,672 17,913

TOTAL OTHER EXPENDITURES/RECIPIENTS* $171,647,936 152,513

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

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

1 The State of 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.

National Pharmaceutical Council Michigan-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization

Michigan Department of Community Health, Medical Formulary: Closed formulary.


Services Administration.
Prior Authorization: State currently has a formal prior
D. PROVISIONS RELATING TO DRUGS authorization procedure. In order to appeal prior
authorization decisions, a department appeals section in
Benefit Design the Medicaid program sets up hearings for beneficiaries.
The beneficiary is sent a letter with instructions on their
Drug Benefit Product Coverage: Products covered: appeal rights when appealing the coverage of an excluded
prescribed insulin; disposable needles and syringe product.
combinations used for insulin; blood glucose test strips;
and urine ketone test strips. Products covered with Prescribing or Dispensing Limitations
restrictions: total parenteral nutrition (paid to medical
suppliers) and interdialytic parenteral nutrition. Prior Prescription Refill Limit: Based on State law.
authorization required for: brand name products equivalent
to MACs; Accutane & Retin-A; Dexedrine and Adderall; Monthly Quantity Limit: Prescribed quantities should be
Persantine; Lactulose (Cephulac); Methylphenidate limited to an amount necessary to keep the recipient
(selected ages); selected benzodiazepines; Epogen supplied during the therapy regimen. In certain cases and
administered in the home setting; dietary formulas; and conditions, more than a month’s supply will be
drugs not listed on the formulary. Products not covered: appropriate. However, in no instance may more than 100
cosmetics; fertility drugs; and experimental drugs. days supply be dispensed per prescription.
Over-the-Counter Product Coverage: Products covered
with restrictions (only selected products in each category): Drug Utilization Review
allergy, asthma and sinus products; analgesics; digestive
products (non-H2 and H2 antagonists); feminine products; PRODUR system implemented in July 2000. State
topical products; and smoking deterrent products (patches currently has a DUR Board with a quarterly review.
and gum). Products not covered: cough and cold
preparations. Pharmacy Payment and Patient Cost Sharing

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.

2-Michigan National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

E. USE OF MANAGED CARE M-Caid


2301 Commonwealth Blvd.
Approximately 710,000 Medicaid recipients were enrolled Ann Arbor, MI 48105-1573
in MCOs in FY 2001. Recipients receive pharmaceutical 800/527-5549
benefits through the State and managed care plans.
McLaren Health Plan
401 S. Ballenger Highway
Managed Care Organizations Flint, MI 48532
888/327-0671
Botsford Health Plan
28050 Grand River
Midwest Health Plan
Farmington Hills, MI 48336
5050 Schaefer Road
248/473-6190
Dearborn, MI 48126
800/479-5122
313/581-3700
888/654-2200
Cape Health Plan
26711 Northwestern Highway, Suite 300
Molina Healthcare of Michigan
Southfield, MI 48034
100 W. Big Beaver Road, Suite 600
248/386-3000
Troy, MI 48084
888/354-2273
248/925-1700
888/898-7969
Care Choices HMO
34605 Twelve Mile Road
OmniCare Health Plan
Farmington Hills, MI 48331
1155 Brewery Park Blvd.
248/489-6000
Suite 250
800/893-1113
Detroit, MI 48207
313/259-4000
Community Care Plan
800/955-4578
2100 Raybrook, SE
Grand Rapids, MI 49546
616/252-4500
800/807-5244

National Pharmaceutical Council Michigan-3


Pharmaceutical Benefits 2002

PHP of Mid-Michigan, Inc. DUR Contact


P.O. Box 30377
Mary Sandusky, R.Ph.
Lansing, MI 48909-7877
Pharmacist Consultant
517/364-8400
MDCH- Medical Services Administration
800/661-8299
400 S. Pine St.
Lansing, MI 48933
PHP of Southwest Michigan, Inc.
T: 517/335-5280
106 Farmers Alley, Suite 300
F: 517/241-7813
Kalamazoo, MI 49007
E-mail: sanduskyM@state.mi.us
269/341-7200
800/261-0084
Medicaid DUR Board
Priority Health
1231 E. Beltline, NE Richard Henderson, M.D.
Grand Rapids, MI 49525-4501 34650 Versailles Court
616/942-0954 Farmington Hills, MI 48331
888/975-8102 810/474-1397

Total Health Care Frank Check, M.D.


3011 W. Grand Blvd., Suite 1600 St. Joseph Mercy Hospital
Detroit, MI 48202 900 Woodward Avenue
313/871-2000 Pontiac, MI 48341
800/826-2862 313/858-3233

Upper Peninsula Health Plan Duane Kirking, Ph.D.


228 W. Washington Street College of Pharmacy
Marquette, MI 49855 University of Michigan
906/225-7500 Ann Arbor, MI 48109-1065
800/835-2556 313/764-4483
313/764-7312
The Wellness Plan
2875 W. Grand Blvd. William Overkamp
Detroit, MI 48202 2929 Walker, N.W.
313/875-4200 Grand Rapids, MI 49544
800/875-9355
Karen Jonas, R.Ph.
13121 Willow Grove Road
F. STATE CONTACTS Dewitt, MI 48820
517/315-1243
State Drug Program Administrator
James Kenyon, R.Ph. James Kenyon, R.Ph.
Pharmacist Consultant Michigan Department of Community Health
MDCH/Medical Services Administration Medical Services Administration
400 South Pine Street P.O. Box 30479
Lansing, MI 48933 Lansing, MI 48909
T: 517/335-5265
F: 517/335-5294 Otto Graesser, DO
E-mail: kenyonj@state.mi.us 1421 W. Mt. Hope
Internet address: www.michigan.gov/mdhc Lansing, MI 48910

Prior Authorization Contact Prescription Price Updating


James Kenyon, R.Ph., 517/335-5265 First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578

4-Michigan National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Drug Rebate Contacts Patrick Barrie


Deputy Director
Technical: Randy Rothfuss, 517/335-5040
Health Programs Administration
Audits: James Kenyon, 517/335-5265
400 South Pine Street
PA: Barbara Jones, 517/335-5061
Lansing, MI 48909
T: 517/335-5001
Claims Submission Contact F: 517/335-5007
E-mail: barriep@michigan.gov
First Health Services Corp
4300 Cox Rd.
Glen Allen, VA 23060 Formulary Review Committee
James Kenyon, R.Ph.
Medicaid Managed Care Contact Giovannino Perri, M.D.
Debera Eggleston, M.D.
Rick Murdock, Director Max Robins, D.O.
Comprehensive Health Plan Division Lawerence Nagel, D.D.S.
MDCH- Medical Services Administration Chris Farrell
400 S. Pine Street Robert Pheteplace, R.Ph. (Alternate)
Lansing, MI 48933
T: 517/241-7933 Addresses for all members:
F: 517/241-8231 Medical Services Administration
Michigan Department of Community Health
Disease Management Program/Initiative Contact 400 S. Pine Street
Lansing, MI 48933
Mary Sandusky, 517/335-5280

Michigan Pharmacy and Therapeutics


Elderly Expanded Drug Coverage Contact Committee
Doris Gellert David R. Johnson, M.D., M.Ph. (Chair)
Dept. of Community Health Robert P. Coffey, Pharm.D.
611 West Ottawa Debera Hayes Eggleston, M.D.
P.O. Box 30676 Robert Ernest, M.D.
Lansing, MI 48909-8176 Jonathan G.A. Henry, M.D.
517/335-5182 Edward J. Keating, R.Ph.
E-mail: gellert@michigan.gov James Kenyon, R.Ph.
Larry W. Lawhorne, M.D.
Physician-Administered Drug Program Contact Giovannino A. Perri, M.D.
Max Robins, D.O.
Linda McCardel Sandra A. Silecchia, Pharm.D.
Medical Services Administration
P.O. Box 30479
Lansing, MI 48909 Executive Officers of State Medical and
517/335-5115 Pharmaceutical Societies
Michigan State Medical Society
Michigan Dept. of Community Health (MDCH) William E. Madigan, Executive Director
120 West Saginaw Street
Janet Olszewski East Lansing, MI 48823
Director T: 517/337-1351
Lewis Cass Building F: 517/337-2490
320 South Walnut Street E-mail: wmadigan@msms.org
Lansing, MI 48913 Internet address: www.msms.org
T: 517/335-0267
F: 517-373-4288
E-mail: norris@michigan.gov

National Pharmaceutical Council Michigan-5


Pharmaceutical Benefits 2002

Michigan Pharmacists Association


Larry D. Wagenknecht, Executive Director
815 N. Washington Avenue
Lansing, MI 48906-5198
T: 517/484-1466
F: 517/484-4893
E-mail: larry@michiganpharmacists.org
Internet address: www.michigan pharmacists.org

Michigan Osteopathic Association


Dennis Paradis, Executive Director
2445 Woodlake Circle
Okemos, MI 48864
T: 517/347-1555
F: 517/347-1566
E-mail: dennis@moa-do.com
Internet address: www.moa-do.com

State Board of Pharmacy


Melanie Brim
Licensing Manager
611 W. Ottawa, P.O. Box 30670
Lansing, MI 48909-8170
517/373-9102
Internet address: www.michigan.gov/cis/

Michigan Health and Hospital Association


Spencer C. Johnson
President
6215 West St. Joseph Highway
Lansing, MI 48917
T: 517/323-3443
F: 517/323-0946
E-mail: sjohnson@lans.mha.org
Internet address: www.mha.org

Health Care Association of Michigan


Reginald Carter, Ph.D.
President & CEO
P.O. Box 80050
Lansing, MI 48908
T: 517/627-1561
F: 517/627-3016
E-mail: recarter@hcam.org
Internet address: www.hcam.org

6-Michigan National Pharmaceutical Council


Pharmaceutical Benefits 2002

MINNESOTA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN) Other
Aged Blind/ Child Adult Aged Blind/ Child Adult Other
Disabled Disabled SFO
Prescribed Drugs        
Inpatient Hospital Care        
Outpatient Hospital Care        
Laboratory & X-ray Service        
Nursing Facility Services        
Physician Services        
Dental Services        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $221,682,000 180,104 $265,726,228

RECEIVING CASH ASSISTANCE, TOTAL $127,824,974 85,255


Aged $7,450,342 5,273
Blind / Disabled $113,608,005 47,543
Child $3,308,774 17,506
Adult $3,457,853 14,933

MEDICALLY NEEDY, TOTAL $15,090,970 6,848


Aged $3,644,001 2,804
Blind / Disabled $11,429,954 3,951
Child $16,970 91
Adult $45 2

POVERTY RELATED, TOTAL $710,680 722


Aged $168,845 366
Blind / Disabled $541,647 353
Child $188 3
Adult $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $78,055,376 87,279

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

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

National Pharmaceutical Council Minnesota-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Unit Dose: Unit dose packaging reimbursable.


Minnesota Department of Human Services, Health Care
Management Division, Medical Assistance Program. Formulary/ Prior Authorization

D. PROVISIONS RELATING TO DRUGS Formulary: Open formulary with general exclusions.

Benefit Design Prior Authorization: State currently has a prior


authorization procedure and a Drug Formulary
Drug Benefit Product Coverage: Products not covered: Committee. Recipient has the right to appeal prior
drugs used for cosmetic purposes; drugs used for hair authorization decisions and coverage of an excluded
growth; fertility drugs; appetite supressants; and product by appeals referee followed by an appeal in court.
experimental drugs. Products covered with limitations:
interdialytic parenteral nutrition, sildenafil, Prescribing or Dispensing Limitations
methylphenidate (including d-methylphenidate), Adderall,
pemoline, dextroamphetamine, vitamins, and cough and Monthly Quantity Limit: 3 month supply. Minimum 30-
cold preparations. Prior authorization required for: days for maintenance drugs. Contraceptives may be filled
alglucerase; Interferon Alfa N-3; Interferon Gamma-1B; to provide a 3-month supply.
Ondansetron; Granisetron; omeprazole (including s-
omeprazole); sertraline 25mg and 50mg tablets;
Butulinum Toxin Types A & B; valdecoxib; Drug Utilization Review
Esomeprazole; dolasetron; celecoxib; rofecoxib;
escitalopram 10mg; citalopram 10mg and 20mg; PRODUR system implemented in February 1996. State
paroxetine 10mg; modafinil 100mg; trandolapril; currently has a DUR Board with a quarterly review.
trandolapril/verapamil combination; quinapril; Heritage Information Systems provides software and
quinapril/HCTZ; amlodipine/benazepril; assistance with RetroDUR.
benazepril/HCTZ; benazepril; fosinopril; and
fosinopril/HCTZ.
Pharmacy Payment and Patient Cost Sharing
Over-the-Counter Product Coverage: Products covered
with limitations: allergy, asthma and sinus products; Dispensing Fee: $3.65, effective 7/1/97.
analgesics; cough and cold preparations; digestive
products (non-H2 antagonist); feminine products Ingredient Reimbursement Basis: EAC = AWP - 9%.
(antifungals covered); topical products; and smoking
deterrent products; vitamins; ocular lubricants; Prescription Charge Formula: Reimbursement is based
pediculocides; activated charcoal and ipecac; and insulin. on the lesser of submitted AWP minus 9% plus a
dispensing fee, MAC plus a dispensing fee, or usual and
Therapeutic Category Coverage: Therapeutic categories customary. Special rules for IV admixtures.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Maximum Allowable Cost: State imposes a combination
antidepressants; antidiabetic agents; antihistamine drugs of Federal Upper Limits and State-specific MAC on
(OTC loratadine products are preferred second generation generic drugs. Override requires “brand medically
antihistamines, all other require prior authorization); necessary” or “dispense as written.” Brand medically
antilipemic agents; anti-psychotics; anxiolytics, sedatives, necessary must be handwritten on the prescription by the
and hypnotics; cardiac drugs; chemotherapy agents; prescriber. No pre-printed DAW allowed.
contraceptives; ENT anti-inflammatory agents; estrogens;
growth hormones; hypotensive agents; prescribed Incentive Fee: None.
smoking deterrents; sympathominetics (adrenergic); and
thyroid agents. Patient Cost Sharing: No copayment.

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.

2-Minnesota National Pharmaceutical Council


Pharmaceutical Benefits 2002

Managed Care Organizations F. STATE CONTACTS


Itasca Medical Care State Drug Program Administrator
Itasca Resource Center
1209 SE 2nd Ave. Cody Wiberg, Pharm.D., R.Ph.
Grand Rapids, MN 55744-3983 Pharmacy Program Manager
T: 218/327-6133 Minnesota Department of Human Services
F: 218/327-5545 444 Lafayette Road
Blue Plus St. Paul, MN 55155-3853
P.O. Box 64179 T: 651/296-8515
St. Paul, MN 55164-0179 F: 651/282-6744
T: 651/662-5200 E-mail: cody.c.wiberg@state.mn.us
Internet address:www.dhs.state.mn.us
First Plan Blue
1601 London Road Prior Authorization Contact
Duluth, MN 55812
T: 218/728-6706 Cody Wiberg, 651/296-8515DUR Contact
F: 218/724-9176 Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator
HealthPartners 444 Lafayette Road
8100 34th Avenue South St. Paul, MN 55155-3853
P.O. Box 1309 T: 651/215-1239
Minneapolis, MN 55414-1309 F: 651/282-6744
T: 952/967-6633 E-mail: mary.beth.reinke@state.mn.us

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

Ron Johnson, R.Ph.


Lloyd’s Pharmacy
720 North Snelling
St. Paul, MN 55104

Peter Marshall, Pharm. D.


HealthPartners Pharmacy Services

National Pharmaceutical Council Minnesota-3


Pharmaceutical Benefits 2002

P.O. Box 1309 Elderly Expanded Drug Coverage Program


8100 - 34th Avenue South Contact
Minneapolis, MN 55440-1309
Cody Wiberg, 651/296-8515

Physician-Administered Drug Program Contact

Cody Wiberg, 651/296-8515


Wendy L. St. Peter, Pharm.D.
Hennepin County Medical Center Department of Human Services Officials
Nephrology Analytical Services
USRDS Coordinating Center Kevin Goodno
914 Eighth Avenue South Commissioner
Minneapolis, MN 55404 Department of Human Services
444 Lafayette Road
Consumers Representative St. Paul, MN 55155-3815
Vacant T: 651/296-2701
F: 651/297-3230
DHS Staff E-mail: commissioner.dhs@state.mn.us
Cody Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager Mary Kennedy
Medicaid Director
Mary Beth Reinke, Pharm.D., R.Ph. Department of Human Services
DUR Coordinator 444 Lafayette Road
St. Paul, MN 55155-3852
T: 651/282-9921
Prescription Drug Updating F: 651/297-3230
First DataBank E-mail: mary.kennedy@state.mn.us
1111 Bayhill Drive
San Bruno, CA 94066 Drug Formulary Committee
T: 650/588-5454
F: 650/588/4003 Al Heaton, Pharm.D., R.Ph.
Senior Director
Prime Therapeutics
Claims Submission Contact 1020 Discovery Road No. 100
Dwaine Voas Eagan, MN 55121
MMIS Unit Supervisor
Minnesota Department of Human Services Charlene Nusman, Consumer Representative
800 Minnehaha Avenue 2534 Lynn Avenue So.
St. Paul, MN 55155 St. Louis Park, MN 55416

William P. Korchik, M.D.


Medicaid Drug Rebate Contacts Veterans Affairs Medical Center
One Veteran Drive (11L)
Jarvis Jackson, R.Ph.
Minneapolis, MN 55417
Drug Rebate Coordinator
Minnesota Department of Human Services
Jack Alexander, M.D.
444 Lafayette Road
Chief Medical Officer
St. Paul, MN 55155-3849
Fairview Red Wing Clinic
T: 651/282-5881
2835 South Service Clinic
F: 651/282-6744
Red Wing, MN 55066-0095
E-mail: jarvis.p.jackson@state.mn.us
Paul Johnson, M.D.
Disease Management Program/Initiative Contact
Metropolitan Health Plan
Cody Wiberg, 651/296-8515 822 South 3rd Street, Suite 140
Minneapolis, MN 55415
Mail Order Pharmacy Benefit

None

4-Minnesota National Pharmaceutical Council


Pharmaceutical Benefits 2002

Kim Allan Macnab, M.D., Pharm.D., CCFP (EM) E-mail: David.Holstrom@state.mn.us


714 Barton Ave, N.W. Internet address: www.phcybrd.state.mn.us
Buffalo, MN 55313

Lynne M. Schneider, R.Ph.


12910-37th Avenue North
Plymouth, MN 55441
Minnesota Hospital and Healthcare Partnership
Robert Straka, Pharm.D.
Bruce Rueben
University of Minnesota College of Pharmacy President
7-148 Weaver-Densford Hall 2550 University Avenue West
308 Harvard Street, S.E.
Suite 350S
Minneapolis, MN 55455
St. Paul, MN 55114-1900
T: 651/641-1121
DHS Staff
F: 651/659-1477
Cody Wiberg, Pharm.D., R.Ph. E-mail: brueben@mnhospitals.org
Pharmacy Program Manager Internet address: www.mhlp.com
Mary Beth Reinke, Pharm.D., R.Ph.
Minnesota Society of Health System-Pharmacists
Dur Coordinator
Judy Schneider
Executive Director
Executive Officers of State Medical and 2419 Margaret Street North
Pharmaceutical Societies Suite 210
Minnesota Medical Association North St. Paul, MN 55109
Paul S. Sanders, M.D. T: 651/639-0506
Chief Executive Officer F: 651/773-0717
3433 Broadway Street NE, Suite 300 E-mail: mshp@qwest.net
Minneapolis, MN 55413-1761 Internet address: www.mnshp.org
T: 612/378-1875
F: 612/378-3875 Care Providers of Minnesota
E-mail: psanders@mnmed.org Rick E. Carter
Internet address: www.mnmed.org President & CEO
2850 Metro Drive
Minnesota Pharmacists Association Suite 200
Julie K. Johnson, R.Ph. Bloomington, MN 55425
Executive Vice-President T: 612/854-2844
1935 W. County Road, B2 #450 F: 612/854-6214
Roseville, MN 55113 E-mail: rcarter@careproviders.org
T: 651/697-1771 Internet address: www.careproviders.org
F: 651/697-1776
E-mail: julie@mpha.org
Internet address: www.mpha.org

Minnesota Osteopathic Medical Society


Colleen Jensen
Executive Director
P.O. Box 314
Lakeland , MN 55043-0314
T: 612/623-3268
F: 612/677-3200
Internet address: www.mndo.org

State Board of Pharmacy


David E. Holmstrom
Executive Director
2829 University Avenue SE, #530
Minneapolis, MN 55414-3251
T: 612/617-2201
F: 612/617-2212

National Pharmaceutical Council Minnesota-5


Pharmaceutical Benefits 2002

6-Minnesota National Pharmaceutical Council


Pharmaceutical Benefits 2002

MISSISSIPPI

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    
Nursing Facility Services    
Skilled Nursing Home Services    
Physician Services    
Dental Services    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $370,355,016 415,925 $493,177,297

RECEIVING CASH ASSISTANCE TOTAL $213,654,399 159,780


Aged $36,653,891 23,329
Blind/Disabled $169,768,566 104,316
Child $3,972,229 22,291
Adult $3,259,713 9,844

MEDICALLY NEEDY, TOTAL $0 0


Aged $0 0
Blind/Disabled $0 0
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $100,396,175 201,384


Aged $35,679,665 22,486
Blind/Disabled $37,583,340 18,026
Child $23,601,427 137,097
Adult $3,531,743 23,775

TOTAL OTHER EXPENDITURES/RECIPIENTS* $56,304,442 54,761

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

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

National Pharmaceutical Council Mississippi-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of EPSDT


services and as part of The Children’s Health Insurance
Division of Medicaid, Office of the Governor. Program.

D. PROVISIONS RELATING TO DRUGS Formulary/Prior Authorization

Benefit Design Formulary: Open formulary, however, general exclusions


include:
Drug Benefit Product Coverage: Products covered:
prescribed insulin, disposable needles and syringe 1. Drugs used for anorexia or weight gain.
combinations used for insulin; blood glucose test strips;
2. Drugs when used for the symptomatic relief of cough
and urine ketone test strips. Products covered with
and colds (except quaifenesin syrup 100 mg/5 ml,
restrictions; total parenteral nutrition; and interdialytic
iodinated glycerol tablets 30 mg, which are covered).
parenteral insulin. Prior authorization required for:
Sandimmune; Viagra; enteral feeding products; Clozaril 3. Prescription vitamins and mineral products (except
(must be prescribed by Board Certified or Board Eligible prenatal vitamins and fluoride preparations, which
Psychiatrist); * Xenical, Benzodiazepines, NSAD, are covered).
Protropin and Humatrope; * all Antihemophilic Factors
including VIII and IX; * Synagis; Enbrel; Brand SR 4. Covered outpatient drugs for which the manufacturer
opioid agonists; and all Home IV drug therapies. Products requires (as a condition of sale) that associated tests
not covered: cosmetics; fertility drugs; experimental or monitoring services be purchased exclusively from
drugs. the manufacturer or its designee.
5. Barbiturates (except amobarbital, butabarbital,
* These products are covered only for children ages 0-21 mephobarbital, pentobarbital, phenobarbital,
years through the Early and Periodic Screening, Diagnosis secobarbital, which are covered).
and Treatment Program (EPSDT).
6. Benzodiazepines (except Klonopin, Lorazapam,
Diazepam and Temazepam which are covered).
Over-the-Counter Product Coverage: Products covered:
smoking deterrent products; Products covered with 7. DESI drugs (those drugs that are designated less than
restrictions; (i.e., certain rebated products) allergy, effective by the FDA).
asthma, and sinus products (Benadryl); analgesics (ASA,
generic Tylenol); cough and cold preparations (generic Prior Authorization: State currently has a prior
Robitussin); digestive products (non-H2 antagonist); authorization procedure. Administrative hearing required
feminine products; topical products; certain vitamins to appeal prior authorization decisions.
(prenatal and dialysis), and digestive products (H2
antagonists-prior authorization required). Prescribing or Dispensing Limitations

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.

Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug Program Pharmacy Payment and Patient Cost Sharing
when used in extended care facilities and through
physician payment when used in physicians’ offices. Dispensing Fee: $3.91 (effective 4/1/02). IV mixtures can
receive up to a $30 per liter dispensing fee.
Unit Dose: Unit dose packaging not reimbursable.

2-Mississippi National Pharmaceutical Council


Pharmaceutical Benefits 2002

Ingredient Reimbursement Basis: EAC = AWP-10%, DUR Contact


effective July 1, 1990.
Rickey Mallory
Prescription Charge Formula: Reimbursement for legend 601/359-6296
drugs will be at the lessor of AWP-12% plus a dispensing
fee or usual and customary charge. OTC drugs will be Mississippi DUR Board
paid at lessor of AWP plus a dispensing fee, AWP + 50%,
or shelf price. OTC drugs are to be billed on pharmacy Robert McMurray, M.D
invoice at shelf price. UMC-Rheumatologg Dept
2500 North State Street
Maximum Allowable Cost: State imposes Federal Upper Jackson, MS
Limits on generic drugs. Override requires prior
authorization for brand multi-source drugs. Tim Alford, M.D.
Kosciusko Medicaid Clinic
Incentive Fee: None. Highway 12
Kosciusko, MS 39090
Patient Cost Sharing: Tiered copayment of $1.00-$3.00.
$1.00 - preferred generic
John R. Mitchell, M.D.
$2.00 - preferred brand
Tupelo Family Medicine Residency Center
$3.00 - non-preferred brand
1665 South Green Street
Cognitive Services: Pays for Disease Management Tupelo, MS 38804
Services for diabetes, hyperlipidemia, asthma, and
coagulatory disorders (effective 8/1/98). Pays $20 for Cynthia Undesser, M.D.
average 30-minute encounter. P.O. Box 5102
Brandon, MS 39047
E. USE OF MANAGED CARE
Warren Jones, M.D.
No Medicaid recipients receive health benefits through 115 Cirencester Drive
MCOs. Ridgeland, MS 39157

Robert Smith, M.D.


F. STATE CONTACTS 971 Lakeland Drive
Suite 563
Jackson, MS 39216
State Drug Program Administrator
Rickey R. Mallory, R.Ph. Joe McGuffee, R.Ph.
Pharmacy Bureau Director McGuffee Drugs
Division of Medicaid 102 North Main Street
Robert E. Lee Building Mendenhall, MS 39114
239 North Lamar St., Suite 801
Jackson, MS 39201-1399 Montez Carter, Pharm.D.
T: 601/359-5253 P.O. Box 1414
F: 601/359-9555 Greenwood, MS 38935
E-mail: phrrm@medicaid.state.ms.us
Internet address: http://www.dom.state.ms.us Leigh Ann Ramsey, Pharm.D.
6295 Old Canton Road, #34 B
Jackson, MS 39211
Division of Medicaid Official
Rica Lewis-Payton, Executive Director Diana McGowan, R.Ph., M.B.A
Division of Medicaid 328 Dover Lane
Suite 801, Robert E. Lee Building Madison, MS 39110
239 North Lamar Street
Jackson, MS 39201-1399 Clarence DuBose, R.Ph.
T: 601/359-6050 Medi-Mart Pharmacy
F: 601/359-6048 3737 Main Street
E-mail: exfmp@medicaid.state.ms.us Moss Point, MS 39563

National Pharmaceutical Council Mississippi-3


Pharmaceutical Benefits 2002

Bob Broadus, R.Ph. Mail Order Pharmacy Program


7147 Creekwood Drive
None
Mandeville, LA 70471

Medicaid Managed Care Contact


Prescription Price Updating
Melzana Fuller
Rickey Mallory
Director of Provider and Beneficiary Relations
601/359-6296
Division of Medicaid
Robert E. Lee Building
Medicaid Drug Rebate Contact 239 North Lamar Street, Suite 801
Jackson, MS 39201
Glenda Grant T: 601/359-6063
Division of Medicaid F: 601/359-4185
Robert E. Lee Building
E-mail: mcmmf@medicaid.state.ms.us
239 North Lamar Street
Jackson, MS 39201
601/359-6050 Physician-Administered Drug Program Contact
E-mail: acgag@medicaid.state.ms.us
Patsy Crews, R.N.
Director of Bureau of Policy
Claims Submission Contact Division of Medicaid
239 N. Lamar Street
Terry Childress
Jackson, MS 39201
Director of Systems Management
601/359-5142
Division of Medicaid
Robert E. Lee Building
239 North Lamar Street Pharmacy and Therapeutics Committee
Jackson, MS 39201
Craig Dawkins, M.D.
T: 601/359-6075
1213 Broad Avenue
F: 601/359-6048
Gulfport, MS 39501
E-mail: pptcc@medicaid.state.ms.us
Yolanda Wilson, M.D.
Disease Management/Patient Education 1600 North State Street
Programs Suite 301
Jackson, MS 39202
Disease/Medical State: Asthma
Program Name: Asthma Disease Management (eff. 2/03)
Shannon Johnson, M.D.
Program Manager: Mckesson
South Mississippi Psychiatric Group
1101 B. South 28th Avenue
Disease/Medical State: Diabetes Hattiesburg, MS 39402
Program Name: Diabetes Disease Management (eff. 2/03)
Program Manager: Mckesson
Gary Davis, M.D.
571 East Beasley Road, Suite D
Disease/Medical State: Hypertension
Jackson, MS 39206
Program Name: Hypertension Disease Management (eff.
2/03) Charles Brock, M.D.
Program Manager: Mckesson 498 Hillcrest
Cleveland, MS 38732
Disease Management/Patient Education Contact
Myrna Alexander, M.D.
Alicia Condon 971 Lakeland Drive, Suite 850
Director of Medical Services Jackson, MS 39216
Division of Medicaid
Robert E. Lee Building Betsy Commings, C.F.N.P
239 North Lamar Street 1740 McClain Street
Jackson, MS 39201 Greenville, MS 38701
601/359-5250
E-mail: MSAKC@medicaid.state.ms.us

4-Mississippi National Pharmaceutical Council


Pharmaceutical Benefits 2002

Guy Phillips, R.Ph. Mississippi Hospital Association


903 Highway 82 East Sam W. Cameron
Indianola, MS 38751 President/CEO
6425 Lakeover Rd.
David Hudson, R.Ph. Jackson, MS 39236-6444
389 NW Depot Street T: 800/289-8884
Durant, MS 39063 F: 601/368-3200
E-mail: scameron@mhanet.org
Todd Barrett, R.Ph.
Covenant Pharmacy Mississippi Society of Health-System Pharmacists
2506 Lakeland Drive, Suite 101 Dianna McGowan
Flowood, MS 39232 Association Manager
328 Dover Lane
Jeff Jones, R.Ph. Madison, MS 39110
Carthage Discount Drugs T: 601/856-9273
602 Highway 16E F: 601/856-8539
Carthage, MS 39051-4212 E-mail : johnnymcg@msn.com

Larry Calvert, R.Ph. Mississippi Health Care Association


720 Sarazen Drive Martha Carole Jones
Gulfport, MS 39507 Executive Director
114 Marketridge Drive
Ridgeland, MS 39157
Executive Officers of State Medical and T: 601/956-3472
Pharmaceutical Societies F: 601/977-0273
Mississippi State Medical Association Internet address: www.mshca.com
William F. Roberts
Executive Director
P.O. Box 2548
Ridgeland, MS 39158-2548
601/853-6733
E-mail: wroberts@msmaonline.com
Internet address: www.msmed.org

Mississippi Pharmacists Association


Bo Dalton, R.Ph.
Executive Director
341 Edgewood Terrace Drive
Jackson, MS 39206-6217
601/981-0416

Mississippi State Board of Pharmacy


Leland “Mac” McDivitt
Executive Director
625 North State Street
Jackson, MS 39202
T: 601 354-6750
F: 601/354-6071
E-mail: lmcdivitt@mbp.state.ms.us
Internet address: www.mbp.state.ms.us

Mississippi Osteopathic Medical Association


Jeffrey J. LeBoeuf
Executive Director
P.O. Box 16890
Jackson, MS 39236
T: 601/366-3105
F: 601/366-2868
Internet address: www.moma-net.org

National Pharmaceutical Council Mississippi-5


Pharmaceutical Benefits 2002

6-Mississippi National Pharmaceutical Council


Pharmaceutical Benefits 2002

1
MISSOURI

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $600,484,118 447,062 $675,647,147

RECEIVING CASH ASSISTANCE TOTAL $235,086,301 148,738


Aged $47,641,532 20,176
Blind/Disabled $164,250,713 57,092
Child $9,663,268 41,803
Adult $13,530,788 29,667

MEDICALLY NEEDY, TOTAL $0 0


Aged $0 0
Blind/Disabled $0 0
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $38,069,254 104,337


Aged $5,491,622 3,740
Blind/Disabled $10,845,153 3,533
Child $20,303,141 84,243
Adult $1,429,338 12,821

TOTAL OTHER EXPENDITURES/RECIPIENTS* $327,328,563 193,987

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

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

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

National Pharmaceutical Council Missouri-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Monthly Quantity Limit: Physician encouraged to


prescribe 34-day or 100 dose supply but may, at own
Division of Medical Services, Missouri Department of discretion, prescribe up to a maximum 90-day supply.
Social Services.
Dose Limit: Prescriptions for the following must be
D. PROVISIONS RELATING TO DRUGS dispensed for at least 200 units per prescriptions: Aspirin
5 gr.; Aspirin buffered 5 gr.; Aspirin enteric-coated 5 gr.;
Benefit Design Acetaminophen 5 gr. Prenatal vitamins must be
dispensed in a quantity of at least 100.
Drug Benefit Product Coverage: Categories or drugs that
are covered: prescribed insulin; disposable needles and Drug Utilization Review
syringe combinations used for insulin; nonlegend
ophthalmic preparations; nonlegend acne preparations; PRODUR system implemented in 1993. State currently
nonlegend weight control preparations; hemorrhoid has a DUR Board with a quarterly review.
products; estazolam; halazepam; prazepam; and
quazepam. Products covered through the Durable Pharmacy Payment and Patient Cost Sharing
Medical Equipment Program: blood glucose test strips;
urine ketone test strips; total parenteral nutrition; and Dispensing Fee: $4.09, effective 9/17/91.
interdialytic parenteral nutrition. Prior authorization
required for: amphetamines; Isotretinoin; and Retinoic Ingredient Reimbursement Rate: EAC = AWP-10.43% or
Acid. Products not covered: cosmetics; fertility drugs; WAC+10%.
anoretics; experimental drugs; smoking deterrent
products; feminine products; and topical products.
Prescription Charge Formula:
(For additional information on products and/or category
1. Method of reimbursement payment is based on
coverage, see the pharmacy provider bulletin at
acquisition cost plus a dispensing fee of $4.09 per
www.medicaid.state.mo.us.)
prescription filled. Acquisition may vary depending
whether it is based on AWP and Federal or Missouri
Coverage of Injectables: Injectable medicines MAC.
reimbursable through the Prescription Drug Program
when used in physician offices, home health care settings, 2. Any drug that is not a Federal or Missouri MAC drug
and extended care facilities. will be based on the AWP-10.43% or the
WAC+10%. The majority of drugs listed are based
Vaccines: Vaccines reimbursable as part of EPSDT on AWP. The method of pricing will be taken from
program, Children Health Insurance Program, and the NDC number.
Vaccines for Children Program.
Maximum Allowable Cost: State imposes Federal Upper
Unit Dose: Unit dose packaging reimbursable. Limits as well as State-specific limits on generic drugs.
199 drugs are listed on the State-specific MAC list.
Override requires prior authorization.
Formulary/Prior Authorization
Incentive Fee: None.
Formulary: Open formulary with exclusions.

Prior Authorization: State currently has a prior


authorization procedure and a Drug Prior Authorization
Committee composed of 7 members who meet quarterly.

Prescribing or Dispensing Limitations

Prescription Refill Limit: Federal regulations must be


observed for all drugs on the formulary that are listed in
BNDD Schedules 2, 3, 4, and 5. All other prescriptions
refilled should be in accordance with the directions given
by the prescribing physician.

2-Missouri National Pharmaceutical Council


Pharmaceutical Benefits 2002

Patient Cost Sharing: Variable copayment: FirstGuard Health Plan


3801 Blue Parkway
Kansas City, MO 64130
Drug Ingredient Cost Copayment 816/922-7250

$0.00 to $10.00 $0.50 Family Health Partners Health Plan


215 W. Pershing Road, Suite 310
$10.01 to $25.00 $1.00 P.O. Box 411806
Kansas City, MO 64141
$25.01 or more $2.00 816/855-1871

($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

Cognitive Services: Payment for cognitive services is


provided to qualified pharmacies who enroll to provide F. STATE CONTACTS
diabetes education.
State Drug Program Administrator
E. USE OF MANAGED CARE Susan McCann, R.Ph.
Pharmaceutical Consultant
Approximately 380,000 Medicaid recipients are enrolled Division of Medical Services
in managed care organizations in 2001. All receive P.O. Box 6500
pharmacy services through managed care. Jefferson City, MO 65102-6500
T: 573/751-6963
Managed Care Organizations F: 573/526-4650
E-mail: susanmccann@mail.medicaid.state.mo.us
Healthcare USA
100 South 4th Street, Suite 1100 Social Services Department Officials
St. Louis, MO 63102
314/444-7239 Dana Katherine Martin, Director
Department of Social Services
Blue Advantage Plus Health Plan Broadway State Office Building
P.O. Box 419130 P.O. Box 1527
2301 Main St. Jefferson City, MO 65102
Kansas City, MO 64141 T: 573/751-4815
816/395-3891 F: 573/751-3203
E-mail: dlorts@mail.dss.state.mo.us
Mercy Health Plan
425 S. Woods Mill Road Gregory A. Vadner, Director
Chesterfield, MO 63017 Division of Medical Services
314/214-8000 615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102-6500
Care Partners Health Plan T: 573/751-3425
The Clayton Center F: 573/751-6564
120 S. Central, 8th Floor E-mail: gvadner@mail.state.mo.us
St. Louis, MO 63105
314/505-5400 Prior Authorization Contact
Allison Lauf, R.N.
Community Care Plus Health Plan Nurse Consultant
5615 Pershing Avenue, Suite 29 Division of Medical Services
St. Louis, MO 63112 P.O. Box 6500
314/454-0055 ext. 234 Jefferson City, MO 65102
T: 573/751-3762
HealthNet Health Plan F: 573/751-2439
2300 Main Street, Suite 700 E-mail: allisonlauf@mail.medicaid.state.mo.us
Kansas City, MO 64108
816/221-8400

National Pharmaceutical Council Missouri-3


Pharmaceutical Benefits 2002

DUR Contact Sandra Bollinger, Pharm.D.


Health Priorities, Inc.
Jayne Zemmer
707 Specialty Drive
DUR Coordinator
Dexter, MO 63841
Division of Medical Services
P.O. Box 6500
Stephen Calloway, Pharm.D.
Jefferson City, MO 65102
Columbia, MO
T: 573/751-6963
F: 573/526-4650
Robert Dale Potter, R.N.
E-mail: jaynezemmer@mail.medicaid.state.mo.us
422 West Robin Ridge Road
Columbia, MO 65203
DUR Board
John W. Newcomer, M.D. (Chair) Drug Prior Authorization Committee
Associate Professor of Psychiatry
Patrick J. Bryant, Pharm.D.
Washington University, School of Medicine
Drug Information Center
Campus Box 8134
School of Pharmacy
660 S. Euclid
University of Missouri - Kansas City
St. Louis, MO 63110
MG-200 Medical School Building
2411 Holmes Street
Ronald Graham, Pharm.D.
Kansas City, MO 64108-2792
Government Relations Manager
Novartis Corporation
M. Dale Terrell, M.D.
1311 Granite Creek Drive
Washington University School of Medicine
Blue Springs, MO 64015
Division of Geriatric Medicine
Room M238
Randall Huss, M.D.
1402 South Grand Blvd.
Rolla Family Practice
St. Louis, MO 63104
910 W. 10th Street
Rolla, MO 65401
Gene Forrester, R.Ph.
2400 S. Blackthorne
Joy S. Gronstedt, D.O.
Columbia, MO 65201
30580 Summers Drive
Sedalia, MO 65301
Henry Petry, D.O.
Laurie Clinic
Joseph M. Yasso, D.O.
P.O. Box 1277
3513 NW Primrose Lane
Laurie, MO 65038
Lee’s Summit, MO 64064
James E. Edwards, M.D.
Harold Lurie, M.D.
1000 Executive Pkwy, Suite 103
Springfield, MO
St. Louis, MO 63141
Karla Dwyer, R.Ph.
Lorraine C. Brown, D.O.
901 Cherry Lane
Rt. 2, Box 247C
Kirksville, MO 63501
Camdenton, MO 65020
Susan Abdel-Rahman, Pharm.D.
Conrad S. Balcer, D.O.
Division of Clinical Pharmacology
1241 W. Stadium Blvd.
Children’s Mercy Hospital
Jefferson City, MO 65109
2401 Gillham Road, Suite 0411
Kansas City, MO 64108
Prescription Price Updating
Peggy Wanner-Barjenbrunch, M.D.
Mexico Health Services First DataBank
1111 Bayhill Dr.
809 Medical Park Drive, Suite 104
San Bruno, CA 94066
Mexico, MO 65265
T: 650/588-5454
F: 650/872-4578

4-Missouri National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Drug Rebate Contacts Craig Leonard, R.Ph.


Lee’s Summit Pharmacy
Technical: Julie Schulte, 573/751-7996
615 W. 3rd Street
Policy: Susan McCann, 573/751-6963
Lee’s Summit, MO 64063
Dispute Resolution: Lynn Hebenheimer, 573/526-5778
Audits: Lynn Hebenheimer, 573/526-5778
Executive Officers of State Medical and
Pharmaceutical Societies
Claims Submission Contact
Missouri State Medical Association
Jim Judge
C. C. Swarens
Claims Process Administrator
Executive Secretary
Verizon
113 Madison Street, P.O. Box 1028
905 Weathered Rock Road
Jefferson City, MO 65102
Jefferson City, MO 65101
573/636-5151
573/635-2434
E-mail: cswarens@msma.org
Internet address: www.momed.net/momed/index.htm
Medicaid Managed Care Contact
Missouri Pharmacy Association
Janice Gentile Ron Fitzwater
Regional Administrator Chief Executive Officer
Division of Medical Services 211 East Capitol Avenue
P.O. Box 6500 Jefferson City, MO 65101-3001
Jefferson City, MO 65102 T: 573/636-7522
T: 573/526-4274 F: 573-636-7485
F: 573/526-4651 E-mail: ron@morx.com
Internet address: www.morx.com
Mail Order Pharmacy Program
Missouri Assoc. of Osteopathic Physicians/Surgeons, Inc.
None Bonnie M. Bowles
Executive Director
Physician-Administered Drug Program Contact 1423 Randy Lane - P.O. Box 748
Jefferson City, MO 65102
Pam Jarrett T: 573/634-3415
Division of Medical Services F: 573/634-5635
P.O. Box 6500 E-mail: maopsemail@cs.com
Jefferson City, MO 65102-6500 Internet address: www.maops.com
573/751-3277
State Board of Pharmacy
Pharmacy Subcommittee Roster Kevin E. Kinkade
Bill Fitzpatrick, R.Ph. Executive Director
Interlock Pharmacy Systems P. O. Box 625
2292 Weldon Parkway Jefferson City, MO 65102
St. Louis, MO 63146 573/751-0091
E-mail: kkinkade@mail.state.mo.us
Philip A. Bangert, R.Ph. Internet address: www.ecodev.state.mo.us/pr/pharmacy
Bangert Pharmacy, Ltd.
13300 New Halls Ferry Missouri Hospital Association
Florissant, MO 63033 Marc Smith
President
4712 Country Club Drive
Tom Beetem, R.Ph., Chairman P.O. Box 60
1425 Eastview Drive Jefferson City, MO 65102-0060
Holts Summit, MO 65043 T: 573/893-3700
F: 573/893-2809
Robert D. Hurley, R.Ph. E-mail: msmith@mail.mhanet.com
Walgreens Internet address: www.mhanet.com
440 N. Highway 67
Florissant, MO 63031

National Pharmaceutical Council Missouri-5


Pharmaceutical Benefits 2002

6-Missouri National Pharmaceutical Council


Pharmaceutical Benefits 2002

MONTANA

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       

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $58,634,278 58,899 $72,577,455

RECEIVING CASH ASSISTANCE, TOTAL $27,165,774 22,015


Aged $2,488,683 1,594
Blind / Disabled $21,977,137 10,148
Child $979,128 6,707
Adult $1,720,826 3,611

MEDICALLY NEEDY, TOTAL $16,977,885 7,426


Aged $10,217,068 5,248
Blind / Disabled $6,753,450 2,145
Child $7,287 30
Adult $80 3

POVERTY RELATED, TOTAL $1,897,790 11,493


Aged $0 0
Blind / Disabled $0 0
Child $1,191,540 8,796
Adult $706,250 2697

TOTAL OTHER EXPENDITURES/RECIPIENTS* $12,592,829 17,965

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

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

National Pharmaceutical Council Montana-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Coverage of Injectables: Injectable medicines


reimbursable through the Prescription Drug Program
Department of Public Health and Human Services. when used in home health care and extended care
facilities, and through physician payment when used in
physician offices.
D. PROVISIONS RELATING TO DRUGS
Vaccines: Vaccines reimbursable as part of the EPSDT
Benefit Design service, the Children Health Insurance Program, and the
Vaccines for Children Program.
Drug Benefit Product Coverage: Products covered:
legend drugs, prescribed insulin; certain prescribed over- Unit Dose: Unit dose packaging reimbursable.
the-counter products, vaccines except children 18 and
under and clients with Medicare Part B coverage; Formulary/Prior Authorization
compounded prescriptions; contraceptive supplies and
devices. Products not covered: cosmetics; fertility drugs; Formulary: Open formulary. Drugs classified as less-
experimental drugs; disposable needles used for insulin, than-effective (LTE) by the FDA are not covered. Drugs
syringe combinations for insulin use; blood glucose test with no manufacturer rebate are not covered.
strips; urine ketone test strips; total parenteral nutrition;
and interdialytic parenteral nutrition. Prior authorization Prior Authorization: State has a formal prior
required for non-steroidal anti-inflammatory drugs; all authorization procedure. Prescriber letter documenting
single source NSAIDs; Celebrex, Vioxx; disease- evidence for use of prescribed medication in treatment of
modifying anti-rheumatic drugs (Arava, Enbrel, disease is reviewed by DUR Board for appeal of excluded
Remicade); growth hormones; single-source product. An appeal procedure through the Department
benzodiazepines; gastro-intestinal drugs (including H2 possible for PA decisions.
antagonists, proton pump inhibitors, Carafate and
Cytotec); migraine headache drugs for certain monthly Prescribing or Dispensing Limitations
quantities on Imitrex, Maxalt, Zomig, Migranal, Amerge; Prescription Refill Limit: 25% grace period over a 3-
weight reduction drugs (Fastin, Ionamin, Meridia, month period is allowed.
Xenical); smoking-cessation drugs; Toradoloral;
Dipyridamole; Aggrenox; Trental, Pletal; Ambien and Monthly Quantity Limit: 100 doses or 34-day supply,
Sonata; Viagra; Thalomid; Zyvox; Tretinoin; Zoloft; whichever is greater.
Hismanal; Bextra; Kineret; Stadol; Isoetherine; and
Isoproterenol. Drug Utilization Review
Over-the-Counter Product Coverage: Products covered PRODUR system implemented in September 1994. State
with restrictions (i.e., when prescribed): analgesics DUR Board has 6 members and meets monthly.
(aspirin only); Insulin laxatives; antacids; head lice
treatment; H2 antagonist GI products; bronchosaline; and Pharmacy Payment and Patient Cost Sharing
smoking deterrent products. Products not covered:
Dispensing Fee: $2.00-4.70; effective 7/1/02. Pharmacies
allergy, asthma, and sinus products; cold and cough
submit documentation showing their costs. Dispensing
preparations; feminine products; and topical products.
fee is based on their cost up to a maximum of $4.70.
Pharmacies that do not submit documentation receive a
Therapeutic Category Coverage: Therapeutic categories dispensing fee of $2.00.
covered: anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents; Ingredient Reimbursement Basis: EAC = AWP - 15%, or
antilipemic agents; anti-psychotics; cardiac drugs; manufacturer’s direct price, if available.
chemotherapy agents; contraceptives; ENT anti-
Prescription Charge Formula: The lower of EAC, the
inflammatory agents; estrogens; hypotensive agents; misc.
Federal MAC (plus a dispensing fee), or the provider
GI drugs; sympathominetics (adrenergic); and thyroid
usual and customary charge.
agents. Partial coverage for: antihistamines and
prescribed cold medications. Prior authorization required Maximum Allowable Cost: State imposes Federal Upper
for: anorectics; anxiolytics, sedatives, and hypnotics; Limits on generic drugs. Override requires “Brand
analgesics, antipyretics, NSAIDs; growth hormones; and Necessary” or prior authorization.
prescribed smoking deterrents.
Incentive Fee: None.
Patient Cost Sharing: Copayment of $1.00 - $5.00.
Recipient pays 5% of Medicaid allowable cost between
$1.00 and $5.00. $5.00 copayment cap per prescription.
$25.00 copayment cap per month.

2-Montana National Pharmaceutical Council


Pharmaceutical Benefits 2002

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.

Public Health and Human Services Officials


Prescription Price Updating
Dr. Gail Gray
Director First DataBank
Department of Public Health and Human Services 1111 Bayhill Dr.
P.O. Box 4210 San Bruno, CA 94066
111 N. Sauders T: 650/588-5454
Helena, MT 59604 F: 650/827-4578
T:406/444-5622
F: 406/444-1970 Medicaid Drug Rebate Contacts
E-mail: ggray@state.mt.us
Betty DeVaney
Margaret A.Bullock, Administrator Drug Rebate Coordinator
Division of Health Policy and Services Department of Public Health & Human Services
Department of Public Health and Human Services Medicaid Services Bureau
1400 Broadway P.O. Box 202951
Helena, MT 59601 1400 Broadway
T: 406/444-4141 Helena, MT 59620-2591
F: 406/444-1861 T:406/444-3457
E-mail: mbullock@state.mt.us F: 406/444-1861
E-mail: bdevaney@state.mt.us
Jeff Buska, Bureau Chief
Medicaid Services Bureau Claims Submission Contact
406/444-4145
Kevin Quinn
Duane Pershinger Executive Account Manager
Acute Services Section ACS, Inc.
406/444-4144 34 N. Last Chance Gulch, Suite 200
Helena, MT 59601
Mary Angela Collins, Supervisor T: 406/442-7693
Managed Care Section F: 406/442-2819
406/444-4146 E-mail: kevin.quinn@acs-inc.com

National Pharmaceutical Council Montana-3


Pharmaceutical Benefits 2002

Medicaid Managed Care Contact Montana State Pharmaceutical Association


Jim E. Smith
Jo Thompson
Executive Director
Program Officer
P. O. Box 1569
Dept. of Public Health and Human Services
34 West 6th Avenue, Suite 2E
Medicaid Services Bureau
Helena, MT 59601-5074
P.O. Box 202951
T: 406/449-3843
1400 Broadway
F: 406/443-1592
Helena, MT 59620-2951
E-mail: jimesmith@qwest.net
T: 406/444-4148
Internet address: www. Rxmt.org/services.htm
F: 406/444-1861
E-mail: jothompson@state.mt.us
State Board of Pharmacy
Rebecca Deschamps, R.Ph.
Disease Management Program/Initiative Contact Executive Director
P.O. Box 200513
Dan Peterson 111 N. Jackson
Pharmacy Program Officer Helena, MT 59620-0513
Dept. of Public Health and Human Services T: 406/841-2356
Medicaid Services Bureau F: 406/841-2343
P.O. Box 202951 E-mail: dlibspdha@state.mt.us
Helena, MT 59620-2951 Internet address:
T: 406/444-2738 discoveringmontana.com/dli/bsd/license/bsd_boards/pha_
F: 406/444-1861 board/board_page.htm
E-mail: danpeterson@state.mt.us
Montana Osteopathic Medical Association
Mail Order Pharmacy Benefit William Munro, D.O.
Executive Director
None 6364 Toohey Road
Bozeman, MT 59715
Physician-Administered Drug Program Contact T: 406/522-9615
F: 406/522-9615
Denise Brunett E-mail: drbillmunro@mcn.net
P.O. Box 202951 Internet address: www.momor.com
1400 Broadway
Helena, MT 59624 Montana Hospital Association
406/444-3995 Dick Brown
E-mail: dbrunett@state.mt.us Sr. Vice President/Executive Director
P.O. Box 5119
Executive Officers of State Medical and Helena, MT 59604
Pharmaceutical Societies 406/442-1911
E-mail: dick@mtha.org
Montana Medical Association Internet address: www.medassets.com/mtha.htm
Noel D. Drury, M.D.
President
2021 11th Avenue, Suite 1
Helena, MT 59601-4890
T: 406/443-4000
F: 406/443-4042
E-mail: noel@mmaoffice.com
Internet address: www.mmaoffice.com

4-Montana National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEBRASKA

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $135,355,734 165,891 $170,897,014 178,365

RECEIVING CASH ASSISTANCE TOTAL $50,573,088 44,609 58,978,402 45,490


Aged $7,711,090 3,995 8,756,182 3,599
Blind/Disabled $35,790,933 14,893 42,225,001 15,234
Child $3,262,675 16,938 3,734,776 17,651
Adult $3,808,390 8,783 4,262,443 8,646

CATEGORICALLY NEEDY NON-CASH TOTAL $34,036,309 28,217 40,152,899 30,671


Aged $22,294,042 9,614 25,640,472 9,676
Blind/Disabled $5,226,769 1,557 5,365,283 1,463
Child $1,515,549 6,330 1,810,841 6,569
Adult $4,999,949 10,716 7,336,303 12,963

MEDICALLY NEEDY TOTAL $40,512,630 67,425 50,564,381 78,571


Aged $11,554,591 6,115 13,567,579 6,293
Blind/Disabled $18,849,429 7,103 22,577,439 7,496
Child $9,832,487 51,785 13,960,793 60,808
Adult $276,123 2,422 458,570 3,974

TOTAL OTHER EXPENDITURES/RECIPIENTS* $10,233,707 25,640 11,881,817 23,633

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2001 data provided by State Department of Health and Human Services, Finance and Support, Medicaid Division.

Source: CMS, MSIS Report, FY 2000 and Nebraska Medicaid Statistical information System, FY 2001.

National Pharmaceutical Council Nebraska-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Vaccines: Vaccines reimbursable by Medicaid for


individuals under 21 years of age as part of EPSDT
State Department of Health and Human Services, Finance Services, through the Children’s Health Insurance
and Support, Medicaid Division. Program, and through the Vaccines for Children Program.

D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging not reimbursable.

Benefit Design Formulary/Prior Authorization

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.

2-Nebraska National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council Nebraska-3


Pharmaceutical Benefits 2002

Barbara Mart Medicaid Drug Rebate Contacts


Clinical Pharamacist
Technical
Health and Human Services
Karen Jaques
301 Centennial Mall South
Accountant II
5th Floor-NSOB
Health and Human Services – Finance and Support
P.O. Box 95026
301 Centennial Mall South
Lincoln, NE 68509-5026
5th Floor – NSOB
T: 402/471-9301
P.O. Box 95026
F: 402/471-9092
Lincoln, NE 68509-5026
E-mail: barb.mart@hhhs.state.ne.us
F: 402/471-9397
E-mail: karen.jaques@hhss.state.ne.us
DUR Contacts
Beth Wilson Policy
DUR Director Dyke Anderson, R.Ph.
Nebraska Pharmacists Association 402/471-9379
6221 South 58th; Ste A
Lincoln, NE 68516 Claims Submission Contact
T: 402/420-1500
Glenn Sharp
F: 402/420-1406
Account Representative
E-mail: beth@npharm.org
First Health Services Corp.
4300 Cox Road
Nebraska DUR Board
Glen Allen, VA 23060
T: 804/527-3013
Pharmacist Members: F: 804/290-4831
Kevin Borcher, R.Ph.
E-mail: JMPrater@fhsc.com
Janet Darnell, R.Ph.
Patty Gollner, R.Ph.
Medicaid Managed Care Contact
Duane Mines, R.Ph.
John Guzallis, R.Ph.
David Cygan
Kim Hamik, R.Ph.
Managed Care Program Administrator
Shannon Nelson, R.Ph.
HHSS-Finance & Support-Medicaid
Phillip Vuchetich, R.Ph.
301 Centennial Mall South
Lincoln, NE 68509
Physician Members:
T: 402/471-9050
Kay Anderson, M.D.
F: 402/471-9455
Fred Ayers, M.D.
E-mail: David.Cygan@hhss.state.ne.us
Kirk Muffly, M.D.
Thomas B. Murray, M.D.
Sam Perry, M.D. Mail Order Pharmacy Program
None
Prescription Price Updating
Physician-Administered Drug Program Contact
First DataBank Lorelee Novak, R.N.
1111 Bayhill Dr. Department of Health and Human Services
San Bruno, CA 94066 301 Centennial Mall, 5th floor
T: 650/588-5454 Lincoln, NE 68509
F: 650/827-4578 402/471-9368

Health and Human Services Department


Medical Care Advisory Committee
Marlene Brondel
League of Human Dignity
1701 P Street
Lincoln, NE 68508

4-Nebraska National Pharmaceutical Council


Pharmaceutical Benefits 2002

Tim Bruner Executive Officers of State Medical and


Director of Fiscal Services Pharmaceutical Societies
Lincoln General Hospital
Nebraska Medical Association
2300 South 16th Street
Sandra Johnson
Lincoln, NE 68502
Executive Vice President
233 S. 13th Street, Suite 1512
Joni Cover, J.D.
Lincoln, NE 68508-2091
Executive Vice President
402/474-4472
Nebraska Pharmacists Association
E-mail: sandy_nma@alltel.net
6221 South 58th Street, Suite A
Internet address: www.nebmed.org
Lincoln, NE 68502
Nebraska Pharmacists Association
Karen Miller
Joni Cover, J.D.
Health Insurance Specialist
Executive Vice President
Room 227, Federal Building
6221 South 58th, Suite A
601 East 12th Street
Lincoln, NE 68516-3679
Kansas City, MO 64106
T: 402/420-1500
F: 402/420-1406
Edmund A. Schneider, O.D.
E-mail: gary@npharm.org
Lincoln Vision Clinic
Internet address: www.npharm.org
810 North 48th Street
Lincoln, NE 68504
Nebraska Assn. of Osteopathic Physicians & Surgeons
Arthur Weaver, D.O.
Steven Lorenzen
Secretary
Director, Federal Programs
16556 Dorcas Street
Blue Cross/Blue Shield of NE
Omaha, NE 68130
Main P. O. Station Box 3248
402/554-2374
Omaha, NE 68180
State Board of Pharmacy
John Milligan
Becky Wisell
Legal Services of Southeast Nebraska
Executive Secretary
825 Terminal Building
P. O. Box 94986
Lincoln, NE 68508
Lincoln, NE 68509
T: 402/471-2115
Joan Penrod, Ph.D.
F: 402/471-3577
Department of Preventive and Social Medicine
E-mail: becky.wisell@hhss.state.ne.us
UNMC
Internet address: www.hhs.state.ne.us/lis/lis.asp
Box 984350, 600 S. 42nd Street
Omaha, NE 68198
Nebraska Association of Hospitals and Health Systems
Laura J. Redoutey, FACHE
Larry Rennecker
President
NAHHS
1640 L St., Suite D
1640 L Street, Suite D
Lincoln, NE 68508-2509
Lincoln, NE 68508
T: 402/458-4900
Sandy Johnson
F: 402/475-4091
Executive Secretary
E-mail:lredoutey@nhanet.org
Nebraska Medical Association
Internet address: www.nhanet.org
First Bank Bldg., Suite 1512
Lincoln, NE 68508

Pat Snyder
Executive Director
Nebraska Health Care Assoc.
421 South 9th Street, Suite 137
Lincoln, NE 68508

James Walker, D.D.S.


1640 South 70th, Suite 200
Lincoln, NE 68506

National Pharmaceutical Council Nebraska-5


Pharmaceutical Benefits 2002

6-Nebraska National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEVADA

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $51,682,326 51,169 $72,352,089 57,891

RECEIVING CASH ASSISTANCE TOTAL $37,621,017 26,574


Aged $8,254,244 5,730
Blind/Disabled $28,548,043 15,336
Child $349,567 3,162
Adult $469,173 2,346

MEDICALLY NEEDY, TOTAL $0 0


Aged $0 0
Blind/Disabled $0 0
Child $0 0
Adult $0 0

POVERTY RELATED, TOTAL $1,498,797 9,469


Aged $116,959 129
Blind/Disabled $268,968 261
Child $668,618 5,669
Adult $444,252 3,410

TOTAL OTHER EXPENDITURES/RECIPIENTS* $12,562,512 15,126

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

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

National Pharmaceutical Council Nevada-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Vaccines: Vaccines reimbursable at cost plus an


administration fee ($3.83) as part of the EPSDT service.
Division of Health Care Financing and Policy of the Unit Dose: Unit dose packaging reimbursable.
Department of Human Resources.
Formulary/Prior Authorization
D. PROVISIONS RELATING TO DRUGS
Formulary: Open formulary. General exclusions include:
Benefit Design
1. Agents used for cosmetic purposes or hair growth.
Drug Benefit Product Coverage: Products covered:
2. Yohimbine (e.g., Yocon).
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test strips; 3. Radiopaque agents (e.g., Telepaque, Hypaque,
and urine ketone test strips. Products covered under Barium Sulfate).
DME: total parental nutrition; interdialytic parenteral
nutrition. Products not covered: cosmetics; fertility drugs; 4. Radiographic adjuncts (e.g., Perchloracap).
and experimental drugs. 5. Pharmaceuticals designed “ineffective,” or “less than
effective” (including identical, related, or similar
Over-the-Counter Product Coverage: Products covered: drugs) by the FDA.
allergy, asthma, and sinus products; analgesics; cough and
cold preparations; digestive products; and smoking 6. Non-rebated medications.
deterrent products. Products covered with restrictions: Prior Authorization: State currently has a prior
topical products. OTC drugs are reimbursed at authorization procedure with appeals process. Prior
EAC+$4.76 or the usual and customary amount, authorization procedure screening for individual drugs.
whichever is less, and require prior authorization. Drugs requiring PA include:
Products not covered: feminine products.
1. Amphetamine (e.g., Dexedrine)
Therapeutic Category Coverage: Therapeutic categories 2. Chorionic Gonadotropin (HCG)
covered: analgesics, antipyretics, and NSAIDs;
antibiotics; anticoagulants; anticonvulsants; anti- 3. Dipyridamole (e.g., Persantine)
depressants; antidiabetic agents; antihistamine drugs; 4. Erythropoietin (e.g., Epogen, Procrit)
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents; 5. Gonadotropin releasing hormone analog (e.g.,
prescribed cold medications; contraceptives; ENT anti- Lupron, Zoladex)
inflammatory agents; hypotensive agents; misc. GI 6. Growth hormone (e.g., Protropin, Nutropin)
products; prescribed smoking deterrents;
sympathominetics (adrenergic); and thyroid agents. Prior 7. Interferon (all combinations manufactured by
authorization required for: CNS stimulants; recombinant DNA technology)
Hemapopoiletic; PPIs; Cox2 inhibitors; erectile 8. Intravenous antibiotic therapy
dysfunction medications; duragisic patches; HCG;
Gonadotropin, Gonadotropin releasing hormone analog; 9. Methylphenidate (e.g., Ritalin)
Erythropoetin; Interferon; IV antibiotic; Methylpenidate, 10. Non-legend pharmaceuticals
Peomoline; vitamins; and Remicade. Partial coverage for:
growth hormones (prior authorization required); 11. Nutritional supplements or replacements
estrogens; and anabolic steroids. Therapeutic categories 12. Pemoline (e.g., Cylert)
not covered: anorectics; amphetamine combinations;
radiopague and radiographic products; DESI drugs; 13. Pulmozyme
yohimbine; and drugs not participating in the drug rebate 14. Vitamins, vitamin/mineral combinations or
program. hematinics
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Prescribing or Dispensing Limitations
when used in home health care and extended care Monthly Quantity Limit: The maximum dispensable
facilities, and through physician payment when used in quantity is limited to a 34-day supply. Maintenance
physicians’ offices. medications limited to a 100 day supply.

2-Nevada National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drug Utilization Review Human Resources Department Officials


State currently has a DUR Board with a quarterly review Michael J. Willden, Director
by a PRODUR contractor. PRODUR system implemented Department of Human Resources
in 2003. State Capital Complex
505 East King Street, Room 600
Pharmacy Payment and Patient Cost Sharing
Carson City, NV 89710
T: 775/684-4000
Dispensing Fee: $4.76, effective 10/1/98. IV dispensing
F: 775/684-4010
fee is $16.80 for first ingredient; $5.60 for other
E-mail: slindsey@dhr.state.nv.us
ingredients.
Chuck Duarte
Ingredient Reimbursement Basis: EAC = AWP-15%. Administrator
Division of Health Care Financing and Policy
Prescription Charge Formula: The lowest of (1) specific 1100 E. Williams Street, Suite 116
upper limit (SUL) plus a dispensing fee, (2) estimated Carson City, NV 89710
acquisition cost (EAC) plus a dispensing fee, or (3) the T: 775/684-3676
pharmacy's usual charge to the general public. F: 775/684-8792
Maximum Allowable Cost: State does not impose Upper E-mail: cduarte@govmail.state.nv.us
Limits on generic drugs.
Prior Authorization Contact
Incentive Fee: None.
Dionne Coston, R.N.
Patient Cost Sharing: None. 775/684-3775
HealthInsight
Cognitive Services: Does not pay for cognitive services. 800/748-6944

E. USE OF MANAGED CARE DUR Contact

Approximately 56,000 Medicaid recipients are enrolled in Dionne Coston, R.N.


MCOs in 2001; all receive pharmacy benefits through 775/684-3775
there managed care plan.
DUR Board
Managed Care Organizations
Joseph W. Johnson, M.D.
Health Plan of Nevada 110 E. Lake Mead Boulevard, #201
P.O. Box 15645 Henderson, NV 89015
Las Vegas, NV 89114
Steven W. Parker, M.D.
NevadaCare, Inc. 75 Pringle Way, #603
1701 W. Charleston Blvd. Reno, NV 89503
Suite 420
Las Vegas, NV 89102 David England, R.Ph.
University Medical Center Pharmacy
1800 W. Charleston Boulevard
F. STATE CONTACTS
Las Vegas, NV 89102
State Drug Program Administrator
Lori Winchell, R.N.
Dionne Coston, R.N. 341 Pinnacle Court
Medical Services Specialist Henderson, NV 89014
Division of Health Care Financing and Policy
Pharmacy Program Vanetta Christopherson
1100 E. Williams Street 2149 Hidden Ranch Terrace
Carson City, NV 89701 Henderson, NV 89052
T; 775/684-3775
F: 775/684-3762
Email: dcpstpm@dhcfp.state.nv.us
Internet Address: www.dhcfp.state.nv.us

National Pharmaceutical Council Nevada-3


Pharmaceutical Benefits 2002

Prescription Price Updating Executive Officers of State Medical and


Pharmaceutical Societies
First DataBank
1111 Bayhill Dr., Suite 350 Nevada State Medical Association
San Bruno, CA 94066 Lawrence P. Matheis
T: 650/588-5454 Executive Director
F: 650/827-4578 3660 Baker Lane, Suite 101
Reno, NV 89509
Medicaid Drug Rebate Contacts T: 775/825-6788
F: 775/825-3202
Technical: Anita Sheard, 775/684-3749 E-mail: nsma@nsmadocs.org
Policy: Dionne Coston, R.N., 775/684-3755 Internet address: www.nsmadocs.org
Rebate: Anita Sheard, 775/684-3749
Nevada Pharmacy Alliance
Claims Submission Contact Mary Grear, R.Ph.
Executive Vice President
First Health Services Corp. c/o Nevada College of Pharmacy
4300 Cox Road 5740 S. Eastern Avenue, Suite 240
Glen Allen, VA 23060 702/990-4433
800/884-3238 E-mail: nvphall@ludi.net
Internet address: www.nvphall.org
Medicaid Managed Care Contact
Nevada Osteopathic Medical Association
Hilary Jones, R.N. Denise Selleck Davis
Medicaid Services Specialist III Executive Director
1100 E. Williams St., Ste 204 2920 N. Green Valley Parkway, Suite 527
Carson City, NV 89701 Las Vegas, NV 89014
775/684-3697 T: 702/434-7112
E-mail: hjones@dhcfp.state.nv.us F: 702/434-7110
E-mail: nvoma@aol.com
Mail Order Pharmacy Program Internet address: www.nevadaosteopathic.com
None
State Board of Pharmacy
Physician-Administered Drug Program Contact Keith W. MacDonald, R.Ph.
Executive Secretary
Coleen Lawrence, 775-684-3744 555 Double Eagle Court, Suite 1100
Reno, NV 89511-8991
Medical Care Advisory Group T: 775/850-1440
David England, Pharm.D. F : 775/850-1444
E-mail: pharmacy@govmail.state.nv.us
Trudy Larson, M.D.
Internet address: glsuitewww.glsuite.com/nvbopweb
Dr. William Bannen, Medical Director, Anthem BC/BS
Mr. Paul Boyar, Administrator, Plaza Regency at Sun
Nevada Hospital Association
Mountain
Patricia Craddock, D.D.S. Bill M. Welch
President/CEO
Ms. Jessie Harris
5250 Neil Road
Mr. Keith MacDonald, RPh.
Suite 302
Mr. Ken Richardson, Clinic Director, Walker River Tribal
Reno, NV 89502
Health Clinic
T: 775/827-0190
Ms. Linda Sheldon, State Coordinator, Nevada Covering
Kids Coalition F : 775/827-0190
E-mail: bill@nvha.net
Mary Guinan, M.D., Nevada State Healht Officer, Health
Internet address: www.nvha.net
Division

4-Nevada National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEW HAMPSHIRE

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         

B. EXPENDITURES FOR DRUGS


2000 2001
Expenditures Recipients Expenditures Recipients

TOTAL $80,562,181 73,313 $90,927,579 73,489

RECEIVING CASH ASSISTANCE, TOTAL $23,066,270 18,762 $25,669,473 18,137


Aged $2,925,696 1,455 $3,216,921 1,436
Blind/Disabled $16,212,070 5,464 $18,263,975 5,335
Child $1,409,682 7,859 $1,567,158 7,533
Adult $2,518,822 3,984 $2,621,419 3,833

MEDICALLY NEEDY, TOTAL $20,779,582 9,003 $24,027,775 9,047


Aged $8,581,974 3,980 $10,097,853 4,233
Blind/Disabled $10,016,239 2,525 $11,643,790 2,676
Child $346,290 942 $328,662 819
Adult $1,835,079 1,556 $1,957,470 1,319

POVERTY RELATED, TOTAL $5,788,703 26,423 $6,948,883 26,834


Aged $262,235 197 $421,825 293
Blind/Disabled $333,470 181 $437,532 257
Child $4,908,651 24,340 $5,787,235 24,563
Adult $284,347 1,705 $302,291 1,721

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $30,927,626 19,125 $34,281,448 19,471

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: CMS, MSIS Report, FY 2000 and New Hampshire Medicaid Statistical Information System, FY 2001.

National Pharmaceutical Council New Hampshire-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization


Office of Health Planning and Medicaid, Department of Formulary: Open formulary. General exclusions include
Health and Human Services. cosmetic agents for hair growth, experimental and fertility
drugs.
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal prior
Benefit Design authorization procedure with an associated grievance and
appeal procedure.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Prescribing or Dispensing Limitations
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and Monthly Quantity Limit: Limited to 30-day supply
interdialytic parenteral nutrition. Products not covered: Maintenance Medications: Limited to 90-day Supply
cosmetics; fertility drugs; and experimental drugs.
Monthly Dollar Limits: None.
Over-the-Counter Product Coverage: Products covered:
allergy, asthma, and sinus products; analgesics; cough and
cold preparations; digestive products (including H2 Drug Utilization Review
antagonists); feminine products smoking deterrents; and
topical products. PRODUR system implemented in July 1995. State
currently has a DUR Board with a quarterly review.
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, and
Pharmacy Payment and Patient Cost Sharing
NSAIDs, antibiotics; anticoagulants; anticonvulsants;
anti-depressants; antidiabetic agents; antihistamine drugs;
Dispensing Fee: $2.50, effective 2/1/96.
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
and hypnotics; cardiac drugs; chemotherapy agents;
Ingredient Reimbursement Basis: EAC = AWP-12%.
prescribed cold medications; contraceptives; ENT anti-
inflammatory agents; estrogens; growth hormones;
hypotensive agents; sympathominetics (adrenergic); Prescription Charge Formula: Lesser of usual and
thyroid agents; and prescribed smoking deterrents. customary charge or AWP-12%, Federal Upper Limit;
Therapeutic categories/products requiring prior State MAC; or DOJ pricing, plus a dispensing fee.
authorization: anorectics; analgesics, antipyretics,
NSAIDs; misc. GI drugs; erectile dyfunction products; Maximum Allowable Cost: State imposes Federal Upper
PPIs; Cox IIs; and oxycontin. Brand approval overrides Limits as well as State-specific limits on generic drugs.
required for NSAIDs, controlled substances, and GI drugs Override requires “Brand Medically Necessary.” Med
for which there are therapeutically equivalent (AB-rated) Watch form for PA.
generics available.
Incentive Fee: None.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program Patient Cost Sharing: Copayment – Generics: $0.50;
when used in home healthcare and extended care Brand: $1.00. Copayments apply to all recipients except
facilities, and through physician payment when used in nursing home patients in SNF or ICF facilities; home and
physicians’ offices. community based care waived recipients holding form
949; pregnant women; children under 18 years; and
Vaccines: Vaccines reimbursable as part of the EPSDT, prescriptions for family planning drugs.
CHIP, and VCP service. Childhood immunization
vaccine is provided to all children through the Division of Cognitive Services: Does not pay for cognitive services.
Public Health Services. The Medicaid program does not
reimburse providers for routine vaccines, although an E. USE OF MANAGED CARE
administration fee is allowed.
Approximately 11,000 Medicaid recipients are enrolled in
Unit Dose: Unit dose packaging reimbursable. MCOs in 2002. None receive pharmaceutical benefits
through managed care.

2-New Hampshire National Pharmaceutical Council


Pharmaceutical Benefits 2002

Managed Care Organizations Elizabeth Gower, R.Ph.


Helen Pervanas, R.Ph.
Anthem Blue Cross/Blue Shield of New Hampshire
Michael Smith, R.Ph. (Chair)
Matthew Thornton Health Plan
John Zinka, R.Ph.
3000 Goffs Falls Road
Jody Goodrich, A.R.N.P.
Manchester, NH 03103-6020

F. STATE CONTACTS Prescription Price Updating


Farah L. Jiwa
State Drug Program Administrator Account Manager
Margaret A. Clifford First Health Services Corp.
Pharmacy Services Administrator 17 Chenell Drive
Office of Health Planning & Medicaid Concord, NH 03301
129 Pleasant Street, Annex 603/224-2083
Concord, NH 03301 E-mail: JiwaFa@fhsc.com
T: 603/271-4210
F: 603/271-8701
Medicaid Drug Rebate Contacts
E-mail: mclifford@dhhs.state.nh.us
Internet Address: www.dhhs.state.nh.us Glen Hutchinson
First Health Services Corp.
4300 Cox Road
Department of Health and Human Services Glen Allen, VA 23060
Officials T: 800/884-2822
Lori Real F :804/965/7647
Director E-mail: hutchig@fhsc.com
Office of Health Planning & Medicaid
129 Pleasant Street, Annex Claims Submission Contact
Concord, NH 03301
T: 603/271-5254 Farah L. Jiwa, 603/224-2083
F: 603/271-8431
E-mail: lreal@dhhs.state.nh.us
Medicaid Managed Care Contact
Nicholas Vailas Diane M Kemp
Commissioner Administrator 1
Department of Health and Human Services Office of Health Planning & Medicaid
129 Pleasant Street 6 Hazen Drive
Concord, NH 03301-3857 Concord, NH 03301
T: 603/271-4331 T: 603/271-4365
F: 603/271-4912 F: 603/271-4376
E-mail : kheuders@dhhs.state.nh.us E-mail: dkemp@dhhs.state.nh.us

DUR Contact Mail Order Pharmacy Benefit


Lisè Farrand, R.Ph. None
Pharmaceutical Services Specialist
Office of Health Planning & Medicaid
129 Pleasant Street Annex Disease Management Initiative/Program Contact
Concord, NH 03301 State does not currently have a disease management
T: 603/271-4419 program. Intend to implement disease management
F: 603/271-8701 programs for asthma and diabetes through First Health
E-mail: lfarrand@dhhs.state.nh.us Services Corp within the next year.

Medicaid DUR Board


Paul S. Collins, M.D.
Mark Henschke, D.O.
Emory Kaplan, M.D.
Steve Lawrence, M.D.
Thomas Mellman, M.D.

National Pharmaceutical Council New Hampshire-3


Pharmaceutical Benefits 2002

Disease Management/Patient Education Contact New Hampshire Osteopathic Association, Inc.


Bill Paternal, D.O.
Doris Lotz, M.D.
Vice President
Medicaid Medical Director
7 North State Street
Office of Health Planning & Medicaid
Derry, NH 03301
129 Pleasant Street, Annex
603/224-1909
Concord, NH 03301
E-mail: osteo@worldpath.net
T:603/271-7348
Internet Address: www.nh-osteopath.org
F:603/271-8431
E-mail:dlotz@dhhs.state.nh.us
State Board of Pharmacy
Paul G. Boisseau
Physician-Administered Drug Program Contact Executive Secretary
Vacant 57 Regional Drive
Concord, NH 03301-8518
603/271-2350
Pharmacy & Therapeutics Advisory Committee E-mail: nhpharmacy@nhsa.state.nh.us
William Kassler, M.D., M.P.H. Internet Address : www.state.nh.us/pharmacy
Stephen Bartels, M.D.
Doris Lotz, M.D.
Bryan King, M.D. New Hampshire Hospital Association
Steven Paris, M.D. Michael J. Hill, C.H.E.
Richard Lafleur, M.D. President
Eric Pollak, M.D., M.P.H. 125 Airport Road
Lenny Parker, R.Ph. Concord, NH 03301-7300
Margaret Clifford, R.Ph. T: 603/225-0900
Roger Herbert, R.Ph. F: 603/225/4346
Paul Santos, Pharm.D. E-mail: mhill@nhh.org
Robert Lenza, Pharm.D. Internet Address: www.nhha.org

Executive Officers of State Medical and


Pharmaceutical Services
New Hampshire Medical Society
Palmer P. Jones
Executive Vice President
7 N. State Street
Concord, NH 03301-6389
T:603/224-1909
F: 603/226-2432
E-mail: nhmsppj@aol.com
Internet address: www.nhms.org

New Hampshire Pharmacists Association


David Minnis
Executive Director
2 Eagle Square, Suite 400
Concord, NH 03301-8905
T: 603/229-0292
F: 603/224-7769
E-mail: mms@worldpath.net
Internet Address: www.state.nh.us/pharmacy/nhpa.htm

4-New Hampshire National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEW JERSEY 1

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       

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $584,533,211 298,450 $651,442,945

RECEIVING CASH ASSISTANCE, TOTAL $345,292,113 153,179


Aged $59,196,426 30,876
Blind / Disabled $282,211,059 98,842
Child $1,292,073 12,645
Adult $2,592,555 10,816

MEDICALLY NEEDY, TOTAL $6,684,313 3,366


Aged $5,936,189 2,927
Blind / Disabled $682,891 211
Child $65,233 228
Adult $0 0

POVERTY RELATED, TOTAL $87,818,883 61,127


Aged $28,757,139 14,783
Blind / Disabled $56,515,195 16,258
Child $1,976,812 22,013
Adult $569,737 8,073

TOTAL OTHER EXPENDITURES/RECIPIENTS* $144,737,902 80,778

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

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

1 The State of 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.

National Pharmaceutical Council New Jersey-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure. Periodic review for
Division of Medical Assistance and Health Services, reconsideration possible for excluded product from
Department of Health and Human Services. formulary. Fair hearings possible for appealing prior
authorization decisions.

D. PROVISIONS RELATING TO DRUGS


Prescribing or Dispensing Limitations
Benefit Design
Prescription Refill Limit: 5 times within a 6-month
Drug Benefit Product Coverage: Products covered: period.
prescribed insulin; disposable needles and syringe
combinations for insulin use; blood glucose test strips; Monthly Quantity Limit: Original, 34-day supply. Refills,
urine ketone test strips; total parenteral nutrition; and 34 days or 100 units, whichever is more.
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs, and Drug Utilization Review
DESI drugs. Prior authorization required for: methadone;
IV infusions; and protein replacement supplements. PRODUR system implemented in October 1996. State
currently has a DUR Board with a quarterly review.
Over-the-Counter Product Coverage: Products covered:
allergy, asthma, and sinus products; analgesics; topical Pharmacy Payment and Patient Cost Sharing
products; and cough and cold preparations for children
under age 21 and smoking deterrent products (inhaler or Dispensing Fee: $3.73 for legend drugs. Additional add-
nasal spray). Products not covered: digestive products; ons per/Rx shall be given to pharmacy providers who
feminine products; contraceptives; pregnancy test kits; provide the following:
family planning supplies; inhalation drugs; and antacids.
1. 24-hr Emergency Service: add $0.11
Therapeutic Category Coverage: Therapeutic categories
covered: analgesics, antipyretics, NSAIDs; antibiotics; 2. Patient Consultation: add $0.08
anticoagulants; anticonvulsants; anti-depressants; 3. Impact Area Location: add $0.15 (provider shall have
antidiabetic agents; antihistamine drugs; anti-psychotics; a combined Medicaid, NJ KidCare and PAAD
anxiolytics, sedatives, and hypnotics; cardiac drugs; prescription volume equal to or greater than 50% of
chemotherapy agents; prescribed cold medications; total prescription volume.
contraceptives; ENT anti-inflammatory agents; estrogens;
hypotensive agents; misc. GI drugs; sympathominetics Ingredient Reimbursement Basis: EAC = AWP-10%,
(adrenergic); and thyroid agents. Prior authorization WAC + 30%. AAC for injectables, effective 5/1/00.
required for: antilipemic agents. Partial coverage for:
anabolic steroids; anorectics (for ADD); growth Prescription Charge Formula: “Maximum Allowable
hormones; and prescribed smoking deterrents. Cost,” or Average Wholesale Price-10% (reduction from
AWP is pharmacy specific) plus a dispensing fee or the
Coverage of Injectables: Injectable medicines provider’s usual and customary charge, whichever is
reimbursable through the Prescription Drug Program lower.
when used in home health care and extended care
facilities and through physician payment when used in Maximum Allowable Cost: State imposes Federal Upper
physician offices. Limits on generic drugs. Override requires “Brand
Medically Necessary”.
Vaccines: Vaccines reimbursable at AWP as part of the
EPSDT program and the Vaccines for Children Program. Incentive Fee: None.

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).

2-New Jersey National Pharmaceutical Council


Pharmaceutical Benefits 2002

Managed Care Organizations DUR Contact


AMERIGROUP New Jersey, Inc Edward J. Vaccaro, R.Ph.
399 Thornall Street, 9th Floor Assistant Director, Office of Utilization Management
Edison, NJ 08837 Dept. of Human Services, Div. of Medical Assistance and
800/600-4441 Health Services
P.O. Box 712, Bldg. 11-A
Health Net of New Jersey, Inc. Trenton, NJ 08625
CNA Building T: 609/588-2726
3501 State Highway 66 F: 609/588-3889
Neptune, NJ 07754 E-mail: ejvaccaro@dhs.state.nj.us
800/555-2604

AmeriChoice of New Jersey, Inc. Medicaid DUR Board


Two Gateway Center, 13th Floor Christopher A. Cella, R.Ph.
Newark, NJ 07102 Alfred F. Sorbelo, D.O.
800/941-4647 Edith Kessler-Feinstein, R.Ph.
Joseph Nicholas Micale, M.D.
Horizon Mercy Rochelle Dallago, R. Ph..
275 Phillips Boulevard Thomas A. Cavalieri, D.O.
Trenton, NJ 08618-1426 Linda Gooen, R.Ph.
800/656-3729 Mary E Petit, Pharm.D.
David Ethan Swee, M.D.
University Health Plans, Inc.
550 Broad Street, 17th Floor
Newark, NJ 07102 Prescription Price Updating
800/564-6847 First DataBank
1111 Bayhill Dr.
F. STATE CONTACTS San Bruno, CA 94066
415/588-5454
State Drug Program Administrator
Carl D. Tepper, R.Ph. Medicaid Drug Rebate Contacts
Chief, Pharmaceutical Services
Technical: Daniel Upright, 609/588-2792
Department of Human Services
Policy: Carl Tepper, 609/588-2744
Division of Medical Assistance and Health Services
PA: Carl Tepper, 609/588-2744
P.O. Box 712, Bldg. 11-A
Trenton, NJ 08625-0712
T: 609/588-2744 Claims Submission Contact
F: 609/588-3889
E-mail: cdtepper@dhs.state.nj.us Peter Ringel
Deputy Project Director
Unisys
Department of Human Services Officials 3705 Quakerbridge Rd., Suite 101
Trenton, NJ 08619
Gwendolyn L. Harris, Commissioner
T:609/588-6000
Department of Human Services
F: 609/584-8270
Capitol Place One CN-700, 5th Floor
E-mail: ringelp@nipo1.him.unisys.com
Trenton, NJ 08625
T: 609/292-3717
F: 609/292-3824 Medicaid Managed Care Contact
E-mail: webmaster@dhs.state.nj.us
Edward Vaccaro, 609/588-2726
Kathryn A. Plant, Director
Division of Medical Assistance and Health Services Mail Order Benefit Program
Department of Human Services
P.O. Box 712 State currently has a mail order benefit program. All
Trenton, NJ 08625-0712 Medicaid recipients are entitled to participate.
T: 609/588-2600
F: 609/588-3583
E-mail: kathryn.plant@dhs.state.nj.us

National Pharmaceutical Council New Jersey-3


Pharmaceutical Benefits 2002

Elderly Expanded Drug Coverage Contact New Jersey Hospital Association


Gary S. Carter, FACHE
Kathleen Mason President & CEO
Assistant Commissioner, Benefits and Utilization 760 Alexander Road, P.O. Box 1
Management
Princeton, NJ 08543-0001
Dept. of Health and Senior Services
609/275-4000
P.O. Box 715
E-mail: gcarter@njha.com
Trenton, NJ 08625
Internet address: www.njha.com
T: 609/588-7032
F: 609/584-7037

Physician-Administered Drug Program Contact


Edward Vaccaro, 609/588-2726

Executive Officers of State Medical and


Pharmaceutical Societies
Medical Society of New Jersey
Vincent A. Maressa
Executive Director
2 Princess Road
Lawrenceville, NJ 08648-2302
T: 609/896-1766
F: 609/896-1368
E-mail: vamaress@msnj.org
Internet address: www.msnj.org

New Jersey Pharmacists Association


Joseph V. Roney, R.Ph.
Chief Executive Officer
760 Alexander Road, P.O. Box 1
Princeton, NJ 08543-0001
T: 609/275-4246
F: 609/275-4066
E-mail: joeroney@njaj.com
Internet address: www.njpharma.org

New Jersey Association of Osteopathic Physicians &


Surgeons
Stephen G. Papish, D.O.
President
1 Distribution Way, Suite 201
Monmouth Junction, NJ 08852
T: 732/940-9000
F: 732/940-8899
E-mail: ajbi@aol.com
Internet address: www.njosteo.org

State Board of Pharmacy


Debora C. “Debbie” Whipple
Executive Director
P.O. Box 45013
Newark, NJ 07101
201/504-6450
E-mail: askconsumeraffairs@dca.lps.state.nj.us
Internet address: www.state.nj.us/lps/ca/brief/pharm.htm

4-New Jersey National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEW MEXICO

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     

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $57,502,713 67,238 $57,995,801

RECEIVING CASH ASSISTANCE TOTAL $32,602,025 32,148


Aged $6,860,767 6,106
Blind/Disabled $24,878,408 14,756
Disabled $249,345 4,962
Child $613,505 6,324
Adult
$0 0
MEDICALLY NEEDY, TOTAL $0 0
Aged $0 0
Blind/Disabled $0 0
Child $0 0
Adult
$1,388,162 18,561
MEDICALLY NEEDY, TOTAL $108,303 133
Aged $177,285 121
Blind/Disabled $974,363 15,529
Child $128,211 2,778
Adult
$23,512,526 16,529
TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

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

National Pharmaceutical Council New Mexico-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization

Human Services Department (HSD). Formulary: Open formulary

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.

Coverage of Injectables: Injectable medicines E. USE OF MANAGED CARE


reimbursable when used in physician offices, home health
care, and extended care facilities. Approximately 250,000 Medicaid recipients enrolled in
are MCOs in FY 2002. Recipients receive pharmaceutical
Vaccines: Only the administration for vaccines is benefits through managed care plans.
reimbursable. The vaccines are available at no charge
through the vaccine replacement program of the Health
Department.

Unit Dose: Does not reimburse for unit dose packaging.

2-New Mexico National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Medicare Managed Care Contact


Debra Stolk
State Drug Program Administrator Bureau Chief
Contracts Administration Bureau
Neal Solomon, M.P.H., R.Ph. P.O. Box 2348
Drug Program Administrator Santa Fe, NM 85705-2348
Medical Assistance Division 505/827-3174
P. O. Box 2348
Santa Fe, NM 87504-2348
T: 505/827-3174 Mail Order Pharmacy Program
F: 505/827-3185 None
E-mail: neal.solomon@state.nm.us

Human Services Department Officials


DUR Contact
Pamela Hyde
Neal Solomon, M.P.H., R.Ph. Secretary
505/827-3174 New Mexico Department of Human Services
P. O. Box 2348
DUR Board Santa Fe, NM 87504-2348
T: 505/827-7750
DUR Board functions to be subsumed by a new F: 505/827-6286
committee that is in the process of being created. E-mail: pam.hyde@state.nm.us

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

Yvette Ramirez Ammerman


Prescription Price Updating Contact Policy Analyst
Neal Solomon, M.P.H., R.Ph. New Mexico Primary Care Association
505/874-3174 2309 Renard, S.E., Suite 209
Albuquerque, NM 87106

Claims Submission Chris Isengard


Executive Director
ACS, Inc.
Developmental Disabilities Planning Council
365 Northridge Road
435 St. Michael’s Dr., Bldg. D
Northridge Center One, Suite 400
Santa Fe, NM 87501
Atlanta, GA 30350
T: 770/352-8592
Michelle Lujan-Grisham
F: 770/730-5198
New Mexico State Agency on Aging
228 East Palace Avenue
Santa FE, NM 87501

National Pharmaceutical Council New Mexico-3


Pharmaceutical Benefits 2002

Sam Cata, Commissioner Bert Umland, M.D.


Office of Indian Affairs Division of Family Practice
224 E. Palace Avenue UNM Medical Center
Santa FE, NM 87501 Albuquerque, NM 87131
505/277-2165
Loyola Burgess
1801 Dorothy Street, NE
Albuquerque, NM 87112 Executive Officers of State Medical and
Pharmaceutical Societies
Walace Begay, Co-Chairman New Mexico Medical Society
Pueblo Health Council/All Indian Pueblo Council G. R. “Randy” Marshall
P.O. Box 56 Executive Director
New Laguna, NM 87038 7770 Jefferson NE, Suite 400
Albuquerque, NM 87109
Rosalyn Curtis T: 505/828-0237
Director of the Navajo Nation F: 505/828-0336
Division of Health E-mail: rmarshal@nmms.org
P.O. Box 1390 Internet address: nmms.org
Window Rock, AZ 86515
New Mexico Pharmaceutical Association
Lila Maples, R.N. R. Dale Tinker
2769 Villa Venado Executive Director
Santa Fe, NM 87505 4800 Zuni, S.E.
Albuquerque, NM 87108-2898
Clarice Pick, D.D.S T: 505/265-8729
1405 Luisa Street F: 505/255-8476
Suite #2 E-mail: daletinker@cs.com
Santa Fe, NM 87505
New Mexico Osteopathic Medical Association
Richard L. Ragel, D.O. Elizabeth “Betty” Barrett
1010 Bridge Blvd., SW Executive Director
Suite D P. O. Box 53098
Albuquerque, NM 87105-3734 Albuquerque, NM 87153-3098
T: 505/332-2146
Kathy Minoli, C.F.N.P. F: 505/343-0012
1835 Solano, NE E-mail: admin@nmoma.org
Albuquerque, NM 87110 Internet address: www.nmoma.org

Mary Lou Edward State Board of Pharmacy


16 Applewood Lane, N.W. Jerry Montoya, Director
Albuquerque, NM 87107 University Towers
505/898-5103 1650 University Blvd., NE, Suite 400B
Albuquerque, NM 87102
Richard Honsinger, M.S. 505/841-9102
Los Alamos Medical Center E-mail: joseph.montoya@state.nm.us
Los Alamos, NM 87544 Internet address: www.state.nm.us/pharmacy

Maureen Boshier New Mexico Hospitals and Health Systems Association


New Mexico Hospital Association Maureen L. Boshier
2121 Osuna Road NE President/CEO
Albuquerque, NM 87113 2121 Osuna Road, NE
Albuquerque, NM 87113
Joie Glen T: 505/343-0010
Executive Director F: 505/343-0012
New Mexico Association for Home Care E-mail: mboshier@nmhsa.com
3200 Carlisle N.E., Suite 115 Internet address: nmhsa.org
Albuquerque, NM 87110

4-New Mexico National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEW YORK

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         

B. EXPENDITURES FOR DRUGS


2000 2001
Expenditures Recipients Expenditures Recipients

TOTAL $2,366,900,006 2,173,791 $3,390,973,955 2,481,167

RECEIVING CASH ASSISTANCE, TOTAL $1,566,162,641 1,099,774 $2,066,395,705 864,288


Aged $269,550,109 146,598 $371,073,880 142,133
Blind/Disabled $1,128,385,170 436,852 $1,576,755,987 445,939
Child $56,154,649 348,160 $46,937,418 200,026
Adult $112,072,713 168,164 $71,628,420 76,190

MEDICALLY NEEDY, TOTAL $547,905,224 677,751 $885,113,975 1,076,587


Aged $148,246,132 90,476 $227,428,001 111,017
Blind/Disabled $288,329,753 96,831 $411,454,776 107,484
Child $54,125,642 337,243 $114,487,217 514,744
Adult $57,203,697 153,201 $131,743,981 343,342

POVERTY RELATED, TOTAL $17,330,385 117,970 $406,942,387 480,355


Aged $104 1 $195 2
Blind/Disabled $0 0 $0 0
Child $16,701,956 111,422 $43,631,597 209,682
Adult $628,325 6,547 $363,310,595 270,671

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $235,501,756 278,296 $32,521,888 59,937

* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
Source: CMS, MSIS Report, FY 2000 and New York Medicaid Statistical Information System, FY 2001.

National Pharmaceutical Council New York-1


Pharmaceutical Benefits 2002

Prior Authorization: State currently has a formal prior


C. ADMINISTRATION authorization procedure.
State Department of Health.
Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS Prescription Refill Limit: Maximum of 5 refills within 6
months. Also, annual limits on number of prescriptionS
Benefit Design and prescription and nonprescription drugs without an
override.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Dollar Limits: None.
combinations for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Products not covered: Drug Utilization Review
cosmetics; fertility drugs; and experimental drugs.
PRODUR system implemented in March 1995. State
Over-the-Counter Product Coverage: Products covered currently has a DUR Board which meets bimonthly.
with restrictions: allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive Pharmacy Payment and Patient Cost Sharing
products (non H2 antagonist); feminine products;
smoking deterrent products (max, 2 courses of treatment/ Dispensing Fee: $3.50 for brand name drugs, $4.50 for
year); and topical products. Products not covered: generic drugs. Effective 8/1/98.
digestive products (H2 antagonists).
Ingredient Reimbursement Basis: EAC = AWP-10%.
Therapeutic Category Coverage: Therapeutic categories
covered: anabolic steroids; analgesics, antipyretics, Prescription Charge Formula:
NSAIDs; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine drugs; 1. Payment for multiple source drugs must not exceed
antilipemic agents; anti-psychotics; anxiolytics, sedatives, the aggregate of the specified upper limit set by the
and hypnotics; cardiac drugs; chemotherapy agents; federal Centers for Medicare and Medicaid Services
contraceptives; ENT anti-inflammatory agents; estrogens; (CMS), plus a dispensing fee, for a particular drug;
hypotensive agents; prescribed smoking deterrents; and
sympathominetics (adrenergic); and thyroid agents. 2. Payment for brand name drugs and other multiple
Therapeutic categories partially covered: prescribed cold source drugs not covered by clause (1) will be the
medication and misc. GI drugs. Therapeutic categories lower of: EAC plus a dispensing fee; or
requiring prior authorization: antibiotics (zyvox only);
growth hormones; (serostim) medical/surgical supplies; 3. The billing pharmacy's usual and customary price
orthopedic shoes; compression stockings; and some DME charged to the general public.
items. Therapeutic categories not covered: anorectics and
Maximum Allowable Cost: State imposes Federal Upper
agents used for hair growth.
Limits on generic drugs. Override requires “Dispense as
Written” and “Brand Necessary, ” or “Brand Medically
Coverage of Injectables: Injectable medicines
Necessary.”
reimbursable through the Prescription Drug Program
when used in home health care and extended care
Incentive Fee: $1.00 for dispensing a lower cost multi-
facilities, and through physician payment when used in
source product.
physician offices. No special coverage policies exist for
self-administered injectable medicines.
Patient Cost Sharing: Copayment is $2.00 for brand name
drugs, $0.50 for generic and OTC drugs. Exceptions
Vaccines: Vaccines are reimbursable under the EPSDT
include psychotropic drugs as well as drugs FDA
service, CHIP, and the Vaccines for Children program.
approved for the treatment of tuberculosis and family
planning drugs.
Unit Dose: Unit dose packaging not reimbursable.
Cognitive Services: Does not pay for cognitive services.
Formulary/Prior Authorization

Formulary: Open formulary. General Exclusions: New


York State follows OBRA '90 guidelines in the
reimbursement of prescription drugs.

2-New York National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE Pharmacy Advisory Committee


Kandyce Daley, R.Ph.
Approximately 781,000 Medicaid recipients were Patricia Donato, R.Ph.
enrolled in MCOs in FY 2001. Recipients receive Steven Giroux, R.Ph.
pharmaceutical benefits through the State. Thomas Golden, R.Ph.
Dilip Patel, R.Ph.
Health Maintenance Organizations John Navarra, R.Ph.
− ABC Mohammed Saleh, R.Ph.
− Affinity Health Plan John Westerman, R.Ph.
− AmeriChoice
− Broome MC Formulary Contact
− Buffalo Com. Health Mark-Richard A. Butt, 518/474-9219
− Care Plus Health Plan
− CDPHP
Prior Authorization Contact
− Community Choice HP
− Community Premier Plus Mark-Richard A. Butt, 518/486-3209
− Excellus
− Fidelis/NYS Catholic Health Pharmacy and Therapeutics Committee
− Health Choice
− HealthFirst PHPS Roxanne Hall Richardson, R.Ph.
− Health Plus PHPS Maria Amodio-Groton, Pharm.D.
− HealthNow/BCBS-WNY/Community Blue Andrew G. Flynn, R.Ph., C.G.P.
William P. Scheer, R.Ph.
− HealthNow/Blue Shield of NENY
Carl R. Reed, R.Ph., M.B.A.
− HIP
Judy K. Shaw, M.S., A.C.R.N., ANP-C
− IHA
Marc A. Johnson, M.D.
− Manhattan PHSP/Centercare Scott C. Bello, M.D.
− Metropolitan Plus Health Plan Steven E. Barnes, D.O.
− Neighborhood Health Providers Aaron Satloff, M.D.
− NY Hospital Community PHSP Glenn A. Martin, M.D.
− PCMP
− Preferred Care
− Primary Health DUR Contact
− Southern Tier Michael Zegarelli
− Suffolk Co PHSP DUR Manager
− Total Care/Syracuse PHSP Office of Medicaid Management
− United Healthcare Plan of NY, Inc. NYS Department of Health
− United Healthcare of Upstate 99 Washington Ave. Suite 601
− Vytra Albany, NY 12210
− Wellcare T: 518/474-6866
− Westchester Prepaid Health Services Plan F: 518/473-5332
E-mail: maz03@health.state.ny.us
F. STATE CONTACTS
DUR Committee
State Drug Program Administrator
Physicians
Mark-Richard A. Butt, M.S., R.Ph. Richard S. Blum, M.D.
Director, Pharmacy Policy and Operations Ronald J. Dougherty, M.D.
Bureau of Program Guidance David F. Lehmann, M.D.
Office of Medicaid Management Jill Braverman-Panza, M.D., R.Ph.
NYS Department of Health
99 Washington Ave., Suite 606 Pharmacists
Albany, NY 12210 Sidney Falow, R.Ph.
T: 518/474-9219 John Gotowko, R.Ph., M.S., M.B.A.
F: 518/473-5508 Marc L. Speert, R.Ph.
E-mail: mrb01@health.state.ny.us Frank Barone, R.Ph.
Internet Address: www.health.state.ny.us James R. Suhrbier, R.Ph.

National Pharmaceutical Council New York-3


Pharmaceutical Benefits 2002

DUR Experts Disease/Medical State: Smoking Cessafion


Marilyn C. Fortin, R.Ph. Program Name: Smokers’ Quit Line
Robert A. Hamilton, Pharm.D., R.Ph. Program Sponser: Roswell Park

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

Disease/Medical State: Asthma


Program Name: Asthma Intervention
Program Sponser: NYSDOH

Disease/Medical State: Diabetes


Program Name: Diabetes Intervention
Program Sponser: NYSDOH

4-New York National Pharmaceutical Council


Pharmaceutical Benefits 2002

Kathryn Kuhmerker Pharmasists Society of the State of New York


Deputy Commissioner Craig Burridge, M.S., CAE, Executive Director
Office of Medicaid Management Pine West Plaza IV
NYS Department of Health 210 Washington Avenue Extension
Corning Tower Albany, NY 12205-5335
The Governor Nelson A. Rockefeller Empire State Plaza T:518/869-6595
Albany, NY 12237 F:518/464-0618
T: 518/474-3018 E-mail:craigb@ppssny.org
Internet Address: www.pssny.org/index_new.htm
Karen A. Fuller, Ph.D.
Director, Bureau of Program Guidance New York State Osteopathic Medical Society, Inc.
Division of Policy and Program Guidance/Office of Michael Mallie
Medicaid Management Executive Director
99 Washington Ave., Suite 606 142 East Ontario Avenue
Albany, NY 12210 Chicago, IL 60611-2854
518/474-9219 T: 800/841-4131
F : 312/202-8224
Mark-Richard A. Butt, MS, R.Ph. E-mail : nysoms@nysoms.org
518/474-9219 Internet Address: www.nysoms.org

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

National Pharmaceutical Council New York-5


Pharmaceutical Benefits 2002

6-New York National Pharmaceutical Council


Pharmaceutical Benefits 2002

NORTH CAROLINA

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        

B. EXPENDITURES FOR DRUGS


2000* 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $794,550,074 827,039 $931,725,857 817,779

RECEIVING CASH ASSISTANCE TOTAL $456,999,341 363,502


Aged $136,264,920 67,403
Blind/Disabled $264,833,598 123,166
Child $17,861,977 97,135
Adult $38,038,846 75,798

MEDICALLY NEEDY, TOTAL $54,666,399 26,690


Aged $38,295,187 16,847
Blind/Disabled $13,515,582 5,557
Child $192,054 685
Adult $2,663,576 3,601

POVERTY RELATED, TOTAL $266,152,143 392,416


Aged $112,488,906 57,682
Blind/Disabled $102,028,657 46,101
Child $45,864,710 248,570
Adult $5,769,870 40,063

TOTAL OTHER EXPENDITURES/RECIPIENTS* $16,732,191 44,431

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

Source: CMS, MSIS Report, FY 2000 and North Carolina Statistical Information System, FY 2001.

Note: North Carolina estimates 2002 drug expenditures to be $1.056 billion and the number of Medicaid recipients to be
941,491.

National Pharmaceutical Council North Carolina-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescription Dollar Limits: None.

Division of Medical Assistance, Department of Health Drug Utilization Review


and Human Services.
PRODUR system implemented in May 1996. State
D. PROVISIONS RELATING TO DRUGS currently has a DUR Board with a quarterly review.

Benefit Design Pharmacy Payment and Patient Cost Sharing

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.

Vaccines: Vaccines reimbursable as part of the ESPDT


E. USE OF MANAGED CARE
service and The Vaccines for Children Program.
Approximately 44,000 Medicaid recipients were enrolled
in MCOs in FY 2001. Recipients receive pharmaceutical
Unit Dose: Unit dose packaging not reimbursable.
benefits through the State.
Formulary/Prior Authorization
Managed Care Organizations
Formulary: Open formulary.
SouthCare/Coventry
2815 Coliseum Center Dr.
Prior Authorization: State currently has a formal prior
Charlotte, NC 28217
authorization procedure. A prescriber’s written
justification is required to appeal a prior authorization
decision. All written justifications are approved.

Prescribing or Dispensing Limitations

Monthly Quantity Limit: 34-day supply maximum.


Except birth control tablets and hormonal replacement
therapy dial packs: 3 months.

Monthly Prescription Limit: Six prescriptions per month


per recipient.

2-North Carolina National Pharmaceutical Council


Pharmaceutical Benefits 2002

F. STATE CONTACTS Medicaid Drug Rebate Contact


State Drug Program Administrator Audits: Sharman C. Leinwand, 919/857-4034
Rebate Disputes: Sharon Greeson, R.Ph., 919/816-4475
Sharman C. Leinwand
Pharmacy Program Manager Claims Submission Contact
Division of Medical Assistance
Department of Health and Human Services Sharon Greeson, R.Ph., 919/816-4475
1985 Umstead Drive
2511 Mail Service Center
Medicaid Managed Care Contact
Raleigh, NC 27699-2511
T: 919/857-4034 Jeffrey Simms, 919/857-4267
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net Mail Order Pharmacy Program
Internet address: www.dhhs.state.nc.us/dma
None
Prior Authorization Contact
Disease Management Program/Initiative Contact
Sharman C. Leinwand, 919/857-4034
Sharman C. Leinwand, 919/857-4034
DUR Contact
Physician-Administered Drug Program Contact
Sharman C. Leinwand, 919/857-4034
Maclyn Powell
Department of Health and Human Services
Medicaid Drug Utilization Review Board
Division of Medical Assistance
Physicians: 1985 Umstead Drive
Patricia Burns, M.D. 2511 Mail Service Center
Raleigh, NC 27699-2511
Edward Treadwell, M.D. 919/857-4254
Department of Human Resources Officials
LaVie Ellison, M.D.
Gary Fuquay, Acting Director
David Gremillion, M.D. Department of Health and Human Services
Division of Medical Assistance
Steve Wegner, M.D. 1985 Umstead Drive
2501 Mail Service Center
Pharmacists: Raleigh, NC 27699-2501
Joseph S. Moose, R.Ph., Pharm. D. T: 919/857-4011
F: 919/733-6608
Dale Christensen, Ph.D.. E-mail: gary.fuquay@ncmail.net
Wayne Creech, R. Ph.
Carmen Hooker Odom
Secretary
Martha Jones, Pharm. D.
Department of Health and Human Services
2001 Mail Service Center
Mary Williford, R.Ph.
101 Blair Drive
Raleigh, NC 27699-2001
Prescription Price Updating T: 919/733-4534
Sharon Greeson, R.Ph. F: 919/715-4645
Pharmacy Program Manager Office of Research Demonstration and Rural
EDS Health Development
4905 Waters Edge Drive
Raleigh, NC 27606 Torlen Wade
T: 919/816-4475 311 Ashe Avenue
F: 919/816-4399 Raleigh, NC 27606
E-mail: sharon.greeson@eds.com 919/857-4267

National Pharmaceutical Council North Carolina-3


Pharmaceutical Benefits 2002

Executive Officers of State Medical and


Pharmaceutical Societies
North Carolina Medical Society
Bob Seligson, M.B.A., CAE
Executive Vice President & CEO
P.O. Box 27167
Raleigh, NC 27611-7167
T: 919/833-3836
F: 919/833-2023
E-mail: rseligson@ncmedsoc.org
Internet address: www.ncmedsoc.org

North Carolina Association of Pharmacists


Fred Eckel
Executive Director
109 Church Street
Chapel Hill, NC 27516-2505
T: 919/967-2237
F: 919/968-9430
E-mail: fred@ncpharmacists.org
Internet address: www.ncpharmacists.org

North Carolina Osteopathic Medical Association


Brenda Brow -
Executive Director
1104 Medical Center Drive
Wilmington, NC 28401
T: 888/626-6248
F: 910/763-4666
E-mail: www.ncoma.org
Internet address: www.ncoma.org

State Board of Pharmacy


David R. Work
Executive Director
P. O. Box 459
Carrboro, NC 27510-0459
T: 919/942-4454
F: 919/967-5757
E-mail: drw@ncbop.org
Internet address: www.ncbop.org

North Carolina Hospital Association


William A. Pulley
President
P.O. Box 4449
Cary, NC 27519-4449
T: 919/677-2400
F : 919/677-4200
E-mail : wpully@ncha.org
Internet address: www.ncha.org

4-North Carolina National Pharmaceutical Council


Pharmaceutical Benefits 2002

NORTH DAKOTA

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $38,076,519 38,957 $44,067,986

RECEIVING CASH ASSISTANCE, TOTAL $17,000,686 13,169


Aged $3,973,736 2,001
Blind/Disabled $11,399,758 5,016
Child $563,277 3,894
Adult $1,063,915 2,258

MEDICALLY NEEDY, TOTAL $17,364,506 11,099


Aged $11,416,811 5,621
Blind/Disabled $5,178,138 2,103
AFDC-Child $352,340 2,247
AFDC-Adult $417,217 1,128

POVERTY RELATED, TOTAL $737,830 5,375


Aged $6,224 28
Blind/Disabled $15,592 29
AFDC-Child $606,172 4,570
AFDC-Adult $109,842 748

TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,973,497 9,314

*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.

National Pharmaceutical Council North Dakota-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescribing or Dispensing Limitations

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.

Vaccines: Vaccines reimbursable as part of the EPSDT F. STATE CONTACTS


service.
State Drug Program Administrator
Unit Dose: Unit dose packaging not reimbursable.
Brendan K. Joyce, Pharm.D., R.Ph.
Administrator, Pharmacy Services
Formulary/Prior Authorization Department of Human Services
600 East Boulevard Avenue, Dept. 325
Formulary: Open formulary Bismarck, ND 58505-0250
T:701/328-4023
Prior Authorization: State does not currently have a F: 701/328-1544
formal prior authorization procedure. E-mail: sojoyb@state.nd.us

2-North Dakota National Pharmaceutical Council


Pharmaceutical Benefits 2002

Prior Authorization Contact Brendan Joyce, Pharm.D., R.P.h.


701/328-4023
Brendan K. Joyce, Pharm.D.
701/328-4023
Karen Tescher
Administrator, Utilization Management
DUR Contact Medical Services,
ND Department of Human Services
Brendan K. Joyce, Pharm.D. 600 East Boulevard Ave, Dept 325
701/328-4023 Bismarck, ND 58505-0250
701/328-4893
DUR Board
Mark Biel, R.Ph. Prescription Price Updating
517 W. Reno Ave. Brendan K. Joyce, Pharm.D.
Bismarck, ND 58504 701/328-4023
701/223-0936

Patricia M. Churchill, R.Ph. Medicaid Drug Rebate Contact


103 West Ave. B
Brendan K. Joyce, Pharm.D.
Bismark, ND 58501
701/328-4023
701/663-5188

Greg Pfister, Pharm.D., R.Ph. Claims Submission Contact


505 Cottonwood Loop
Brendan K. Joyce, Pharm.D.
Bismark, ND 58504
701/328-4023
701/530-6928

Community Practice Medical Resident Medicaid Managed Care Contact


(rotational contact: Susan Thompson)
UND Family Practice Center Tom Solberg, Administrator
515 Broadway Avenue Managed Care
Bismarck, ND 58501 ND Department of Human Services
701/328-9950 600 East Boulevard Avenue, Dept. 325
Bismark, ND 58505-0250
Bob Treitline, R.Ph. T: 701/328-1884
1404 C Empire Road F: 701/328-1544
Dickinson, ND 58601 E-mail: sosolt@state.nd.us
701/225-4434
Disease Management Program/Initiative Contact
Marty Meese, Pharm.D., R.Ph.
St. Alexis Pharmacy Brendan K. Joyce, Pharm.D.
900 East Broadway 701/328-4023
Bismarck, ND 58501
701/224-6954 Mail Order Pharmacy Benefit Program
Ex-Officio Members State currently has a mail order pharmacy program
Herbert Wilson, M.D. capability in which all Medicaid recipients are entitled to
Medical Consultant participate. However, the mail order pharmacy must be a
Medical Services, ND Department of Human Services North Dakota Medicaid provider.
600 East Boulevard Ave, Dept 325
Bismarck, ND 58505-0250
701/328-2056

National Pharmaceutical Council North Dakota-3


Pharmaceutical Benefits 2002

Department of Human Services Officials Herbert J. Wilson, M.D.


1244 W. Coulee Road
Carol K. Olson
Bismarck, ND 58501
Executive Director
ND Dept. of Human Services
Karla Broeckel
600 E. Boulevard Avenue, Dept. 325
725 S. 12th Street, Lot 202
Bismarck, ND 58505-0250
Bismarck, ND 58504
T: 701/328-2538
F: 701/328-2359
Delores Farrell
E-mail: dhseo@state.nd.us
301 N. 19th Street
Bismark, ND 58501
Dave Zentner
Medicaid Director
Carrie Steinwand
600 E. Boulevard Avenue, Dept. 325
24 Santee Road
Bismarck, ND 58505-0261
Lincoln, ND 58504
T: 701/328-2321
F: 701/328-1544
Teri Lyn Aguilar
E-mail: sozend@state.nd.us
3123 Twin City Drive
Mandan, ND 58554
Department of Human Services Advisory
Committees Commission on Socio-Economic Affairs
Robert F. Szczys, M.D., Chairman
Medical Care Advisory Committee Grand Forks Clinic Ltd.
Terry Dwelle, M.D. Grand Forks, ND 58206
State Health Officer
State Health Department Russel J. Kuzel, M.D., Vice Chairman
600 East Boulevard Dakota Clinic Ltd.
Bismarck, ND 58505 Fargo, ND 58103
T: 701/328-2372
Bipin B. Amin, M.D.
Lynn Blakeman Mid Dakota Clinic
St. Vincent’s Care Center Bismarck, ND 58502
1021 N. 26th Street
Bismarck, ND 58501 William W. Barnes, M.D.
T: 701/223-6888 307 5th Avenue, SE
Minot, ND 58701
Alison Fallgater, D.D.S.
121 E. Front Avenue Norman E. Bystol, M.D.
Bismarck, ND 50504 Dakota Clinic Ltd.
T: 701/223-1194 Fargo, ND 58108
Amy Fleck, O.D. James R. Carpenter, M.D.
Family Vision Clinic Meritcare Medical Group
111 E. Century Avenue Fargo, ND 58123
Bismark, ND 58501
T: 701/222-1420 Stanley T. Diede, M.D.
Heart and Lung Clinic
Howard Anderson, R.Ph. Bismarck, ND 58502
PO Box 70
Turtle Lake, ND 58575 Harold W. Evans, M.D.
T: 701/448-2542 Grand Forks Clinic Ltd.
Grand Forks, ND 58206
Dean Rosen, M.D.
5801 Lariat Place Gregory A. Gapp, M.D.
Bismark, ND 58503 Grand Forks Clinic Ltd.
T: 701/258-7125 Grand Forks, ND 58206

4-North Dakota National Pharmaceutical Council


Pharmaceutical Benefits 2002

Stephen H. Goldberger, M.D. Anton P. Welder, R.Ph.


Grand Forks Clinic Ltd. P.O. Box 835
Grand Forks, ND 58206 Bismarck, ND 58502

Genevieve M. Goven, M.D. Doreen M. Beiswanger, R.Ph


Meritcare Clinic Valley City 1140 SE 6 Street, Unit 10
Valley City, ND 58072 Valley City, ND 58072

Mark B. Hart, M.D. David L. Just, R.Ph.


The Bone and Joint Center P.O. Box 99
Bismack, ND 58504 Beulah, ND 58523

George H. Hilts, M.D. David J. Olig, R.Ph.


Dakota Eye Institute 2400 32nd Avenue South
Bismarck, ND 58504 Fargo, ND 58103

Mark O. Jensen, M.D. DuWayne Schlittenhard, R.Ph.


300 Main Avenue 3408 Par Street
Fargo, ND 58103 Fargo, ND 58102

Donald R. Lamb, M.D. Mary Beth Reinke, R.Ph.


100 4th Street, S., Ste. 504 3530 SW 28 #301
Fargo, ND 58103 Fargo, ND 58104

Gregory J. Post, M.D. Cindy Yeager, R.Ph.


Meritcare Medical Group Box 9512
Fargo, ND 58123 Fargo, ND 58108

David A. Rinn, M.D.


Towner County Medcenter Executive Officers of State Medical and
Cando, ND 58324 Pharmaceutical Societies
North Dakota Medical Association
Pierre A. Rioux, M.D. Bruce Levi
307 5th Avenue, SE Ste. 300 Executive Vice President
Minot, ND 58701 204 W. Thayer Avenue
P.O. Box 1198
Thomas R. Templeton, M.D. Bismarck, ND 58502-1198
Great Plains Clinic T: 701/223-9475
Dickinson, ND F: 701/223-9476
E-mail: blevi@ndmed.com
Brian C. Willoughby, M.D. Internet address: www.ndmed.com
West River Health Clinics
Hettinger, ND 58639 North Dakota State Osteopathic Association
Lloyd Mark Bell
Councilors Assigned President Director
David H. Lane, M.D. 1600 2nd Avenue, SW. Suite 120
Anesthesia Associates Ltd. Minot, ND 58701
Grand Forks, ND 58208 701/852-8798
Internet Address:
Larry E. Johnson, M.D. web.ndak.net/~ndoa/north_Dakota_osteopathic_a.htm
Dakota Clinic Ltd.
P. O. Box 1980
Jamestown, ND 58402

Pharmacy Advisory Committee


Robert L. Treitline, Chair
941 9th Avenue West
Dickinson, ND 58601

National Pharmaceutical Council North Dakota-5


Pharmaceutical Benefits 2002

North Dakota Pharmaceutical Association


Robert Treitline
Executive Vice President
1906 E. Broadway
Bismarck, ND 58501-4700
T: 701/258-4968
F: 701/258-9312
E-mail: ndpha@nodakpharmacy.com
Internet address: www.nodakpharmacy.com

State Board of Pharmacy


Howard C. Anderson
Executive Director
P. O. Box 1354
Bismarck, ND 58502-1354
701/328-9535
E-mail: ndboph@btinet.net

North Dakota Hospital Association


Arnold R. Thomas
President
3205 E. Thayer Avenue
Bismarck, ND 58501
701/224-9732
E-mail: athomas@ndha.org
Internet address: www.ndha.org

6-North Dakota National Pharmaceutical Council


Pharmaceutical Benefits 2002

OHIO

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients
TOTAL $882,579,749 777,632 $1,087,552,923 904,380

RECEIVING CASH ASSISTANCE, TOTAL $459,330,337 295,724 $540,895,726 292,077


Aged $73,527,758 33,224 $84,684,721 32,916
Blind/Disabled $364,181,040 161,699 $430,791,473 161,509
Child $9,576,244 70,616 $11,864,467 66,278
Adult $12,045,295 30,185 $13,555,065 31,374

MEDICALLY NEEDED, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $27,219,090 151,832 $35,401,852 148,249


Aged $1,985,542 1,994 $2,188,262 1,883
Blind/Disabled $4,564,574 3,076 $5,157,289 2,989
Child $17,835,201 123,412 $24,761,193 122,129
Adult $2,833,773 23,350 $3,295,108 21,248

TOTAL OTHER EXPENDITURES/RECIPIENTS* $396,030,322 330,076 $511,255,345 464,054

*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.

National Pharmaceutical Council Ohio-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescribing or Dispensing Limitations


Ohio Department of Job and Family Services. Prescription Refill Limit: 11 for non-controlled drugs up
to one year. Twelve for birth control drugs up to one
year. Five for Scheduled III, IV, V drugs up to six
D. PROVISIONS RELATING TO DRUGS months. None for Scheduled II drugs.
Benefit Design Monthly Quantity Limit: Maximum 34-day supply for
Drug Benefit Product Coverage: Products covered: most acute and 102-dosage units for chronic maintenance
drugs. Products not covered: cosmetics; fertility drugs; medications. Amount designated in Ohio Approved Drug
obesity drugs; experimental drugs. Prior authorization List.
required for some drugs including these examples: Drug Utilization Review
Ceredase; Cerebyx; Cerezyme; Clorazepates; Depo-
Provera; Enbrel; immunoglobulins; Lioresal Intrathecal; PRODUR system implemented through POS in Feb 2000.
Lodosyn; Nascoral; Orgaran; Oxandrin Panretin; State currently has a DUR Board with quarterly review.
Periostat; Priftin; Prolastin; Proleukin; Provigil; Pharmacy Payment and Patient Cost Sharing
Psoralens; Remicade; Rituxan; Stimate; Synagis; and
Targretin. Dispensing Fee: $3.70, effective 7/1/98.

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

2-Ohio National Pharmaceutical Council


Pharmaceutical Benefits 2002

2200 Jefferson Avenue, 6th Floor Bureau of Health Plan Policy


Toledo, OH 43624 614/466-6420
419/241-6501
Sheila Fujii, Chief
Paramount Care, Inc. Bureau of Medical Assistance
P.O. Box 928 255 E. Main Street
Toledo, Oh 43697 Columbus, OH 43215
419/887-2550 614/466-2365

Peoples Health Plan of Ohio Prior Authorization Contacts


4580 Stephen Circle, N.W., Suite 200
Drugs: Robert P. Reid, R.Ph.
Canton, OH 44718
614/466-6420
330/499-3100
DME/Nutritions: Bonnie Brownlee
QualChoice Health Plan
6000 Parkland Boulevard 614/466-6065
Cleveland, OH 44124 DUR Contact
440/460-0093
Jan Lawson
SummaCare DUR Administrator
P.O. 3620 30 East Broad Street, 31st Floor
Akron, OH 44309 Columbus, OH 43266-0423
330/996-8410 T: 614/466-9698
F: 614/-466-2866
F. STATE CONTACT DUR Board
State Drug Program Administrator Thomas E. Gretter, M.D.
Timothy Garner, M.D.
Robert P. Reid, R.Ph.
Jacob F. Palomaki, M.D.
Administrator, Pharmacy Services Unit
Beth T. Tranen, D.O.
Ohio Department of Job and Family Services
Rob Kubasak, R.Ph.
Bureau of Health Plan Policy
Sue Eastman, R.Ph.
30 East Broad St., 27th Floor
Jill Orn, R.Ph.
Columbus, OH 43215-3414
Donald Sullivan, Ph.D., R.Ph.
T: 614/466-6420
F: 614/466-2908 Prescription Price Updating
E-mail: reidr@odjfs.state.oh.us
First DataBank
1111 Bayhill Drive, Suite 350
Thomas Hayes, Director San Bruno, CA 94066
Ohio Department of Job and Family Services T: 650/588-5454
30 East Broad Street, 32nd Floor F: 650/827-4578
Columbus, OH 43215-3414 Medicaid Drug Rebate Contacts
T: 614/466-6282
Technical: JD Salvatore, 614/387-8402
F: 614/466-2815
Policy: Robyn Colby, 614/466-6420
E-mail: hayest@odjfs.state.oh.us
Audits: Robert Reid, 614/466-6420
Barbara C. Edwards, Deputy Director Claims Submission Contact
Ohio Health Plans
First Health Services Corp.
Ohio Department of Job and Family Services
4300 Cox Road
30 East Broad Street, 31st Floor
Glen Allen, VA 23060
Columbus, OH 43215-3414
T: 800/884-2822
T: 614/466-4443
F: 800/884-7682
F: 614/752-3986
E-mail: Medicaid@odhs.state.oh.us

Robyn Colby, Chief

National Pharmaceutical Council Ohio-3


Pharmaceutical Benefits 2002

Medicaid Managed Care Contact Executive Officers of State Medical and


Pharmaceutical Societies
Cynthia Burnell
Bureau Chief Ohio State Medical Association
Managed Health Care Brent Mulgrew
Ohio Department of Job and Family Services Executive Director
255 E. Main St. 3401 Mill Run Drive
Columbus, OH 43215 Hilliard, OH 43026
614/466-4693 T: 614/527-6762
F: 614/527-6763
Mail Order Pharmacy Benefit E-mail: brentm@osma.org
Internet address: www.osma.org
State has mail order providers.
Physician Administered Drug Program Contact Ohio Pharmacists Association
Ernest “Ernie” Boyd
Robert Reid, R.Ph. Executive Director
614/466-6420 6037 Frantz Road, Ste. 106
Pharmacy and Therapeutics Committee Dublin, OH 43017
Robert P. Reid, R.Ph., Chairman T: 614/798-0037
Bureau of Health Plan Policy F: 614/798-0978
30 East Broad Street, 27th Floor E-mail: eboyd@ohiopharmacists.org
Columbus, OH 43266-0423 Internet address: www.ohiopharmacists.org

Suzanne Eastman, R.Ph., M.S. Osteopathic Association


3922 North Cliff Lane Jon F. Wills
Cincinnati, OH 43220 Executive Director
53 W. 3rd Avenue
Michael Alexander, D.O. P.O. Box 8130
3219 Sullivant Avenue Columbus, OH 43201
Columbus, OH 43204 T: 614/299-2107
F: 614/294-0457
Ruth E. Purdy, D.O. E-mail: execdir@ooanet.org
4830 Slate Run Ct Internet address: www.ooanet.org
Columbus, OH 43220
State Board of Pharmacy
Susan Baker, APN William T. Winsley
2288 Kings Corners East Executive Director
Lexington, OH 44904 77 S. High Street, 17th Floor
Mary Jo Welker, M.D. Columbus, OH 43215-6126
2231 North High Street T: 614/466-4143
Columbus, OH 43201 F: 614/752-4836
E-mail: exec@bop.state.oh.us
Jennifer Christner, M.D. Interent address: www.state.oh.us/pharmacy/
2262 Parkwood Ohio Hospital Association
Toledo, OH 43620 James Castle, CEO
155 E. Broad St., 15th Floor
Sandra Hrometz, R.Ph, Ph.D. Columbus, OH 43215-3620
740 E. College Ave T: 614/221-7614
Bluffton, OH 43209 F: 614/221-4771
E-mail: oha@ohanet.org
Tammie J. Stroup, R.Ph. Internet address: ohanet.org
30 E. Broad Street, 27th Fl.
Columbus, OH 43215-3414

4-Ohio National Pharmaceutical Council


Pharmaceutical Benefits 2002

OKLAHOMA

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $178,254,361 221,984 $215,717,760 249,678

RECEIVING CASH ASSISTANCE, TOTAL $60,522,664 58,549 $71,737,280 62,218


Aged $18,286,078 18,301 $21,886,460 21,329
Blind/Disabled $40,651,081 32,693 $48,377,145 35,113
Child $996,925 5,578 $903,823 4,161
Adult $588,580 1,977 $569,852 1,615

MEDICALLY NEEDY, TOTAL $378,918 640 $296,233 562


Aged $12,713 24 $13,911 31
Blind/Disabled $217,183 151 $149,640 137
Child $69,108 201 $61,257 210
Adult $79,914 264 $71,425 184

POVERTY RELATED, TOTAL $19,223,396 104,483 $26,864,537 129,023


Aged $142,110 248 $85,695 170
Blind/Disabled $158,133 206 $134,217 149
Child $17,386,942 88,931 $24,942,717 114,054
Adult $1,536,211 15,098 $1,701,908 14,650

TOTAL OTHER EXPENDITURES/RECIPIENTS* $98,129,383 58,312 $116,819,710 57,875

*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.

National Pharmaceutical Council Oklahoma-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescription or Dispensing Limitations


Oklahoma Health Care Authority. Prescription Refills: None

Monthly Quantity Limits: Three prescriptions per


D. PROVISIONS RELATING TO DRUGS month/recipient. ICF-MR, Medicaid children, and
Benefit Design nursing home recipients are allowed unlimited orders.
Clients on Home and Community Based Waivers and
Drug Benefit Product Coverage: Products covered: DDSD Waivers are also allowed an unlimited number of
prescribed insulin. Products covered (DME benefit): prescriptions each month.
disposable needles and syringe combinations for insulin;
blood glucose test strips; and urine ketone test strips. Quantity Limit per Prescription: 34-day supply or 100
Products covered with restrictions: total parenteral units.
nutrition (reimburse single most costly ingredient).
Products not covered: cosmetics; fertility drugs; and Drug Utilization Review
experimental drugs. PRODUR system implemented in 2000. State currently
has a DUR Board with a monthly review.
Over-the-Counter Product Coverage: Products covered:
birth control. Products not covered: analgesics; cough and Pharmacy Payment and Patient Cost Sharing
cold preparations; digestive products, feminine products; Dispensing Fee: $4.15, effective 10/95.
topical products; and smoking deterrent products.
Products covered with restrictions: allergy, asthma, and Ingredient Reimbursement Basis: EAC = AWP – 12.0%.
sinus products (Claritin OTC only for children < 21
years). Prescription Charge Formula: Estimated Acquisition
Cost (EAC) plus dispensing fee, or usual and customary
Therapeutic Category Coverage: Therapeutic categories charge, whichever is lower. In no event shall charges to
covered: antibiotics; anticoagulants; anticonvulsants; the Welfare Department exceed charges made to the
antidepressants; antidiabetic agents; antilipemic agents; general public for the same prescription or item.
anti-psychotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents; estrogens; Maximum Allowable Cost: State imposes Federal Upper
hypotensive agents; sympathominetics (adrenergic); and Limits as well as State-specific limits on generic drugs.
thyroid agents. Prior authorization required for: Override requires “Brand Medically Necessary.”
analgesics, antipyretics, NSAIDs; antihistamine drugs Currently, 355 drugs on MAC list.
(partially covered); anxiolytics, sedatives, and hypnotics;
growth hormones; misc. GI drugs; prescribed smoking Incentive Fee: None.
deterrents (partially covered) and stimulants for ADHD.
Therapeutic categories not covered: anabolic steroids; Patient Cost Sharing: Copayment is $1.00 for
anorectics; and prescribed cold medications. OBRA ’90 prescriptions up to $29.99, $2.00 for prescriptions over
Drugs identified as "coverage optional." $30.00.
Coverage of Injectables: Injectable medicines Cognitive Services: Does not pay for cognitive services.
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used in E. USE OF MANAGED CARE
physician offices. Approximately 137,000 Medicaid recipients were
enrolled in MCOs in FY 2001. Recipients receive benefits
Vaccines: Vaccines reimbursable as part of EPSDT through both State and managed care plans.
services and the Vaccines for Children Program.
Managed Care Organizations
Unit Dose: Unit dose packaging reimbursable.
Community Care
P.O. Box 3249
Formulary/Prior Authorization
Tulsa, OK 74033
Formulary: Open formulary.
Heartland
Prior Authorization: State currently has a formal prior 100 North Broadway, Ste. 1400
authorization procedure and DUR Board. Agency Oklahoma City, OK 73102-8601
grievance process exists for appeal of prior authorization
decisions or coverage of an excluded product.

2-Oklahoma National Pharmaceutical Council


Pharmaceutical Benefits 2002

Prime Advantage Oklahoma Healthcare Authority


1602 SW 82nd St. 4545 N. Lincoln, Suite 124
Lawton, OK 73505 Oklahoma City, OK 73105-9901
T: 405/522-7327
Unicare F: 405/530-3236
P.O Box 268985 E-mail: simonsoT@ohca.state.ok.us
Oklahoma City, OK 73126
Claims Submission Contact
F. STATE CONTACTS Chris Shearier
EDS
State Drug Program Administrator 2401 N.W. 63rd Street, Suite 11
Nancy Nesser Oklahoma City, OK 73107
Pharmacy Director 405/416-6794
Oklahoma Health Care Authority Medicare Managed Care Contact
4545 N. Lincoln, Ste. 124
Oklahoma City, OK 73105-9901 Melinda Jones
T: 405/522-7325 Senior Compliance Analyst
F: 405/522-3240 Oklahoma Health Care Authority
E-mail: nessern@ohca.state.ok.us 4545 N. Lincoln, Suite 124
Internet address: www.ohca.state.ok.us Oklahoma City, OK 73105-9901
T: 405/522-7125
Prior Authorization Contact F: 405/530-3281
Ronald Graham, Pharm. D. E-mail: jonesm@ohca.state.ok.us
Manager, Operations/DUR
University of Oklahoma, College of Pharmacy Mail Order Pharmacy Program
P.O. Box 26801 Oklahoma does not sponsor a mail order pharmacy
Oklahoma City, OK 73109 benefit. However, mail order pharmacies are allowed to
T: 405/271-6614 contract with the Oklahoma Medicaid program to provide
F: 405/271-2615 prescription products to Oklahoma Medicaid
E-mail: ronald-graham@ouhsc.edu beneficiaries. Pharmacy must be a contracted provider.
DUR Contact Disease Management Program/Initiative Contact
Ronald Graham, Pharm. D., 405/271-9039 Kathe Eastham, R.N
Nurse Case Manager III
Medicaid DUR Board Oklahoma Health Care Authority
4545 N. Lincoln, Ste. 124
Rick Crensaw, D.O. Oklahoma City, OK 73105-9901
Dick Robinson, R.Ph. (Vice-Chair) T: 405/522-7155
Dorothy Gourley, D.Ph. F: 405/522-7378
Cliff Meece, D.Ph. E-mail: easthamk@ohca.state.ok.us
William Banner, M.D.
Cathy E. Hollen, D.Ph. Physician-Administered Drug Program Contact
Francois DuToit, M.D. J. Paul Keenan, M.D.
Thomas Whitsett, M.D. (Chair) Associate Medical Director
Dan McNeill, Ph.D., PA-C 4545 N. Lincoln, Ste. 124
James Swaim, D.Ph. Oklahoma City, OK 73105
Prescription Price Updating T: 405/522-7176
F: 405/530-3245
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
E-mail: www.firstdatabank.com

Medicaid Drug Rebate Contacts


Tom P. Simonson
Manager, Medicaid Drug Rebate Program

National Pharmaceutical Council Oklahoma-3


Pharmaceutical Benefits 2002

Oklahoma Health Care Authority Officials Lynette C. McLain


Executive Director
Michael Fogarty, J.D.
4848 N. Lincoln Boulevard
Chief Executive Officer
Oklahoma City, OK 73105-3321
Oklahoma Health Care Authority
T: 405/528-4848
4545 N. Lincoln, Ste. 124
F: 405/528-6102
Oklahoma City, OK 73105
E-mail: ooa@okosteo.org
T: 405/522-7300
Internet address: okosteo.org
F: 405/522-7187
E-mail: fogartym@ohca.state.ok.us
State Board of Pharmacy
Janis K. McAllister
Lynn Mitchell, M.D.
President
State Medicaid Director
4545 N. Lincoln Boulevard, Ste. 112
Oklahomah Health Care Authority
Oklahoma City, OK 73105-3488
4545 N. Lincoln, Ste. 124
T: 405/521-3815
Oklahoma City, OK 73105
F: 405/521-3758
T: 405/530-7365
E-mail: pharmacy@oklaosf.state.ok.us
F: 405/530-3218
Internet address: www.state.ok.us/~pharmacy
E-mail: Mitchell@ohca.state.ok.us
Oklahoma Hospital Association
Darcedia McCauley, Ph.D.
Craig W. Jones
Director of Quality Assurance
President
405/530-3355
4000 Lincoln Boulevard
Advisory Committee on Medical Care for Public Oklahoma City, OK 73105
Assistance Recipients T: 405/427-9537
F: 405/424-4507
Frank Wilson, III, M.D., Chairman E-mail: oha@okoha.com
4545 N. Lincoln, Ste. 124 Internet address: www.okoha.com
Oklahoma City, OK 73105
Executive Officers of State Medical,
Pharmaceutical, and Osteopathic Societies
Oklahoma State Medical Association
Brian O. Foy, Executive Director
601 NW Grand Boulevard
Oklahoma City, OK 73118
T: 405/843-9571 or 800/522-9452
F: 405/842-1834
E-mail: osma@osmaonline.org
Internet address: www.osmaonline.org

Oklahoma Pharmaceutical Association


Phil Woodward, D.Ph., Executive Director
Box 18731
Oklahoma City, OK 73154
T: 405/528-3338
F: 405/528-1417
E-mail: pwoodward@opha.com
Internet address: www.opha.com

Oklahoma Osteopathic Association

4-Oklahoma National Pharmaceutical Council


Pharmaceutical Benefits 2002

OREGON
1

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       

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $163,263,562 191,901 $228,670,426

RECEIVING CASH ASSISTANCE TOTAL $58,691,711 51,031


Aged $5,742,701 6,123
Blind/Disabled $48,569,477 28,510
Child $861,860 8,089
Adult $3,517,673 8,309

MEDICALLY NEEDY, TOTAL $25,659,100 6,483


Aged $4,063,302 1,695
Blind/Disabled $21,595,798 4,788
Child $0 0
Adult $0 0

MEDICALLY NEEDY TOTAL $5,071,877 31,027


Aged $586,943 478
Blind/Disabled $1,519,991 748
Child $2,445,545 25,579
Adult $519,398 4,222

TOTAL OTHER EXPENDITURES/RECIPIENTS* $73,840,874 103,360

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

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

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

National Pharmaceutical Council Oregon-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prior Authorization: State currently has a formal prior


authorization procedure. Client may request an
Office of Medical Assistance Programs (OMAP), administrative hearing to appeal a prior authorization
Department of Human Services. decision or to appeal the coverage of excluded products.
Prescribing or Dispensing Limitations
D. PROVISIONS RELATING TO DRUGS
Limit initial prescription for chronic medications to 15
Benefit Design days to prevent wasting if drug is changed due to
Drug Benefit Product Coverage: Products covered: intolerance, side effects, etc. Effective 4/02.
prescribed insulin and syringe combinations used for Drug Utilization Review
insulin (when insulin filled). Products covered under
DME: disposable needles used for insulin; blood glucose PRODUR system implemented in March 1994. State
test strips; and urine ketone test strips. Prior authorization currently has a DUR Board with a quarterly review.
required for: isotretinon; acute anti-ulcer drugs; Pharmacy Payment and Patient Cost Sharing
cosmetics; total parenteral nutrition; interdialytic
parenteral nutrition; retinoic acid; nasal inhalers; coal tar Dispensing Fee: $3.50, $3.80, effective 10/01/01.
preparations; and topical testosterone. Products not
covered: fertility drugs; experimental drugs. 1) $3.50 (retail);

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.

2-Oregon National Pharmaceutical Council


Pharmaceutical Benefits 2002

Cascade Comprehensive Care, Inc. Oregon Health Management Services


900 Main Street, Suite A 1051 NE 6th Street, Suite 2C
P.O. Box 217 Grants Pass, OR 97526
Klamath Falls, OR 97601-0368 541/ 471-4208
541/883-2947
Providence Health Plan
Central Oregon Independent Health Services, Inc. 1235 NE 47th, Suite 220
2650 NE Courtney Drive Portland, OR 97213-2196
P0 Box 5729 800/ 898-8174
Bend, OR 97708-5729
800/431-4155 Tuality Health Alliance
335 SE 8th Avenue
Doctors of The Oregon Coast South (DOCS) PO Box 925
750 Central, Suite 202 Hillsboro, OR 97123-0925
PO Box 1096 800/681-1901
Coos Bay, OR 97420
541/269-7400 F. STATE CONTACTS
Douglas County IPA State Drug Program Administrator
500 SE Cass, Suite 210 Thomas Drawbaugh
Roseburg, OR 97470 Pharmacy Program Manager
541/677-3453 Office of Medical Assistance Programs (OMAP)
Department of Human Resources
Family Care, Inc 500 Summer Street, NE, E-35
2121 SW Broadway, Suite 300 Salem, OR 97301-1077
Portland, OR 97201 T: 503/945-6492
800/335-3205 F: 503/373-7689
E-mail: thomas.drawbaugh@state.or.us
Intercommunity Health Network, Inc Internet address: www.omap.hr.state.or.us
3600 NW Samaritan Drive
Corvallis, OR 97330 Prior Authorization Contact
800/757-5114 Thomas Drawbaugh, 503/945-6492

Kaiser Permanente DUR Contact


500 NE Multnomah, Suite 100 Mariellen Rich, R.Ph.
Portland, OR 97232-2099 Pharmacist Account Manager
800/813-2000 First Health Service Corporation
565 Union St., NE, Suite 205
Lane Individual Practice Association, Inc. (LIPA) Salem, OR 97301
1500 Valley Rive Drive, Suite 370 T: 503/391-1980
Eugene, OR 97401 F: 503/391-1979
541/485-2155 E-mail: merich@fhsc.com
Marion Polk Community Health Plan Medicaid DUR Board
198 Commercial St., SE, Suite 240 Rickland G. Asai, D.M.D. (Chair)
Salem, OR 97301 2375 SW Cedar Hills Blvd.
503/584-2150 Portland, OR 97225
Mid Rogue IPA Health Plan Patrick Bowman, R.Ph.
820 NE 7th Street Portland, OR
Grants Pass, OR 97526
541/471-4106 Gerald D. Fairbanks, R.Ph.
Albany, OR
ODS Health Plans
601 SW 2nd Ave
Portland, OR 97204
800/342-0526

National Pharmaceutical Council Oregon-3


Pharmaceutical Benefits 2002

Dean Haxby, Pharm.D. Delivery Systems Manager


Oregon Health Sciences University Office of Medical Assistance Programs
OSU College of Pharmacy 500 Summer Street, NE
3181 SW Sam Jackson Park Rd., GH212 Salem, OR 97310-1014
Portland, OR 97201-3098 T: 503/945-6497
F: 503/947-5221
Christina Heinrich, Pharm.D.
Eugene, OR Disease Management Program/Initiative Contact

Robert Ingle, Jr., M.D., M.P.H. Thomas Turek, M.D.


Kaiser Permanente Medical Director
Office of Medical Assistance Programs
Salem, OR
500 Summer Street, NE
Salem, OR 97301-1097
Gregory Johnson, M.D. (Vice-Chair)
T: 503/945-5770
Clackamas, OR
F: 503/373-7689
Raymond S. Lee, D.O. E-mail: thomas.turek@state.or.us
Clackamas, OR Mail Order Pharmacy Program

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

Medicaid Managed Care Contact


Joyce Riggi

4-Oregon National Pharmaceutical Council


Pharmaceutical Benefits 2002

Title XIX Medical Care Advisory Committees Tom Holt


Executive Director
Elizabeth Byers
29702-B Town Center Loop West
Bruce Bliatout
Wilsonville, OR 97070-6481
Donna Crawford
T: 503/582-9055
Rosemari Davis
F: 503/582-9046
Rosemari Fitts
E-mail: tomh@oregonpharmacists.com
Michael Garland
Internet address: www.oregonpharmacists.com
John Hogan
Kelley Kaiser
Osteopathic Physicians and Surgeons of Oregon
Noel Larson, D.M.D.
Jeff Heatherington
Amy Malone
Executive Director
Rick Wopat, M.D.
2121 SW Broadway, Suite 300
Consultants to Health and Social Services Portland, OR 97201
Section T: 503/222-2279
F: 503/222-2392
Thomas Turek, M.D. E-mail: jeffh@opso.org
Medical Director
Internet address: www.opso.com
Office of Medical Assistance Programs
Department of Human Resources
State Board of Pharmacy
500 Summer Street, NE
Gary Schnabel
Salem, OR 97301 Executive Director
State Office Bldg., Room 425
Pharmacy Advisory Task Force 800 NE Oregon St., #9
Tom Holt, Chairman Portland, OR 97232
Mike Dardis, R.Ph. T: 503/731-4032
Jim Waletich, R.Ph. F: 503/731-4067
Ed Hughes, R.Ph. E-mail: gary.a.schnabel@state.or.us
Ron Dulwick, R.Ph.
Jenny Kudna, R.Ph. Oregon Association of Hospitals and Health Systems
Dennis Perry, R.Ph. Kenneth M. Rutledge
Larry Cartier, R.Ph. President
Richard Hartmann, R.Ph. 4000 Kruse Way Place
Chris Vorrath, R.Ph. Building 2, Suite 100
Susie Morris, R.Ph. Lake Oswego, OR 97035-2543
Tom Hornsby, R.Ph. T: 503/636-2204
Kathy Ketchum, R.Ph. F: 503/636-8310
John Mansfield, R.Ph. E-mail: krutledg@ix.netcom.com
Dave Lewis, R.Ph. Internet address: www.oahhs.org
Dave Walden, R.Ph.
Cynthia Wong, R.Ph.
Executive Officers of State Medical and
Pharmaceutical Associations
Oregon Medical Association
Robert L. Dernedde, CAE
Executive Director
5210 SW Corbett Street
Portland, OR 97239-3897
T: 503/226-1555
F: 503/241-7148
E-mail: rdernedde@ormedassoc.org
Internet address: www.ormedassoc.org

Oregon State Pharmacists Association

National Pharmaceutical Council Oregon-5


Pharmaceutical Benefits 2002

6-Oregon National Pharmaceutical Council


Pharmaceutical Benefits 2002

PENNSYLVANIA

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         

B. EXPENDITURES FOR DRUGS


2000 2001**

Expended Recipients Expended Recipients


TOTAL $533,527,373 416,498 $533,527,373 416,498

RECEIVING CASH ASSISTANCE, TOTAL $250,790,899 157,601


Aged $54,131,823 25,385
Blind / Disabled $175,740,482 72,923
Child $6,663,349 35,013
Adult $14,255,245 24,280

MEDICALLY NEEDY, TOTAL $44,804,637 32,353


Aged $38,355,424 17,511
Blind / Disabled $2,922,397 989
Child $2,321,542 9,053
Adult $1,205,274 4,800

POVERTY RELATED, TOTAL $117,501,143 149,542


Aged $40,920,296 19,453
Blind / Disabled $59,717,317 23,957
Child $15,316,515 94,966
Adult $1,547,015 11,166

TOTAL OTHER EXPENDITURES/RECIPIENTS* $120,430,694 77,002

*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.

National Pharmaceutical Council Pennsylvania-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Formulary/Prior Authorization

Office of Medical Assistance Programs, Department of Formulary: Open formulary.


Public Welfare.
Prior Authorization: State currently has a prior
authorization procedure screening for drug classes and
D. PROVISIONS RELATING TO DRUGS individual drugs. Products that require PA include BMN
brand name drugs that have A-rate generics, H2
Benefit Design
antagonists used >90 days, and drugs for erectile
Drug Benefit Product Coverage: Products covered: dysfunction. Also, Oxycontin prescriptions with doses in
prescribed insulin; disposable needles and syringe excess of 3 tablets per day, or being on more than 2
combinations used for insulin; blood glucose test strips; different strengths concurrently.
urine ketone test strips; interdialytic parenteral nutrition;
Prescribing or Dispensing Limitations
and total parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs. Quantity Limit: 34-day supply or 100 units, whichever is
greater.
Over-the-Counter Product Coverage: Products covered:
analgesics; feminine products; topical products; laxatives; Refill Limit: Up to 5 within 6 months.
scabicides containing permethrin; oral electrolytes; and
smoking deterrent products. Products covered with Monthly Prescription Limit: 6
restrictions: allergy, asthma, and sinus (indication or
Drug Utilization Review
prescribed); cough and cold preparations (indication other
than C+C on Rx); digestive products (not including H2 PRODUR system implemented in June 1993. DUR
antagonists) (legend products only); and digestive Board has 10 members including 1 vacancy and meets
products (H2 antagonists) (PA > 90 days at acute dose). quarterly.
Products not covered: emollients and digestive products
Pharmacy Payment and Patient Cost Sharing
(non H2 antagonists).
Dispensing Fee: $4.00 ($5.00 for compounds), effective
Therapeutic Category Coverage: Therapeutic categories 10/1/95.
covered: anabolic steroids; analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants; anticonvulsants; Ingredient Reimbursement Basis: EAC = AWP-10%.
anti-depressants; antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics, sedatives, Prescription Charge Formula:
and hypnotics; cardiac drugs; chemotherapy agents; 1. Payment for single source drugs and those
contraceptives; ENT anti-inflammatory agents; estrogens; multisource brand name drugs certified as medically
growth hormones; hypotensive agents; misc. GI drugs; necessary will be the lower of the EAC plus
sympathominetics (adrenergic); thyroid agents; and dispensing fee or the pharmacy's usual and customary
prescribed smoking deterrent products; and prescribed charge.
cold medications. Therapeutic categories not covered:
anorectics (unless for treatment of hyperkinesis or 2. State MAC for the drug plus dispensing fee or the
narcolepsy); hair restoration drugs, vitamins (with some pharmacy's usual and customary charge.
exceptions);and products from companies not 3. For compound prescriptions, an additional fee of
participating in the rebate program. $1.00 is allowed to a pharmacy, bringing the total
dispensing fee to $5.00.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in physician offices, home health care, and Maximum Allowable Cost: State imposes Federal Upper
extended care facilities. Limits as well as State-specific limits on generic drugs.
465 drugs are listed on the State-specific MAC list.
Vaccines: Vaccines reimbursable at AWP – 10% as part Override requires “Brand Medically Necessary”, “Brand
of the Medical Assistance, Children Health Insurance Necessary,” plus prior authorization.
Program, the Vaccines for Children Program, and EPSDT
Program. Incentive Fee: None.

Unit Dose: Unit dose packaging not reimbursable.

2-Pennsylvania National Pharmaceutical Council


Pharmaceutical Benefits 2002

Patient Cost Sharing: Copayment is $1.00; $2.00 for F. STATE CONTACTS


General Assistance. The copayment will not apply to
those recipients who are federally exempt, under 21 years State Drug Program Administrator
of age, pregnancy cases and long-term care patients, plus Joseph E. Concino, R.Ph.
patients receiving drugs in the following categories: Office of Medical Assistance Programs
Pharmacy Services Section
− Anticonvulsants P.O. Box 8046
− Antidiabetic agents Harrisburg, PA 17105
− Antiglaucoma agents T: 717/772-6341
− Antihypertensive agents F: 717/772-6366
− Antineoplastic agents E-mail: jconcino@state.pa.us
− Antiparkinson agents Internet address: www.dpw.state.pa.us/omap
− Cardiovascular preparations
− HIV/AIDS specific drugs Welfare Department Officials
− Psychotherapeutic agents Estelle Richman
Secretary
Cognitive Services: Does not pay for cognitive services. Department of Public Welfare
Health and Welfare Building
P.O. Box 2675
E. USE OF MANAGED CARE
Harrisburg, PA 17120
Approximately 886,000 unduplicated Medicaid recipients
were enrolled in managed care in 2001. All receive Carole W. Rebert
pharmacy services, depending on their category of Official-In-Charge for Medical Assistance Programs
assistance, through managed care.
Christopher P. Gorton, M.D.
Managed Care Organizations
Chief Medical Officer
AmeriHealth HMO/Mercy Health Plan 44,457
1901 Market Street, 45th Floor Carla Huitt, M.D.
Philadelphia, PA 19103 Medical Director

Keystone Mercy Healthplan 244,435 Teresa Shuchart


200 Stevens Drive, Ste. 900 Director
Philadelphia, PA 19113-1570 Division of Data and Claims Management

Americhoice of PA 105,102 Jeffrey Bechtel


The Wanamaker Building Director
100 Penn Square East, Ste. 900 Bureau of Program Integrity
Philadelphia, PA 19107
Suzanne Love
Health Partners of Philadelphia 121,176 Director
841 Chestnut St. Ste. 900 Bureau of Policy, Budget, and Planning
Philadelphia, PA 19107
Guy L. Ridge, III
Three Rivers Health Plans/MedPlus+ 134,646 Director
300 Oxford Drive Bureau of Fee-for-Service Programs
Monroeville, PA 15146
Christine M. Bowser
UPMC Health Plan, Inc./Best 72,280 Director
Healthcare of Western PA Bureau of Managed Care Operations
One Chatam Center
112 Washington Place Andrew Major
Pittsburgh, PA 15219 Director
Bureau of Long Term Care Programs
Gateway Health Plan 164,431
Two Chatam Ctr, Ste. 500 William M. Peifer, R.Ph.
Pittsburgh, PA 15219 Pharmacy Consultant
Pharmacy Services Section

National Pharmaceutical Council Pennsylvania-3


Pharmaceutical Benefits 2002

Louis J. Cappello, R.Ph. Medicaid Drug Rebate Contacts


Pharmacy Consultant
Technical: David Ehrhart, 717/772-6305
Pharmacy Services Section
Policy: Suzanne Love, 717/772-6142
Disputes: Louis Cappello, 610/447-5385
John Ferrara, R.Ph.
Director Claims Submission Contact
Division of Program Integrity
EDS
DUR Board 275 Grandview Avenue
Camp Hill, PA 17011
Richard D. Baltz, M.D.
(Calls with contractor must be made through state
3028 Market Street
agency.)
Camp Hill, PA 17011
Medicaid Managed Care Contact
Richard T. Bell, M.D.
Michael Jacobs
Chairman
Director, Division of MCO Monitoring and Compliance
2016 Redwood Avenue
Wyomissing, PA 19610 Office of Medical Assistance Programs
Cherrywood Bldg, DPW Complex #2
Harrisburg, PA 17110
Richard W. Sloan, M.D.
T: 717/772-6300
Thomas Hart Family Practice Center
F: 717/772-2730
York Hospital
1001 South George Street Mail Order Pharmacy Program
York, PA 17405
None
Otto F. Wolke, R.Ph. Expanded Drug Coverage Program Contact
Geisinger Health Plan
Geisinger Office Building Thomas M. Snedden, Director
Danville, PA 17822 PACE Program
PA Dept. of Aging
Patricia A. Keys, Pharm.D., R.Ph. 555 Walnut St., 5th Floor.
1514 Scenery Ridge Drive Harrisburg, PA 17101
Pittsburgh, PA 15241 717/787-7313
Medical Assistance Advisory Committee
Marshall P. Burnside, R.Ph.
6000 Bell Road Christine Allen
Harrisburg, PA 17111 PACE/LTCCAP c/o LIFE
University of Pennsylvania School of Nursing
Michael A. Zemaitis, Ph.D., R.Ph. 4101 Woodland Avenue
133 Shadowlawn Drive Philadelphia, PA 19104-4510
Pittsburgh, PA 15261 215/898-4417

Robert L. Mayer, Jr., Pharm.D., R.Ph. Shirley Beer


5814 Elmer Street Armstrong County Low Income Rights Organization
Pittsburgh, PA 15232 RD, #8, Box 134
Kittanning, PA 16201
Keith Burkhart, M.D. 724/543-5031
206 Mine Road
Hershey, PA 17033 Shelley Bishop
Pennsylvania Mental Health Consumers Association
Jeffrey P. Staab, M.D., M.S. 4105 Derry Street
5 Heritage Lane Harrisburg, PA 17111
Phoenixville, PA 19460-4607 717/564-4930

Prescription Price Updating


First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453

4-Pennsylvania National Pharmaceutical Council


Pharmaceutical Benefits 2002

Kent D. W. Bream, M.D. Kathy Hubert


Department of Family Practice Pennsylvania County Drug and Alcohol
University of Pennsylvania Program Administrators
2 Gates, HUP, 3400 Spruce Street 17 North Front Street
Philadelphia, PA 19104 Harrisburg, PA 17101
215/614-0523 717/232-7554

Louise Brookins Michelle Jones


Philadelphia State Welfare Rights Org. Healthy Start, Inc.
1231 N. Franklin Street 400 North Lexington Street
Philadelphia, PA 19122 Pittsburgh, PA 15208
214/684-3600 412/247-4009

Kevin Casey George Kimes


Pennsylvania Protection and Advocacy Pennsylvania Community Providers Association
1414 Cameron Street, Suite C 2400 Park Drive
Harrisburg, PA 17103 Harrisburg, PA 17110
717/236-8110 717/657-7078

Michael D. Chambers Christine Klejbuk


County commissioners Association of Pennsylvania PA Assn. Non-Profit Homes for the Aging
17 North Front Street Dir. of Public Policy
Harrisburg, PA 17101 1100 Bent Creek Blvd.
717/232-7554 Mechanicsburg, PA 17050
717/763-5724
Barbara Coffin
Pennsylvania Association of Area Agencies on Aging Ms. Carol Lavoritano
Berks County Office of Aging AmeriChoice
County Services Center The Wanamaker Building
633 Court Street 100 Penn Square East, Suite 900
Reading, PA 19601-4303 Philadelphia, PA 19107
610/478-6500
Yvette Long
Dona Dmitrovic Philadelphia Welfare Rights Organization
Executive Director 1231 North Franklin Street
Pennsylvania Recovery Organization Alliance, Inc. Philadelphia, PA 19122
900 South Arlington Avenue, Suite 119 215/684-3600
Harrisburg, PA 17109
717/545-8929 Donald McCoy (Chair)
Pennsylvania Medical Society
Henry R. Fiumelli 777 East Park Drive
Executive Director P.O. Box 8820
Pennsylvania Forum for Primary Health Care Harrisburg, PA 17105-8820
1035 Mumma Road, Ste. 1 717/558-7823
Wormleysburg, PA 17043
717/761-6443 Anne R. McHugh
Hospital and Healthsystem Association of Pennsylvania
Vickie Hoak (Vice-Chair) 4750 Lindle Road
Pennsylvania Homecare Association P.O. Box 8600
20 Erford Road, Suite 115 Harrisburg, PA 17105-8600
Lemoyne, PA 17043
717/975-9448, Ext. 28 Donna McNonagle
Philadelphia Coordinated Health Care
Dolores Hodgkiss 123 South Broad Street, 22nd Floor
Managed Care Association of Pennsylvania Philadelphia, PA 19109
240 North Third Street, Suite 501 717/546-7643, Ext. 3652
Harrisburg, PA 17101
717/238-2600

National Pharmaceutical Council Pennsylvania-5


Pharmaceutical Benefits 2002

Jonna Miller Pennsylvania Osteopathic Medical Association


Delaware County Office of Behavior Health Mario E.J. Lanni
20 South 69th Street, 3rd Floor Executive Director
Upper Darby, PA 19082 1330 Eisenhower Boulevard
Harrisburg, PA 17111-2395
Richard R. Orlandi T: 717/939-9318
Pennsylvania Medical Society F: 717/939-7255
777 East Park Drive E-mail: poma@poma.org
PO Box 8820 Internet address: www.poma.org
Harrisburg, PA 17105-8820
717/558-7750 Pennsylvania Podiatry Association
Michael Q. Davis
Mary Ellen Rehrman Executive Director
10 Bertolet School Road 757 Poplar Church Road
Spring City, PA 19475 Camp Hill, PA 17011
610/469-9536 or 215/546-0300, Ext. 3251 717/763-7665

Dale Laninga - Ex-Officio Member State Board of Pharmacy


Department of Aging Melanie Zimmerman
Intra Governmental Council on Long Term Care Executive Secretary
555 Walnut Street, 5th Floor 124 Pine St.
Harrisburg, PA 17101-1919 P.O. Box 2649
717/783-1550 Harrisburg, PA 17105-2649
T: 717/783-7157
Michael A. Yantis, Jr. - Ex-Officio Member F: 717/787-7769
Pennsylvania Department of Health Office of Policy E-mail: pharmacy@pados.dos.state.pa.us
Room 808, Health and Welfare Building Internet address:
Harrisburg, PA 17120 www.dos.state.pa.us/bpoa/phabd/mainpage.htm
717/787-4525
Hospital Association of Pennsylvania
Executive Officers of State Medical and Carolyn F. Scanlan
Pharmaceutical Associations President, CEO
4750 Lindle Road
Pennsylvania Medical Society
P.O. Box 8600
Roger F. Mecum
Harrisburg, PA 17105-8600
Executive Vice President
717/564-9200
777 E. Park Drive
E-mail: cscanlan@haponline.org
P.O. Box 8820
Internet address: www.haponline.org
Harrisburg, PA 17105-8820
T: 717/558-7750
F: 717/558-7840
E-mail: rmecum@pamedsoc.org
Internet address: www.pamedsoc.org

Pennsylvania Pharmaceutical Association


Patricia A. Epple, CAE
Executive Director
508 North Third Street
Harrisburg, PA 17101-1199
T: 717/234-6151
F: 717/236-1618
E-mail: ppa@papharmacists.com
Internet address: www.papharmacists.com

6-Pennsylvania National Pharmaceutical Council


Pharmaceutical Benefits 2002

RHODE ISLAND

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients

TOTAL $89,482,143 49,809 $102,708,476

RECEIVING CASH ASSISTANCE TOTAL $53,505,798 27,625


Aged $6,550,737 4,487
Blind/Disabled $46,759,792 21,360
Child $66,792 840
Adult $128,477 938

MEDICALLY NEEDY, TOTAL $8,188,213 3,910


Aged $5,579,162 3,121
Blind/Disabled $2,609,010 786
Child $0 0
Adult $41 3

POVERTY RELATED, TOTAL $243,588 933


Aged $59,273 95
Blind/Disabled $119,373 115
Child $41,117 555
Adult $23,825 168

TOTAL OTHER EXPENDITURES/RECIPIENTS* $27,544,544 17,341

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

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

National Pharmaceutical Council Rhode Island-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Prescribing or Dispensing Limitations


Rhode Island Department Human Services. Prescription Refill Limit: Refills to a maximum of 5 are
allowed for specified drugs: anti-hypertensives, diuretics,
anti-convulsants, coronary vasodilators, tranquilizers,
D. PROVISIONS RELATING TO DRUGS antidepressants, hormones, antibiotics, etc. Refills are not
Benefit Design allowed for specified drugs, e.g., central nervous system
stimulants, narcotics (Schedule II, III), and pentazocine.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: One month’s supply for non-
combinations used for insulin; urine ketone test strips. maintenance drugs.
Products covered under DME: blood glucose test strips;
total parenteral nutrition (prior authorization required); Maintenance Medication: The attending physician may
and interdialytic parenteral nutrition (prior authorization prescribe certain maintenance drugs of 100 tablets,
required). Products not covered: cosmetics; fertility capsules or pint of liquid or a 30-day supply of these
drugs; experimental drugs; DESI drugs. drugs - whichever is greater.

Over-the-Counter Product Coverage: Products covered: Monthly Dollar Limits: None


analgesics (acetaminophen); cough and cold preparations
(guifenisin, diphenhydramine, chlorpheniramine); Drug Utilization Review
digestive products (non-H2 antagonists); feminine PRODUR system implemented in December 1994.
products (contraceptive foams, gels and creams); topical
products; antacids; and laxatives. Products not covered: Pharmacy Payment and Patient Cost Sharing
allergy, asthma, and sinus products; digestive products Dispensing Fee: $3.40 (ambulatory) and $2.85 (nursing
(H2 antagonists); and smoking deterrent products. homes), effective 1987.
Therapeutic Category Coverage: Products covered: Ingredient Reimbursement Basis: EAC = WAC + 5%.
anabolic steroids; analgesics, antipyretics, and NSAIDs;
antibiotics; anticoagulants; anticonvulsants; anti- Prescription Charge Formula:
depressants; antidiabetic agents, antihistamine drugs;
1. In accordance with Federal regulation the upper limit
antilipemic agents; anti-psychotics; anxiolytics, sedatives,
for payment for prescribed drugs will be based upon
and hypnotics; cardiac drugs; chemotherapy agents,
the amount allowed by the Medical Assistance
prescribed cold medications; contraceptives; ENT anti-
Program or the usual and customary charge to the
inflammatory agents; estrogens; hypotensive agents;
general public, whichever is lower.
sympathominetics (adrenergic); and thyroid agents. Prior
authorization required for: anoretics; misc. GI drugs; 2. Payment for over-the-counter drugs (non-legend
erectile dysfunction products; and Cox 2 inhibitors; drugs) will be based upon the lower of either the
partial coverage: growth hormones. Therapeutic allowable cost of the drug plus 50 percent, the usual
categories not covered: prescribed smoking deterrents; and customary charge to the general public, or the
products for hair growth. allowable cost plus the professional fee for service.

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.

2-Rhode Island National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE Department of Human Services Officials


Approximated 120,000 Medicaid recipients were enrolled Jane Hayward
in managed care in 2001. Managed care recipients Director
receive pharmaceutical benefits through managed care Department of Human Services
plans. 600 New London Avenue
Cranston, RI 02920
Managed Care Organizations T: 401/462-2121
− United Healthcare of New England F: 401/462-3677
− Coordinated Health Partners, Inc. E-mail: jhayward@gw.dhs.state.ri.us
− Neighborhood Health Plan of Rhode Island
John Young
Associate Director
F. STATE CONTACTS Medical Services
State Drug Program Administrator Department of Human Services
600 New London Avenue
Paula Avarista, R.Ph. Cranston, RI 02920
Chief of Pharmacy T: 401/462-3575
Department of Human Services F: 401/462-6338
600 New London Avenue E-mail: jyoung@gw.dhs.state.ri.us
Cranston, RI 02920
T: 401/462-6390 Executive Officers of State Medical and
F: 401/462-6336 Pharmaceutical Societies
E-mail: pavarist@gw.dhs.state.ri.us Rhode Island Medical Society
DUR Contact Newell E. Warde, Executive Director
235 Promenade Street, Suite 500
Paula Avarista, R.Ph., 401/462-6390 Providence, RI 02908
Rhode Island DUR Board T: 401/331-3207
F: 401/751-8050
Raymond Maxim, MD E-mail: nwarde@rimed.org
Edward Westlake, MD Internet Address: www.rimed.org
Richard Wagner, MD
Steve Kogurt, PhD Rhode Island Society of Osteopathic Physicians and
Craig Bowen, PharmD Surgeons/Northeast Osteopathic Consortion
John Zevzavadjian RPh Donald J. Halpin, Executive Director
Ellen Mauro, RN, MPH P.O. Box 487
Prescription Price Updating Winchester, MA 01800
781/721-9900
Paula Avarista, R.Ph., 401/462-6390 E-mail: nocdos@shore.net
Medicaid Drug Rebate Contacts Internet Address : www.northeastosteo.org

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

National Pharmaceutical Council Rhode Island-3


Pharmaceutical Benefits 2002

E-mail: dianet@doh.state.ri.us
Internet Address:
www.healthri.org//hsr/professions/pharmacy.htm

Hospital Association of Rhode Island


Edward J. Quinlan, President
880 Butler Drive, Suite One
Providence, RI 02906
T: 401/274-4274
F: 401/274-1838
E-mail: edwardq@hari.org
Internet Address: www.hari.org

4-Rhode Island National Pharmaceutical Council


Pharmaceutical Benefits 2002

SOUTH CAROLINA

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expended Recipients Expended Recipients

TOTAL $334,740,332 474,465 $438,498,935 542,764

RECEIVING CASH ASSISTANCE, TOTAL $180,174,171 156,943 $217,671,240 201,137


Aged $49,524,373 31,494 $54,051,659 30,510
Blind/Disabled $114,485,843 71,255 $133,255,085 73,126
Child $5,723,013 32,302 $11,428,870 53,959
Adult $10,440,942 21,892 $18,935,626 43,542

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $109,063,041 227,756 $135,326,028 239,631


Aged $34,833,839 21,973 $41,923,282 24,199
Blind/Disabled $41,846,031 19,519 $51,608,068 21,735
Child $30,637,849 172,055 $39,949,877 179,897
Adult $1,745,322 14,209 $1,844,801 13,800

TOTAL OTHER EXPENDITURES/RECIPIENTS* $45,503,120 89,766 $85,501,667 101,996

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

Source: CMS, MSIS Report, FY 2000, and CMS-64 Report FY 2001; South Carolina Medicaid Statistical Information System,
FY 2001.

National Pharmaceutical Council South Carolina-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION health center (Synagis is reimbursable through the


Physician Services Program and is non-covered
South Carolina Department of Health & Human Services.
through Pharmacy Services).
6. Products used as flushes to maintain patency of
devices.
D. PROVISIONS RELATING TO DRUGS 7. Devices and supplies (e.g., diabetic supplies, infusion
Benefit Design supplies, etc.)
8. Fertility products.
Drug Benefit Product Coverage: Products covered: 9. Smoking cessation products, whether legend or OTC.
prescribed insulin, and disposable needles and syringe 10. Pharmaceuticals which are not rebated.
combinations used for insulin. Products covered as DME: 11. Nutritional supplements
blood glucose test strips; urine ketone test strips; total 12. Oral hydration therapies for adults.
parenteral nutrition; and interdialytic nutrition. Products 13. Pharmaceuticals used for cosmetic purposes or hair
not covered: cosmetics; fertility drugs; DESI drugs; and growth.
experimental drugs.
Prior Authorization: State currently has a prior
Over-the-Counter Product Coverage: Within program authorization program. Beneficiaries can request a fair
guidelines and limitations, the Medicaid program covers hearing and exception to policy to appeal a prior
all rebated OTC medications and their generic authorization decision. The prescriber must obtain prior
equivalents. Products not covered: smoking deterrent authorization for Medicaid coverage of the following
products. products:

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

2-South Carolina National Pharmaceutical Council


Pharmaceutical Benefits 2002

Pharmacy Payment and Patient Cost Sharing Columbia, SC 29202-8206


T: 803/898-2876
Dispensing Fee: $4.05, effective 7/1/89.
F: 803/255-8353
E-mail: sojourne@dhhs.state.sc.us
Ingredient Reimbursement Basis: EAC = AWP-10%.
DUR Contact
Prescription Charge Formula: Medicaid reimbursement
Caroline Y. Sojourner, 803/898-2876
for pharmacy services will be based on the lowest of: the
Estimated Acquisition Cost (EAC); federal or state DUR Committee
maximum allowable cost (MAC); or the provider's
submitted usual and customary charge. Gwendolyn C. Galphin, M.D.
F. Joseph Hodge, R.Ph.
Henry Rose, R.Ph.
Maximum Allowable Cost: State imposes Federal Upper
Leslie M. Stuck, M.D.
Limits as well as state-specific maximum allowable costs
Caroline Sojourner, R.Ph.
(MAC) on additional drugs. Override requires “Brand
Michele Burnett, R.Ph.
Medically Necessary” with handwritten certification by
the prescriber and prior authorization.
Prescription Price Updating
Incentive Fee: None. First DataBank,
1111 Bayhill Dr., Suite 350
Patient Cost Sharing: $3.00 copayment per prescription. San Bruno, CA 94066
T: 650/588-5454
Cognitive Services: Does not pay for cognitive services. F: 650/588-4003

Medicaid Drug Rebate Contacts


E. USE OF MANAGED CARE
Technical: Rod Davis, 803/898-2610
Approximately 56,000 Medicaid recipients were enrolled Policy: James Assey, 803/898-2876
in MCOs in FY 2002. Recipients receive pharmaceutical DUR & PA: Caroline Sojourner, 803/898-2876
benefits through managed care plans. Disputes: Laurel Kennerly, 803/898-2954
Claims Submission Contact
Managed Care Organizations
Rod Davis
Select Health of South Carolina, Inc.
Bureau Chief, Bureau of Information Systems
Patricia Marquis, Chief Operating Officer
S.C. Department of Health and Human Services
P.O. Box 40024
P.O. Box 8206
Charleston, SC 29403
Columbia, SC 29202-8206
843/569-1759
803/898-2610
E-mail: davisr@dhhs.state.sc.us
F. STATE CONTACTS Medicare Managed Care Contact
State Drug Program Administrator Bruce Harbaugh
Department of Primary Care & Alternative
James M. Assey, R.Ph., Division Director Reimbursement Programs
Division of Health Services S.C. Department of Health and Human Services
S.C. Department of Health & Human Services P.O. Box 8206
P.O. Box 8206 Columbia, SC 29202-8206
Columbia, SC 29202-8206 803/898-2818
T: 803/898-2876
F: 803/255-8353 Mail Order Drug Program
E-mail: asseyj@dhhs.state.sc.us None
Internet Address: www.dhhs.state.sc.us
Disease Management Program/Initiative Contact
Kathie Reed
Prior Authorization Contact Division of Client Education and Outreach Services
Caroline Y. Sojourner, R.Ph., Dept. Head S.C. Department of Health and Human Services
Department of Pharmacy Services P.O. Box 8206
S.C. Department of Health and Human Services Columbia, SC 29202-8206
P.O. Box 8206 803/898-2638
E-mail: reed@dhhs.state.sc.us

National Pharmaceutical Council South Carolina-3


Pharmaceutical Benefits 2002

Physician-Administered Drug Program Contact State Board of Pharmacy


Lee Ann F. Bundrick, Administrator
Susan Bowling, Division Director
South Carolina Board of Pharmacy
Division of Medical Services
P. O. Box 11927
S.C. Department of Health & Human Services
Columbia, SC 29211-1927
P.O. Box 8206
T: 803/898-4700
Columbia, SC 29202-8206
F: 803/896-4596
803/898-2803
E-mail: funderbm@mail.llr.state.sc.us
Internet Address: www.llr.state.sc.us/pol/pharmacy
South Carolina Department of Health and Human
Services Officials South Carolina Hospital Association
Robert C. Toomey, Director Kenneth A. Shull, President
S. C. Department of Health & Human Services 101 Medical Circle
1801 Main Street P.O. Box 6009
P.O. Box 8206 West Columbia, SC 29171-6009
Columbia, SC 29202-8206 T: 803/796-3080
T: 803/898-2504 F: 803/796-2938
F: 803/898-4515 E-mail: kshull@scha.org
E-mail: btoomey@gov.sc.gov Internet Address: www.scha.org

Darlynn Thomas, Chief


Bureau of Health Services & Delivery Systems
803/898-2870

Caroline Y. Sojourner, R.Ph., Department Head


Department of Pharmacy Services
803/898-2876
Executive Officers of State Medical and
Pharmaceutical Societies
South Carolina Medical Association
William F. Mahon
Chief Executive Officer
3210 Fernandina Rd.
P.O. Box 11188
Columbia, SC 29211
T: 803/798-6207
F: 803/772-6783
E-mail: bill@scmanet.org
Internet Address: www.scmanet.org

South Carolina Osteopathic Medical Society


Tom Underwood, Executive Director
655 St. Andrews Road, Suite 1
Columbia, SC 29210-5136
T: 877/886-3672
F: 502/223-4937
E-mail: info@scoms.org
Internet Address: www.scoms.org
South Carolina Pharmacy Association
James R. Bracewell
Executive Vice President
1350 Browning Road
Columbia, SC 29210
T: 803/354-9977
F: 803/354-9207
E-mail: jbracewell@scrx.org
Internet Address: www.scrx.org/scrx

4-South Carolina National Pharmaceutical Council


Pharmaceutical Benefits 2002

SOUTH DAKOTA

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     +
+ Renal Disease

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $44,650,518 53,666 $52,608,524 58,203

RECEIVING CASH ASSISTANCE, TOTAL $23,756,417 20,024 $27,648,344 20,993


Aged $2,983,433 1,883 $3,255,890 1,849
Blind/Disabled $18,641,451 8,644 $21,559,128 8,701
Child $961,330 6,010 $1,147,090 6,450
Adult $1,170,203 3,487 $1,686,236 3,993

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $3,278,820 18,823 $4,526,417 21,497


Aged $35,098 50 $39,540 49
Blind/Disabled $60,276 52 $66,140 61
Child $2,898,842 16,484 $4,065,705 19,072
Adult $284,604 2,237 $355,032 2,315

TOTAL OTHER EXPENDITURES/RECIPIENTS* $17,615,281 14,819 $20,433,763 15,713

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

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

National Pharmaceutical Council South Dakota-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Drug Utilization Review


Department of Social Services, Office of Medical PRODUR system implemented in 1996. State has a DUR
Services. Board with annual review.

D. PROVISIONS RELATING TO DRUGS Pharmacy Payment and Patient Cost Sharing

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.

Coverage of Injectables: Injectable medicines F. STATE CONTACTS


reimbursable through physician payment when used in State Drug Program Administrator
physicians offices, home health care, and extended care
facilities. Mark Petersen, R.Ph.
Pharmacy Consultant
Vaccines: Vaccines reimbursable with HCPC code as part Department of Social Services
of the Vaccines for Children Program. Office of Medical Services
700 Governors Drive
Unit Dose: Unit dose packaging reimbursable. Pierre, SD 57501
T: 605/773-3495
Formulary/Prior Authorization F: 605/773-5246
Formulary: Open formulary. E-mail: markp@state.sd.us
Prior Authorization Contact
Prior Authorization: State currently has a formal prior
authorization procedure. Request for fair hearing required Mark Petersen, R.Ph., 605/773-3495
for appealing coverage of an excluded product or a prior
authorization decision.

Prescribing or Dispensing Limitations


Prescription Dollar Limit: None.

Monthly Quantity Limit: None.

2-South Dakota National Pharmaceutical Council


Pharmaceutical Benefits 2002

DUR Contact Department of Social Services


700 Governors Drive
Michael Jockheck, R.Ph.
Pierre, SD 57501-2291
Pharmacy Consultant
T: 605/773-3495
SD Dept of Social Services
F: 605/773-5246
700 Governors Drive
E-mail: Medicaid@dss.state.sd.us
Pierre, SD 57501
605/773-6439 Medical Advisory Committee
E-mail: mike.jockheck@state.sd.us
Paul Engbrecht, Chairman
Steering Committee (Medicaid DUR Board) Tieszen Memorial Home
437 State Street
Damian Prunty (Program Administrator)
Marion, SD 57043
Tom Carlson, R.Ph.
605/648-3384
Richard Holm, M.D.
Pam Jones, R.Ph.
John Jones, Vice Chairman
Bruce Lushbough, M.D.
Division of Health, Medical & Laboratory Services
Prescription Price Updating Health Laboratory Building
615 E. 4th Street
Mark Petersen, R.Ph., 605/773-3495
c/o 500 E. Capitol Avenue
Medicaid Drug Rebate Contacts Pierre, SD 57501
605/773-3737
Helen Rokusek
Rebate Coordinator Jud Bergan, O.D.
Dept. of Social Services 103 South Eagan
700 Governors Drive Madison, SD 57042
Pierre, SD 57501
605/773-3653 Sheryl Petersen
218 W. Third Street
Claims Submission Contact Pierre, SD 57501
Meredith Heerman
Dept. of Social Services James D. M. Russell
700 Governors Drive Hospital Admin.
Pierre, SD 57501 St. Mary's Hospital
T: 605/773-3495 803 E. Dakota
F: (605) 773-5246 Pierre, SD 57501
E-mail: meredith_heerman@state.sd.us 605/224-3100
Disease Management Program/Initiative Contact Herb McClellan, Jr., D.D.S.
Mark Petersen, R.Ph., 605/773-3495 Box 189
Mobridge, SD 57601-0189
South Dakota Medicaid Agency Officials
James Ellenbecker Lynn Greff
Secretary Apothecary Shop at Medical Arts
Department of Social Services 719 St. Francis Street
700 Governors Drive Rapid City, SD 57701
Pierre, SD 57501-2291
T: 605/773-3165 Stephen Schroeder, M.D.
F: 605/773-4855 Hand Co. clinic
E-mail: info@dss.state.sd.us P.O. Box 287
Miller, SD 57362

Michelle Miller
McKennan Home Health
800 E. 21st Street
Sioux Falls, SD 57105-1016
A.A. Lampert, M.D.
Damian Prunty 13075 Bogus Jim Road
Program Administrator Rapid City, SD 57702-9720
Medical Services

National Pharmaceutical Council South Dakota-3


Pharmaceutical Benefits 2002

Evaluation Committee Suite 1


Sioux Falls, SD 57106
V. R. Brandenburg, M.D.
T: 605/361-2281
Dennis Hodge, Pharm.D.
F: 605/361-5175
Helen Fiechtner, Pharm.D.
E-mail: hewett@sdaho.org
Jane Mort, Pharm.D.
Internet Address: www.sdaho.org
James Clem, Pharm.D.
Marc Aldrich (Physician)
Executive Officers of State Medical and
Pharmaceutical Societies
South Dakota State Medical Association
L. Paul Jenson
Chief Executive Officer
1323 South Minnesota Avenue
Sioux Falls, SD 57105
T: 605/336-1965
F: 605/336-0270
Internet Address: www.sdsma.org

South Dakota Osteopathic Association


David A. Lauer, D.O.
Secretary-Treasurer
P.O. Box 247
Sturgis, SD 57785
T: 605/347-3616
F: 605/347-4713

South Dakota Pharmaceutical Association


Toby Lyon
Executive Director
P.O. Box 518
Pierre, SD 57501-0518
T: 605/224-2338
F: 605/224-1280
E-mail: director@sdpha.org
Internet Address: www.sdpha.org

State Board of Pharmacy


Dennis M. Jones
Executive Secretary
4305 S. Louise Ave., Suite 104
Sioux Falls, SD 57106
T: 605/362-2737
F: 605/361-2738
E-mail: dennis.jones@state.sd.us
Internet Address: www.state.sd.us/dcr/pharmacy

South Dakota Association of Healthcare Organizations


David R. Hewett
President + CEO
3708 Brooks Place

4-South Dakota National Pharmaceutical Council


Pharmaceutical Benefits 2002

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,

National Pharmaceutical Council Tennessee-1


Pharmaceutical Benefits 2002

children below 200 percent of the poverty level, and


people who are “medically eligible” a new term to Formulary: Varying formularies used by the individual
describe what the state previously referred to as MCOs. Most are closed formularies. MCO formularies
“uninsurables.” The difference is that “Medical must conform to TennCare guidelines. TennCare must
eligibility” will be determined by a State-appointed health approve formulary additions/deletions.
insurance underwriter. Under the previous TennCare
system, a denial letter from an insurance company defined Prior Authorization: Prior authorization procedures are
“uninsurability.” TennCare Assist will be created and administered by the individual MCOs.
detailed during the 2003 legislative session. The program
is targeted to be implemented in July 2003. Co-payment: Deductibles and co-payments apply to
services other than preventive services (e.g.,
The five-year waiver that TennCare began on July 1, 2002 immunizations) based on a sliding scale according to
also includes an annual “open enrollment” period, which income. Medicaid recipients and persons or families with
would allow people who are uninsured or medically income under 100% of the Federal poverty level are not
eligible above poverty to enroll in TennCare. The current required to pay premiums, deductibles, or co-payments in
fiscal year’s budget does not allow for an enrollment order to participate in the TennCare program.
period, at least through the end of the current fiscal year,
June 30, 2003. However, if an applicant is both below 100
C. USE OF MANAGED CARE
percent of the poverty level and medically eligible,
enrollment will be allowed at any time during the year. Medicaid recipients and the uninsured/uninsurable are
enrolled in MCOs through the TennCare program. All
Persons wanting to apply for TennCare must visit the receive pharmacy benefits through managed care.
local Tennessee Department of Health (DHS) office.
There is a local Health Department office in every Managed Care Organizations
Tennessee County. For the applicants' convenience, DHS Better Health Plans
will make a copy of the application, date stamp it, and 890 Willow Tree Circle
process the application. Cordova, TN 38018
Source: TennCare Home Page on the World Wide Web,
BlueCare
last updated 01/09/03. http://www.state.tn.us/tenncare/
801 Pine Street
Chattanooga, TN 37402-2555
A. ADMINISTRATION
John Deere Health Plan
Tennessee Department of Finance and Administration,
Executive Tower I, Suite 400
Bureau of TennCare
408 N. Cedar Bluff Road
Knoxville, TN 37923
B. PROVISIONS RELATING TO DRUGS
TLC Family Care Healthplan
Benefit Design
P.O. Box 49
Pharmacy services are provided by the managed care Memphis, TN 38101
organizations. Within Federal and State guidelines, each
individual managed care and pharmacy benefit OmniCare Health Plan, Inc.
management organization makes formulary/drug 1991 Corporate Ave., 5th Floor
decisions. Pharmacy services are to be covered as Memphis, TN 38132
medically necessary, excluding DESI, less than effective
and IRS drugs and some drugs for which TennCare does PHP TennCare
not mandate coverage (e.g., drugs for infertility, weight 1420 Centerpoint Blvd.
reduction, cosmetic purposes, hair growth products, Knoxville, TN 37932
products for symptomatic relief of cough and colds,
experimental drugs; smoking cessation products, and TennCare Select
most OTCs). Growth hormone products and oral 801 Pine Street
contraceptives require approval by the TennCare Prior Chattanooga, TN 37402-2555
Approval Unit. MCOs negotiate discounts with
manufacturers, however, they do not have access to Universal Care of Tennessee, Inc.
rebates extended under the federal Medicaid statute. Also, 1808 West End Avenue, Suite 610
behavioral health products may be carved out of managed Nashville, TN 37203
care with the state responsible for payment. Under such
circumstances, manufactures do pay a rebate on these
products.

2-Tennessee National Pharmaceutical Council


Pharmaceutical Benefits 2002

Xantus Health Plan of Tennessee, Inc. TennCare DUR Advisory Board


3401 West End Avenue, Suite 470
Butch Benson, D.Ph.
Nashville, TN 37203-1069
1310 Mulberry Court
Murfreesboro, TN 37130
VHP Community Care
215 Centerview Drive, Suite 300
Christi Capers, Pharm.D.
Brentwood, TN 37027
Clin. Edu. Consultant, Pfizer Inc.
MCO/Behavioral Health Organization 4043 Farmingham Woods Dr.
Hermitage, TN 37076-4405
Better Health Plans
Blue Care
Diane Crutchfield, D.Ph.
John Deere Health Plan
1223 Eaglenest Lane
OmniCare Health Plan
Knoxville, TN 37922
Preferred Health Partnership (PHP)
Premier Behavioral Systems
Roger L. Davis, Pharm.D.
Tennessee Behavioral Health, Inc.
326 Capitol Boulevard, Suite 810
TLC Family Health Care Health Plan
Nashville, TN 37219
Universal Care
VHP Community Care
Martha Drannon, Pharm.D.
Xantus Gold
Frayser Family Counseling Ctr. Pharmacy
2150 Whitney Avenue
D. STATE CONTACTS Memphis, TN 38127
State Drug Program Administrator
Don Hazlewood, D.Ph.
H. Leo Sullivan, D.Ph. HealthCare Pharmacy
Director of Pharmacy Services 3100 S. First Street
Bureau of TennCare Milan, TN 38358
729 Church Street
Nashville, TN 37247-6501 Connie J. Holladay, M.D.
T: 615/741-0213 6432 River Tide Dr.
F: 615/253-5481 Memphis, TN 38120
E-mail: leo.sullivan@state.tn.us
Internet address: www.state.tn.us/tenncare Mack A. Land, M.D.
TennCare Officials 5210 Poplar Avenue, Suite 200
Memphis, TN 38119
Manny Martins, Deputy Commissioner
Bureau of TennCare J. Sloan Manning, M.D.
Department of Finance and Administration Family Practice
729 Church Street 1112 Union Avenue
Nashville, TN 37247-6501 Memphis, TN 38104
T: 615/741-0213
F: 615/741-0882 David Shepard, Pharm.D., B.C.P.P.
E-mail: many.martins@state.tn.us Dickson Apothecary East
104 Highway 70 East
TennCare Information Line Dickson, TN 37055
800/669-1851
Prior Authorization Contact Daniel D. Sumrok, M.D.
Family Practice
H. Leo Sullivan, D.Ph., 615/741-0213 22700 Highway 22
DUR Contact McKenzie, TN 38201

Jeffrey G. Stockard, D.Ph.


Associate Pharmacy Director
Bureau of TennCare
729 Church Street
Nashville, TN 37247-6501
T: 615/532-3107
F: 615/253-5481
E-mail: jeff.stockard@state.tn.us

National Pharmaceutical Council Tennessee-3


Pharmaceutical Benefits 2002

TennCare Bureau TennCare Advisory Board


Jeff G. Stockard, D.Ph. Joseph M. Dawson, C.E.O. (chairman)
Associate Pharmacy Director Blount Memorial Hospital
Bureau of TennCare Maryville, TN
729 Church Street
Nashville, TN 37247-6501 Calvin Anderson
T: 615/532-3107 Vice President for Corporate Affairs
F: 615/253-5481 BCBS of Tennessee
E-mail: jeff.stockard@state.tn.us Memphis, TN

H. Leo Sullivan, D.Ph. Gary Brukardt


Director of Pharmacy Services Executive Vice President
Bureau of TennCare Renal Care Group
729 Church Street Nashville, TN
Nashville, TN 37247-6501
T: 615/741-0213 Tom Cecil
F: 615/253-5481 Retired Tennessee Administration
E-mail: leo.sullivan@state.tn.us Brentwood, TN
Prescription Price Updating
Nancy Hardt, M.D., Director
First DataBank Institute for Women’s Health and Methodist
1111 Bayhill Drive, Suite 350 Endowed Chair for Women’s Health
San Bruno, CA 94066 Memphis, TN
T: 650/588-5454
F: 650/588-6867 Senator Tommy Haun
Independent Insurance Agency
Medicaid Drug Rebate Contacts Greenville, TN
Audits: Sybil Creekmore, 615/741-0213
Disputes: H. Leo Sullivan, D.Ph., 615/741-0213 Ricks W Mason, Jr.
Public School Administrator (retired)
Claims Submission Contact Memphis City Schools
Becky Garrigan Memphis, TN
PBM Account Manager
ACS Natasha Metcalf, Commissioner
Northridge Center One, Suite 400 Tennessee Department of Human Services
365 Northridge Road Nashville, TN
Atlanta, GA 30350
T: 800/334-5979 Timothy S. Regan, R.Ph., C.Ph.
F: 800/793-2305 Senior Engagement Manager
E-mail: becky.garrigan@acs-inc.com Applied Health Outcomes
Tampa, FL
Pharmacy and Therapeutics Committee
– Director of the Bureau of TennCare Mary Rolando
– TennCare Medical Director Behavioral Health Consultant
– TennCare Pharmacy Director Nashville, TN
– TennCare Associate Medical Director
– Associated Medical Director of the Paul Rutledge, President
TennCare Grievance Unit HCA Mid-America Division and Tri-Star Health System
– Medical Director of the TennCare Grievance Brentwood, TN
Intervention Unit
– One Public Health Physician John S. Sergent, M.D.
– One Physician who is a TennCare Chief Medical Officer
participating provider Vanderbilt University Medical Group
– One Pharmacist who is a TennCare Nashville, TN
participating provider
Larry Stanifer, C.E.O
Rural Medical Services, Inc.
Each MCO is required to have its own Pharmacy and Newport, TN
Therapeutics Committee.

4-Tennessee National Pharmaceutical Council


Pharmaceutical Benefits 2002

Linda Wertz, Director Tennessee Osteopathic Medical Association


Texas Medicaid and Children’s Health Dee Ann Walker, CAE
Insurance Program (CHIP) Executive Director
Austin, TX 200 4TH Avenue North, Suite 900
Nashville, TN 37219
Medicaid Managed Care Contact
T: 615/301-3048
Lola Potter F: 615/254-7047
Public Information Officer E-mail: dawalker@walkermgt.com
Bureau of TennCare Internet address: www.tomanet.org
729 Church Street
Nashville, TN 37247-6501 Tennessee Pharmacists Association
T: 615/532-7542 Baeteena M. Black, Ph.D.
F: 615/741-0882 Executive Director
E-mail: lola.potter@state.tn.us 226 Capitol Boulevard, Suite 840
Nashville, TN 37219-1893
Mail Order Pharmacy Program T: 615/256-3023
Tennessee has a mail order pharmacy option in its F: 615/255-3528
Medical Assistance Program. All beneficiaries are E-mail: tpa@tnpharm.org
entitled to participate. Internet address: www.tnpharm.org
Disease Management Patient Education State Board of Pharmacy
Programs Kendall M. Lynch, Director
Program Name: TennCare Centers for Excellence Davy Crocket Tower
Disease/Medical States: Asthma, Cardiovascular Disease, 500 James Robertson Parkway, 2nd Floor
and Diabetes Nashville, TN 37243-1149
Program Manager: Applied Health Outcomes T: 615/741-2718
F: 615/741-2722
Disease Management Patient Education Contact E-mail: kendall.lynch@state.tn.us
Timothy Regan, R.Ph., C.Ph. Internet address: www.state.tn.us/commerce/pharmacy
Senior Engagement Manager
Applied Health Outcomes Tennessee Hospital Association
Two Urban Centre Craig A. Becker
4890 W. Kennedy Boulevard President
Suite 760 500 Interstate Boulevard South
Tampa, FL 33609 Nashville, TN 37210-4634
T: 800/320-6497 T: 615/256-8240
F: 813/207-8119 F: 615/242-4803
E-mail: tregan@applied-outcomes.com Internet address: www.tha.com
Executive Officers of State Medical and Hospital Alliance of Tennessee
Pharmaceutical Societies Adrienna Knestrick
Tennessee Medical Association President
Donald H. Alexander, CEO 211 Seventh Avenue North, Suite 400
P.O. Box 120909 Nashville, TN 37219
2301 21st Avenue South T: 615/254-1941
Nashville, TN 37212-0909 F: 615/254-1942
T: 615/385-2100 E-mail: adrienna@hospitalalliancetn.com
F: 615/385-3319 Internet address: www.hospitalalliance.com
E-mail: dona@tma.medwire.org
Internet address: www.medwire.org

National Pharmaceutical Council Tennessee-5


Pharmaceutical Benefits 2002

6-Tennessee National Pharmaceutical Council


Pharmaceutical Benefits 2002

TEXAS

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      

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $1,125,238,856 1,852,801 $1,327,222,456 1,917,351

RECEIVING CASH ASSISTANCE, TOTAL $652,580,603 716,096 $757,087,849 713,254


Aged $199,571,641 155,223 $225,287,571 155,312
Blind / Disabled $369,253,617 234,712 $439,674,579 240,642
Child $45,145,922 226,431 $50,653,592 221,789
Adult $38,609,423 99,730 $41,472,107 95,511

MEDICALLY NEEDY, TOTAL $10,650,662 26,077 $13,645,641 30,183


Aged $0 0 $0 0
Blind / Disabled $0 0 $0 0
Child $41,947 250 $56,065 264
Adult $10,608,715 25,827 $13,589,576 29,919

POVERTY RELATED, TOTAL $141,274,060 770,423 $171,959,460 810,157


Aged $690,336 983 $812,066 930
Blind / Disabled $1,059,763 836 $821,022 815
Child $122,180,204 630,742 $149,515,656 665,651
Adult $17,343,757 137,862 $20,810,716 142,761

TOTAL OTHER EXPENDITURES/RECIPIENTS* $320,733,531 340,205 $384,529,506 363,757

*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.

National Pharmaceutical Council Texas-1


Pharmaceutical Benefits 2002

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.

2-Texas National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

Health and Human Services Commission


Officials
Albert Hawkins
Commissioner

National Pharmaceutical Council Texas-3


Pharmaceutical Benefits 2002

Robert L. Hogue, M.D. Manager, Pharmacy Resolutions


101 A South Park Drive Vendor Drug Program
Brownwood, TX 75801 Texas Health and Human Services Commission
1100 West 49th Street
Daniel Saylak, D.O., Chairman Austin, TX 78756-3174
4607 Locksford T: 512/338-6909
Bryan, TX 77802 F: 512/338-6910
E-mail: laura.bagheri@hhsc.state.tx
Mary Spies Maxwell, M.D.
Medicaid Managed Care Contact
4526 Burnet Road
Austin, TX 78731 Laura Jordan
512/794-6884
Adelina Barbosa, R.Ph.
#10 Casa De Palmas Mail Order Pharmacy Program
Brownsville, TX 78521 State has a mail order pharmacy program. Participating
pharmacies contract with the State.
Anita Martinez, R.Ph.
2819 Burning Hill Physician-Administered Drug Program Contact
San Antonio, TX 78247 Billy Milwee
Administrative Contracts Manager
James B. Hills, R.Ph. Texas Health and Human Services Commission
Lava Rock Apothecary 1100 W. 49th Street
1907 E. Southmore Street Austin, TX 78756
Pasadena, TX 77502
Executive Officers of State Medical and
Robert T. Reilly, Pharm.D. Pharmaceutical Societies
Thomason Hospital Texas Medical Association
Department of Pharmacy Frederick L. Merian, M.D.
4815 Alameda Avenue, P. O. Box 2009 President
El Paso, TX 79998 401 W. 15th Street
Prescription Price Updating Austin, TX 78701-1680
T: 512/370-1300
Martha McNeill, R.Ph. F: 512/370-1632
Director, Product and Prescriber Management E-mail: lou.goodman@texmed.org
Texas Health and Human Services Commission Internet address: www.texmed.org
1100 W. 49th Street
Austin, TX 78756-3174 Texas Pharmaceutical Association
T: 512/338-6965 Jim Martin, R.Ph.
F: 512/338-6462 Executive Director
E-mail: martha.mcneill@hhsc.state.tx.us P. O. Box 14709
Medicaid Drug Rebates Contact 1624 E. Anderson Lane
Austin, TX 78761-4709
Heather Murphy T: 512/836-8350
Manager, Pharmacy Rebates F: 512/836-8308
Vendor Drug Program Contracts and Rebates E-mail: jmartin@txpharmacy.com
Texas Health and Human Services Commission Internet address: www.txpharmacy.com
1100 W. 49th Street
Austin, TX 78756-3174
T: 512/338-6963
F: 512/338-6910
E-mail: heather.murphy@tdh.state.tx.us

Claims Submission Contact


Laura Bagheri

4-Texas National Pharmaceutical Council


Pharmaceutical Benefits 2002

Texas Osteopathic Medical Association


Terry Boucher, M.P.H.
Executive Director, Secretary/Treasurer
1415 Lavaca Street
Austin, TX 78701-1634
T: 512/708-8662
F: 512/708-1415
E-mail: terryb@txosteo.org
Internet address: www.txosteo.org

State Board of Pharmacy


Gay Dodson, R.Ph.
Executive Director/Secretary
William P. Hobby Building, Box 21
333 Guadalupe St., Suite 3-600
Austin, TX 78701-3942
T: 512/305-8000
F: 512/305-8082
E-mail: geninfo@tsbp.state.tx.us
Internet address: www.tsbp.tx.us

Texas Hospital Association


Richard Bettis, CAE
President & CEO
P.O. Box 15587
Austin, TX 78761-5587
T: 512/465-1000
F: 512/465-1090
E-mail: rbettis@tha.org
Internet address: www.thaonline.org

National Pharmaceutical Council Texas-5


Pharmaceutical Benefits 2002

6-Texas National Pharmaceutical Council


Pharmaceutical Benefits 2002

UTAH

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $100,794,076 133,164 $117,101,302 136,682

RECEIVING CASH ASSISTANCE TOTAL $42,558,127 33,499 $48,529,173 33,260


Aged $4,495,377 2,801 $5,275,146 2,848
Blind/Disabled $32,336,442 12,256 $37,273,244 12,442
Child $1,873,612 11,525 $1,949,135 11,105
Adult $3,852,696 6,917 $4,031,648 6,865

MEDICALLY NEEDY, TOTAL $5,349,920 3,160 $5,661,159 2,569


Aged $1,005,863 533 $1,083,310 528
Blind/Disabled $3,622,485 1,072 $3,965,954 965
Child $113,112 688 $82,975 441
Adult $608,462 867 $528,920 635

POVERTY RELATED, TOTAL $48,407,497 66,809 $57,527,963 77,811


Aged $13,858,966 6,383 $15,915,526 6,468
Blind/Disabled $21,777,416 7,332 $25,732,028 7,940
Child $4,548,843 30,697 $5,852,559 39,384
Adult $8,222,272 22,397 $10,027,850 24,019

TOTAL OTHER EXPENDITURES/RECIPIENTS* $4,478,532 29,696 $5,383,007 23,042

*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.

National Pharmaceutical Council Utah-1


Pharmaceutical Benefits 2002

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.

2-Utah National Pharmaceutical Council


Pharmaceutical Benefits 2002

P.O. Box 143102


Patient Cost Sharing: Copayment = $3.00-$5.00 per Salt Lake City, UT 84114-3102
month. $3.00 (traditional program); $4.00 (nontraditional T: 801/538-6452
program); $5.00 (Primary care network). F: 801/538-6099
E-mail: dpark@utah.gov
Cognitive Services: Does not pay for cognitive services.
DUR Board
E. USE OF MANAGED CARE Lowry Bushnell, M.D.
Western Institute of Neuropsychiatry
Approximately 14,000 Medicaid recipients are enrolled in 501 Chipeta Way
managed care. Pharmacy benefits are through the state. Salt Lake City, UT 84108
Managed Care Organizations
Carter Burke
Altius Hoechst-Roussel Pharmaceuticals
10421 S. Jordan Gateway 790 East 3800 North
South Jordan, UT 84095 Provo, UT 84604
American Family Care Bradford D. Hare, M.D., Ph.D.
2120 South 13th East #303 Department of Anesthesiology
Salt Lake City, UT 84106 50 North Medical Drive
Salt Lake City, UT 84132
IHC Access
P.O. Box 116670 Jeff Jones, R.Ph.
Salt Lake City, UT 84147 Riverton Drug
1741 West 12600 South
Med Utah Healthwise Riverton, UT 84065
P.O. Box 30804
Salt Lake City, UT 84130-0804 Richard Martinez, D.D.S.
2936 Highland Drive
PHS Salt Lake City, UT 84106
35 West Broadway
Salt Lake City, UT 84101 Karen M. Gunning, Pharm.D.
Univ. of Utah College of Pharmacy
United Medchoice 30 South 2000 East, Room 265
7910 South 3500 East Salt Lake City, UT 84112-5820
Salt Lake City, UT 84121 Colin B. Van Orman, M.D.
PCMC, Suite 2700
Univ. of Utah Health Network 100 North Medical Drive
35 W. Broadway Salt Lake City, UT 84113
Salt Lake City, VT 84101 Derek Christensen, R.Ph.
9842 Grouse Bend Circle
F. STATE CONTACTS South Jordan, UT 84095
State Drug Program Administrator
Joseph Miner, M.D.
RaeDell Ashley, R.Ph. Utah County Health Department
Pharmacy Director 589 South State Street
Division of Health Care Financing Provo, UT 84601
Department of Health
P.O. Box 143102 Dominic DeRose, R.Ph.
Salt Lake City, UT 84114-3102 Value Drug
T: 801/538-6495 1080 West 300 North
F: 801/538-6099 Clearfield, UT 84015
E-mail: rashley@doh.state.ut.us
DUR Contact Laurie Ott, PA-C
2107 West 3500 South
Duane Parke West Valley City, UT 84119
DUR Director
Division of Health Care Financing Richard E. Swinyard, R.Ph.
Department of Health

National Pharmaceutical Council Utah-3


Pharmaceutical Benefits 2002

Prescription Price Updating Michael Deily, Director


Medicaid Bureau
RaeDell Ashley, R.Ph.
Division of HealthCare Financing
801/538-6495
Department of Health
Medicaid Drug Rebate Contacts P.O. Box 143101
Salt Lake City, UT 84114-1000
Technical: RaeDell Ashley, R.Ph., 801/538-6495
T: 801/538-6406
Policy: RaeDell Ashley, R.Ph., 801/538-6495
F: 801/538-6099
PA: RaeDell Ashley, R.Ph. 801/538-6495
E-mail: mdeily@utah.gov
DUR: Duane Parke, 801/538-6452
Executive Officers of State Medical and
Claims Submission Contact Pharmaceutical Societies
Brenda Bryant, Manager
Utah State Medical Association
Bureau of Medicaid
J. Leon Sorenson
Division of Health Care Financing
Executive Vice President
Department of Health
540 East 500 South
P.O. Box 143102 Salt Lake City, UT 84102
Salt Lake City, UT 84114-3102 T: 801/355-7477
T: 801/538-6136
F: 801/532-1550
F: 801/538-6099
E-mail: vma@utahmed.org
E-mail: bbryant@utah.gov
Internet address: www.utahmed.org
Medicaid Managed Care Contact Utah Osteopathic Medical Association
Julie Olsen Shelly Hanks
Managed Care Coordinator Secretary
Division of Health Care Financing 462 South 1240 East
Department of Health Payson, UT 84651-8533
P.O. Box 143102 T: 801/465-9545
Salt Lake City, UT 84114-3102 F :801/794-1495
T: 801/538-6303
F: 801/538-6009 Utah Pharmaceutical Association
E-mail: jolsen@utah.gov Reid L. Barker
Executive Director
Mail Order Pharmacy Program 1850 South Columbia Lane
Orem, UT 84097
State has a mail order pharmacy program. Utah Medicaid T: 801/762-0452
beneficiaries may choose to obtain prescription drugs F: 801/762-0454
through mail order. E-mail: upha@upha.com
Internet address : www.upha.com
Physician-Administered Drug Program Contact
RaeDell Ashley, R.Ph., 801/538-6495 Utah Board of Pharmacy
Diana L. Baker
Department of Health Officials Bureau Director
Rod Betit, M.D. 160 East 300 South
Executive Director P.O. Box 146741
Department of Health Salt Lake City, UT 84116-6741
P.O. Box 141000 T: 801/530-6179
Salt Lake City, UT 84114-1000 F: 801/530-6511
T: 801/538-6111 E-mail: dbaker@utah.gov
F: 801/538-6306 Internet address:
E-mail: rodbetit@utah.gov www.commerce.state.ut.us/dopl/dopll.htm

4-Utah National Pharmaceutical Council


Pharmaceutical Benefits 2002

Utah Hospitals and Health Systems Association


Rick Kinnersley, CAE
President
2180 South 1300 East, Suite 440
Salt Lake City, UT 84016
T: 801/486-9915
F: 801/486-0882
E-mail: rick@uha-utah.org
Internet address: www.uha-utah.org

National Pharmaceutical Council Utah-5


Pharmaceutical Benefits 2002

6-Utah National Pharmaceutical Council


Pharmaceutical Benefits 2002

VERMONT
1

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         

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $91,724,918 103,228 $105,673,417 109,328

RECEIVING CASH ASSISTANCE TOTAL $35,695,094 26,454 $39,685,114 25,169


Aged $3,823,777 1,869 $3,799,046 1,741
Blind/Disabled $26,616,167 10,429 $30,223,439 10,679
Child $1,822,882 9,253 $2,061,532 8,225
Adult $3,432,268 4,903 $3,601,097 4,524

MEDICALLY NEEDY, TOTAL $16,212,159 9,485 $17,804,948 9,407


Aged $6,025,101 2,903 $6,488,482 2,836
Blind/Disabled $8,274,497 2,688 $9,113,456 2,639
Child $502,599 1,824 $537,853 1,641
Adult $1,409,962 2,070 $1,665,157 2,291

POVERTY RELATED, TOTAL $4,128,353 25,450 $4,956,436 26,895


Aged $0 0 $0 0
Blind/Disabled $0 0 $0 0
Child $3,930,066 24,001 $4,726,155 25,385
Adult $198,287 1,449 $230,281 1,510

TOTAL OTHER EXPENDITURES/RECIPIENTS* $35,689,312 41,839 $43,226,919 47,857

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

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

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

National Pharmaceutical Council Vermont-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Monthly Quantity Limit: Initial prescription should be


sufficient to allow for the determination of the patient’s
Agency of Human Services. tolerance of the medication without creating unnecessary
waste (expense) to the program. This quantity could be
D. PROVISIONS RELATING TO DRUGS up to a 60-day supply on all maintenance medication
Benefit Design prescriptions.

Drug Benefit Product Coverage: Products covered: Drug Utilization Review


prescribed insulin; disposable needles and syringe PRODUR system implemented in November 1993. State
combinations used for insulin; blood glucose test strips; currently has a DUR board with a bimonthly review.
urine ketone test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Products not covered: Pharmacy Payment and Patient Cost Sharing
cosmetics and experimental drugs. Dispensing Fee: $4.25, effective 7/1/96.
Over-the-Counter Product Coverage: Products covered Ingredient Reimbursement Basis: EAC = AWP–11.9%.
with prior authorization: allergy, asthma and sinus
products; analgesics; cough and cold preparations; Prescription Charge Formula: Pharmacies bill their usual
digestive products; feminine products; topical products; and customary charge. Medicaid pays the lower of:
and smoking deterrent products.
1. Usual and customary charge;
Therapeutic Category Coverage: Therapeutic categories 2. EAC plus a dispensing fee; or
covered: anabolic steroids; analgesics, antipyretics, 3. Maximum allowable cost plus a dispensing fee.
NSAIDs; anorectics; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents; Maximum Allowable Cost: State imposes Federal Upper
antihistamine drugs; antilipemic agents; anti-psychotics; Limits and State-specific limits on generic drugs.
anxiolytics, sedatives, and hypnotics; cardiac drugs; Override requires “Dispense as Written.”
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents; estrogens; Incentive Fee: None.
hypotensive agents; misc. GI drugs; sympathominetics
(adrenergic); and thyroid agents. Prior authorization Patient Cost Sharing: Copayment of $1.00 per
required for: prescribed smoking deterrents. dispensation required (excluding standard Federal
exemptions). Copayment of $2.00 when ingredient cost
Coverage of Injectables: Injectable medicines exceeds $29.99.
reimbursable when used in physician offices, home health
care, and extended care facilities. Cognitive Services: Does not pay for cognitive services.

Vaccines: Reimbursable at AWP minus 10% as part of E. USE OF MANAGED CARE


EPSDT service.
Approximately 78,000 total Medicaid recipients are
enrolled in MCOs in 2001. None received pharmacy
Unit Dose: Unit dose packaging reimbursable.
services through managed care.
Formulary/Prior Authorization
Formulary: Open formulary. General exclusions include
F. STATE CONTACTS
cosmetics and experimental drugs. State Drug Program Administrator

Prior Authorization: Prior authorization procedure Pat House


screening for drug classes. PA is required for non- Operations Manager
pregnancy multi-vitamins, smoking deterrents, Office of Vermont Health Access
amphetamines, food supplements, and OTC drugs. 103 South Main Street
Waterbury, VT 05671-1201
Prescribing or Dispensing Limitations T: 802/241-2765
F: 802/241-2974
Prescription Refill Limit: Up to 5 may be authorized by a E-mail: pathouse@wpgate1.ahs.state.vt.us
physician.

2-Vermont National Pharmaceutical Council


Pharmaceutical Benefits 2002

Agency of Human Services Officials Medicaid Drug Rebate Contacts


Charles Smith Technical: Christine Dapkiewicz, 802/979-4450
Secretary Policy: Vacant
Agency of Human Services Disputes: Shona M. Lothrop, 802/879-4450
103 South Main Street
Claims Submission Contact
Waterbury, VT 05671-0201
T: 802/241-2220 ACS
F: 802/241-2979 Fiscal Agent
E-mail: charles@wpgatei@aah.state.vt.us 312 Hurricane Lane, Suite 101
Williston, VT 05495
Paul Wallace-Brodeur T: 802/879-4450
Medicaid Director F: 802/878-3440
Dept. of Prevention, Assistance, Transition, and Health
Access Medicaid Managed Care Contact
103 South Main Street Pat House
Waterbury, VT 05676 802/241-2765
T: 802/241-3985
F: 802/241-2897 Disease Management Initiative/Program Contact
E-mail: paulw@path.state.vt.us Shona Mossey-Lothrop
Prior Authorization Contact Pharmacy Consultant
ACS
Pat House 312 Hurricane Lane, Suite 101
802/241-2765 Williston, VT 05495
T: 802/879-4450
DUR Contact
F: 802/878-3440
Gloria Jacobs E-mail: mossesm@vtxix.slg.acs.com
Operations Administrator
Office of VT Health Access Expanded Drug Coverage Program Contact
103 S. Main St. Pat House
Waterbury, VT 05671 802/241-2765
T: 802/241-2763
F: 802/241-2974 Physician-Administered Drug Program Contact
E-mail: gloriaj@wpgate1.ahs.state.vt.us Joseph Jacobs, M.D.
DUR Board Medical Director
Office of Vermont Health Access
James A. Gray, M.D. (Chair) Department of Social Welfare
Jeffrey P. Firlik, R.Ph. 103 South Main Street
Cheryl A. Gibson, M.D. Waterbury, VT 05650-1201
Richard J. Harvie, R.Ph. 802/241-2745
Virginia L. Hood, M.D.
Donna M. Kiley, M.D. Executive Officers of State Medical and
Frank J. Landry, M.D. Pharmaceutical Societies
John R. Low, R.Ph. Vermont Medical Society
Andrew C. Miller, R.Ph. Paul Harrington
Michael Scovner, M.D. Executive Vice President
Lloyd (Tim) L. Thompson, M.D. 134 Main Street
Norman S. Ward, M.D. P.O. Box 1457
Prescription Price Updating Montpelier, VT 05601
T: 802/223-7898
Christine Dapkiewicz F: 802/223-1201
Drug Rebate Coordinator E-mail: info@vtmd.org
ACS Internet address: www.vtmd.org
312 Hurricane Lane, Suite 101
Williston, VT 05495
T: 802/879-4450
F: 802/878-3440

National Pharmaceutical Council Vermont-3


Pharmaceutical Benefits 2002

Vermont Pharmacists Association


Fred Dobson
Executive Director
P. O. Box 245
Richmond, VT 05477
T: 877/483-2646
F: 802/433-4803
Internet address: www.vtpharmacists.org

Vermont State Association of Osteopathic Physicians &


Surgeons, Inc.
John M. Peterson, D.O.
Executive Director
72 Barre Street
Montpelier, VT 05602-3508
T: 802/229-9418
F: 802/229-5619

State Board of Pharmacy


Carla Preston
Board Administrator
26 Terrace Street, Drawer 09
109 State Street, Pavilion Office Building
Montpelier, VT 05609-1101
T: 802/828-2875
F: 802/828-2465
E-mail: cpreston@sec.state.vt.us
Internet address: vtprofessionals.org/oprl/pharmacists

Vermont Association of Hospitals and Healthcare Systems


Marie Beatrice Grause
President & CEO
148 Main Street
Montpelier, VT 05602
T: 802/223-3461
F: 802/223-0364
E-mail: bea@vahhs.org
Internet address: www.vahhs.org

4-Vermont National Pharmaceutical Council


Pharmaceutical Benefits 2002

VIRGINIA

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 All eligible recipients under age 21

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $382,471,744 347,251 $419,133,293 333,880


RECEIVING CASH ASSISTANCE TOTAL $237,026,074 128,007 $252,905,212 102,360
Aged $66,594,390 34,976 $73,894,551 34,599
Blind/Disabled $162,401,999 67,158 $178,608,437 66,480
Child $2,924,705 16,169 $140,364 733
Adult $5,104,980 9,704 $261,860 548
MEDICALLY NEEDY, TOTAL $18,622,035 7,589 $14,259,566 6,474
Aged $6,786,997 4,026 $5,995,613 3,354
Blind/Disabled $9,403,763 3,336 $8,230,689 2,951
Child $2,420,707 164 $27,529 136
Adult $10,568 63 $5,735 33

POVERTY RELATED, TOTAL $27,169,199 127,720 $35,351,169 140,124


Aged $975,696 996 $2,442,573 2,295
Blind/Disabled $1,881,791 1,325 $3,725,012 2,539
Child $21,702,283 105,739 $26,581,071 116,636
Adult $2,609,429 19,660 $2,602,513 18,654

TOTAL OTHER EXPENDITURES/RECIPIENTS $99,654,436* 83,935 $116,617,346 84,922

*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.

National Pharmaceutical Council Virginia-1


Pharmaceutical Benefits 2002

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

Prior Authorization: Prior authorization procedure F. STATE CONTACTS


screening for individual drugs for weight loss.
State Drug Program Administrator
Prescribing or Dispensing Limitations
MaryAnn McNeil, R.Ph.
Prescription Refill Limit: Physicians may authorize refills Pharmacy Manager
according to legal requirements. Department of Medical Assistance Services
600 East Broad Street, Ste. 1300
Monthly Quantity Limit: 34-day supply. Richmond, VA 23219
T: 804/783-2196
Drug Utilization Review
F: 804/786-0973
PRODUR (online) system implemented in July 1994. E-mail: mmcneil@dmas.state.va.us
RetroDUR Program also implemented in 1994. State
DUR Contact
currently has a DUR Board with quarterly meetings.
MaryAnn McNeil, R.Ph.
Pharmacy Payment and Patient Cost Sharing
804/783-2196
Dispensing Fee: $4.25, effective 7/1/95.

Ingredient Reimbursement Basis: EAC = AWP – 10.25%.

2-Virginia National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council Virginia-3


Pharmaceutical Benefits 2002

Virginia Osteopathic Medical Association


Maria Harris
Executive Director
48 East Square Lane
Richmond, VA 23233
T: 804/784-2204
F: 804/784-2231
E-mail: voma@erols.com
Internet Address: www.voma-net.org

Virginia Hospital and Healthcare Association


Laurens Sartoris
President
4200 Innslake Drive
Glen Allen, VA 23060
P.O. Box 1394
Richmond, VA 23294
T: 804/965-1216
F: 804/965-0475
E-mail: lsartoris@vhha.com
Internet Address: www.vhha.com

4-Virginia National Pharmaceutical Council


Pharmaceutical Benefits 2002

WASHINGTON

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $387,877,281 339,440 $458,332,414

RECEIVING CASH ASSISTANCE, TOTAL $218,126,163 136,333


Aged $34,961,221 21,931
Blind / Disabled $177,790,887 77,218
Child $1,338,427 17,639
Adult $4,035,628 19,545

MEDICALLY NEEDY, TOTAL $35,842,053 12,078


Aged $9,317,197 5,042
Blind / Disabled $26,518,846 7,001
Child $1,055 11
Adult $4,955 24

POVERTY RELATED, TOTAL $10,935,934 61,912


Aged $1,335,389 1,374
Blind / Disabled $4,043,531 2,066
Child $2,511,063 29,835
Adult $3,045,951 28,637

TOTAL OTHER EXPENDITURES/RECIPIENTS* $122,973,131 129,117

*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.

National Pharmaceutical Council Washington-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION hearing and exception to policy to appeal an excluded


product or prior authorization decision.
Medical Assistance Administration, Department of Social
and Health Services. Prescribing or Dispensing Limitations
Prescription Refill Limit: Two (2) refills in 30-day period
D. PROVISIONS RELATING TO DRUGS except for antibiotics, anti-asthmatics, Schedule II and III
drugs, anti-neoplastic, topicals, and any propoxyphene,
Benefit Design which may have 4 refills.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Prescription Limit: Review of client drug profile
combinations for insulin; blood glucose test strips; urine by a clinical pharmacist when request for 5th brand name
ketone test strips; total parenteral nutrition; and prescription in any one-month period.
interdialytic parenteral nutrition. Products not covered:
cosmetics; fertility drugs; DESI drugs; and experimental Monthly Quantity Limit: Maximum 34-day supply.
drugs. Drug Utilization Review
Over-the-Counter Product Coverage: Products covered: PRODUR system implemented in March 1996. State
digestive products (non-H2 antagonists) and currently has a DUR Board with a bi-monthly review.
contraceptives. Products covered with restrictions: allergy, Pharmacy Payment and Patient Cost Sharing
asthma and sinus products (selected items); analgesics
(ASA and Acetaminophen); cough and cold preparations Dispensing Fee: $4.20 to $5.20, effective 7/1/02.
(selected items); feminine products (selected items); and − $4.20 - Retail pharmacies, filling over 35,000 Rxs
topical products. Products not covered: digestive products annually.
(H2 antagonists) and smoking deterrent products. − $4.51 - Retail pharmacies, filling 15,001-35,000 Rxs
annually.
Therapeutic Category Coverage: Therapeutic categories − $5.20 - Retail pharmacies, filling 15,000 or less Rxs
covered: antibiotics; anticoagulants; anticonvulsants; annually.
antidiabetic agents; anti-depressants; antilipemic agents; − $5.20 - Unit dose systems (nursing home Rxs).
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; ENT anti-inflammatory Ingredient Reimbursement Basis: EAC = AWP – 14%,
agents; estrogens; hypotensive agents; sympathominetics except drugs on the MAC list with 5 or more
(adrenergic); and thyroid agents. Therapeutic categories labelers/manufacturers are reimbursed at AWP-50%.
requiring prior authorization: antihistamine drugs; anti-
psychotics; anxiolytics, sedatives, and hypnotics; growth Prescription Charge Formula: The amount shall not
hormones; and misc. GI drugs. Therapeutic categories exceed the usual and customary charge to the public or
partially covered requiring prior authorization: anabolic EAC plus a dispensing fee. Any drug with more than 3
steroids; analgesics, antipyretics, NSAIDs; and anoretics. labelers will be reimbursed according to the Maximum
Therapeutic categories not covered: prescribed smoking Allowable Cost.
deterrents and weight loss drugs. (A complete list of drugs
requiring expedited prior authorization may be found on Maximum Allowable Cost: State imposes State-specific
the Medical Assistance Administration’s web site. limits on generic drugs. Override requires “Brand
wwws2.wa.gov/dshs/maa.) Medically Necessary.”

Coverage of Injectables: Injectable medicines Incentive Fee: None.


reimbursable through the Prescription Drug Program when
used in home health care and extended care facilities, and Patient Cost Sharing: No copayment.
through physician payment when used in physician offices.
Cognitive Services: State pays for cognitive services
Vaccines: Vaccines reimbursable at EAC as part of EPSDT under the Emergency Contraceptive Program.
services.

Unit Dose: Unit dose packaging is reimbursable.


Formulary/Prior Authorization
Formulary: Open formulary

Prior Authorization: State currently has a prior


authorization program and a Drug Utilization and
Education Review Council. Recipients can request a fair

2-Washington National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE DUR Contact


Approximately 450,000 Medicaid recipients were enrolled Nicole N. Nguyen, Pharm.D.
in MCOs in FY 2001. Recipients receive pharmaceutical Clinical Pharmacist
benefits through both the State and managed care plans. Medical Assistance Administration, DSHS
Managed Care Organizations 805 Plum Street, SE
P.O. Box 45506
Asuris Northwest Health Plan Olympia, WA 98504-5506
P.O. Box 91130 T: 360/725-1757
Mail Stop BR 325 F: 360/586-2262
Seattle, WA 98111 E-mail: nguyen @dshs.wa.gov
253/573-3248
Department of Social and Health Services Drug
Columbia United Providers Utilization and Education Council
19120 SE. 34th Street, Ste. 201 Council Members
Vancouver, WA 98683 Carol Cordy, M.D.
360/449-8867 Gerald Yorioka, M.D.
Alvin Goo, Pharm.D.
Community Health Plan of Washington Steve Williams, Pharm.D.
720 Olive Way, Ste. 300 Patti Varley, ARNP, MN, CS
Seattle, WA 98101 Kenneth Wiscomb, PA-C
206/613-8940 Dana Hadfield, R.Ph.
Group Health Cooperative Medical Advisor
521 Wall Street Melicent Whinston, M.D.
Seattle, WA 98121
Resource Staff
206/448-6110
Nancy Donigan (Client Advocate)
Premera Blue Cross WSU Staff
P.O. Box 12890 Daniel Baker, Pharm.D., FASCP, FASHP
Seattle, WA 98111-4890 Drug Information Center
800/869-7175
Prescription Price Updating
Molina Healthcare of Washington, Inc. (MHC)
P.O. Box 1469 Tom Zuchlewski
Bothell, WA 98041 Pharmacy Program Manager
800/869-7175 Medical Assistance Administrator, DSHS
P.O. Box 45510
Regence Blue Shield Olympia, WA 98504-5510
P.O. Box 21267 T: 360/725-1837
Mail Stop BR 390 F: 360/753-9152
Seattle, WA 98111-3267 E-mail: zuchltm@dshs.wa.gov
253/573-3248
Medicaid Drug Rebate Contacts
F. STATE CONTACTS Manager: Connie Riddle, 360/725-1243
Technical: Rich Boyesen, 360/586-2593
State Drug Program Administrator Policy: Connie Riddle, 360/725-1243
Siri Childs, Pharm D. Audits/Disputes: Connie Riddle, 360/725-1243
Pharmacy Research Specialist/Manager PA: Valerie Vertz, 360/725-1717
Medical Assistance Administration, DSHS Claims Submission Contact
805 Plum Street, SE
P.O. Box 45506 Chris Johnson
Olympia, WA 98504-5506 Claims Processing Manager
T: 360/725-1564 Medical Assistance Administrator, DSHS
F: 360/586-2262 P.O. Box 45506
E-mail: childsa@dshs.wa.gov Olympia, WA 98504-5506
Agency address: http://wws2.wa.gov/dshs/maa T: 360/725-1067
Prior Authorization Contact F: 360/586-4994
E-mail: johnsc2@dshs.wa.gov
Siri Childs, Pharm.D., 360/725-1564

National Pharmaceutical Council Washington-3


Pharmaceutical Benefits 2002

Medicaid Managed Care Contact P.O. Box 5506


Olympia, WA 98504-5506
MaryAnne Lineblad
Director Social and Health Services Department Medical
Division of Program Support, MAA/DSHS Consultants
P.O. Box 45530
Joan Baumgartner, MD
Lacey, WA 98504-5530
Sam Salama, M.D.
T: 360/725-1786
Nancy Anderson, M.D.
F: 360/753-7315
Carolyn Coyne, M.D.
E-mail: lindem@dshs.wa.gov
Eric Houghton, M.D.
Mail Order Pharmacy Program
Department of Social and Health Services
To be implemented for fee-for-service clients in 2003-04. Title XIX Advisory Committee
Disease Management/Patient Education Programs Janet Varon, Co-chair
Executive Director, NoHLA
Disease/Medical State: Asthma
1820 East Pine Street, Ste. 322
Program Manager: McKesson
Seattle, WA 98122
Disease/Medical State: Congestive Heart Failure
Robert Wardell, Co-chair
Program Manager: McKesson
3815 N. Pearl Apt. K-1
Tacoma, WA 98407
Disease/Medical State: Diabetes
Program Manager: McKesson
Elise Chayet
WSHA
Disease/Medical State: Renal Disease
Harborview Medical Center
Program Manager: Renaissance
325 Ninth Avenue
Disease Management Program/Initiative Contact Seattle, WA 98104-2499
Alice Lind Ted Rudd, M.D.
Managed Care Coordination Section WSMA
Medical Assistance Administration, DSHS
209 S. 12th Avenue, #A
P.O. Box 45530
Yakima, WA 98902
Olympia, WA 98504-45530
T: 360/725-1629
Janene Jones-Heino
F: 360/753-7315 WSPA
E-mail: lindar@dshs.wa.gov 12856 NE Central Valley Road
Poulsbo, WA 98370
Social and Health Services Department Officials 360/377-3753
Dennis Braddock
Secretary Doug Porter
Department of Social and Health Services Assistant Secretary
PO Box 45010 Medical Assistance Administration
Olympia, WA 98504 P.O. box 45080
T: 360/902-7800 Olympia, WA 98504-5080
F: 360/902-7848
E-mail: braddd@dshs.wa.gov Allena Barnes
7827 South 113th Street
Doug Porter Seattle, WA 98178
Assistant Secretary
Medical Assistance Administration Kathy Carson
P.O. Box 45080 Sea-King Co. Dept. of Health
Olympia, WA 98504-5500 999 Third Avenue, Ste. 900
T: 360/902-7807 Seattle, WA 98104-4039
F: 360/902-7855
E-mail: portejd@dshs.wa.gov Shawna Connolly
Premera Blue Cross
(Vacant) P.O. Box 327
DRI Medical Director Seattle, WA 98111-0327
Office of the Medical Director

4-Washington National Pharmaceutical Council


Pharmaceutical Benefits 2002

Steven Gobin Sam Trimble


6700 Totem Beach Road Patty Orth
Marysville, WA 98271
Executive Officers of State Medical and
Pharmaceutical Societies
Blanche Jones
Gentiva Health Services Washington State Medical Association
4020 South 56th Street, Ste. 101 Thomas Curry
Tacoma, WA 98409 Executive Director
2033 Sixth Avenue, Ste. 1100
Barbara Malich Seattle, WA 98121
Peninsula Community Health Services T: 206/441-9762
P.O. Box 960 F: 206/441-5863
Bremerton, WA 98337 E-mail: wsma@wsma.org
Internet address: www.wsma.org
Eleanor Owen
802 Northwest 70th Washington State Pharmacists Association
Seattle, WA 98117 Rod Shafer
Mark Secord CEO
Neighborhood Health Centers 1501 Taylor Avenue, SW
905 Spruce Street, Ste. 201 Renton, WA 98055-3196
Seattle, WA 98104 T: 425/228-7171
F: 425/277-3897
Laura Toepfer E-mail: rshafer@wsparx.org
AOA Internet address: www.wsparx.org
31708 2nd Avenue South
Federal Way, WA 98003-5260 Washington Osteopathic Medical Association, Inc.
Kathleen Itter
Raleigh Watts Executive Director
Department of Health P. O. Box 16486
P.O. Box 47481 Seattle, WA 98116-0486
Olympia, WA 98504-7841 T: 206/937-5358
F: 206/933-6529
Bruce Yoder, D.D.S. E-mail: kathie@woma.org
WSDA Internet address: www.woma.org
1890 Pottery Avenue
Port Orchard, WA 98366

DSHS Staff Members


Debbie Meyer
Secretary
Medical Assistance Administration
P.O. Box 45080
Olympia, WA 98504-5080
Pharmacy Drug Use Review Team Members
Siri Childs, Pharm.D.
Nicole Nguyen, Pharm.D.
Joan Baumgartner, M.D.
Olin Cantrell, PA-C
Linda Ayers, A.R.N.P.
Valerie Vertz
Charles Agte
Debbie Bellerud
Aimee Bennett
David Conaway
Kevin Davenport
Do Huynh
Celeste Moore
Robin Pfeiffer

National Pharmaceutical Council Washington-5


Pharmaceutical Benefits 2002

State Board of Pharmacy


Donald H. Williams
Executive Director
Department of Health
1300 Quince Street, SE
P. O. Box 47860
Olympia, WA 98504-7860
T: 360/236-4825
F: 360/586-4359
E-mail: don.williams@doh.wa.gov
Internet address: wws2.wa.gov/doh/hpqa-
licensing/HPS4/Pharmacy/default.htm

Washington State Hospital Association


Leo F. Greenawalt
President, CEO
300 Elliott Avenue W., Ste. 300
Seattle, WA 98119-4118
T: 206/281-7211
F: 206/283-6122
E-mail: leog@wsha.org
Internet address: www.wsha.org

6-Washington National Pharmaceutical Council


Pharmaceutical Benefits 2002

WEST VIRGINIA

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 Service        
Physician Services        
Dental Services        

B. EXPENDITURES FOR DRUGS


2001 2002
Expended Recipients Expended Recipients
TOTAL $253,163,196 266,778 $272,457,097 273,908

RECEIVING CASH ASSISTANCE, TOTAL $195,222,420 120,106 $205,598,570 113,800


Aged $50,162,902 22,265 $50,676,511 21,404
Blind/Disabled $129,883,613 61,332 $140,221,050 63,111
Child $1,120,726 8,089 $13,569 538
Adult $14,055,179 28,420 $14,687,440 28,747

MEDICALLY NEEDY, TOTAL $6,247,834 4,529 $6,544,451 4,605


Aged $525,697 475 $504,387 458
Blind/Disabled $4,745,795 2,713 $4,797,111 2,712
Child $4,888 14 $2,652 12
Adult $971,454 1,327 $1,240,301 1,423

POVERTY RELATED, TOTAL $28,111,559 106,230 $36,538,255 135,209


Aged $477,716 275 $519,840 282
Blind/Disabled $2,877,606 1,356 $3,889,793 1,572
Child $23,597,221 97,477 $30,296,278 125,627
Adult $1,159,016 7,122 $1,832,344 7,728

TOTAL OTHER EXPENDITURES/RECIPIENTS $23,581,383 35,913 $23,775,822 20,294

Source: West Virginia Medicaid Statistical Information System, FY 2001 and FY 2002.

National Pharmaceutical Council West Virginia-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION cosmetics purposes or hair growth; DESI drugs; fertility


drugs; and products used for anorexia or weight gain.
Bureau for Medical Services, Department of Health &
Human Resources. Prior Authorization: State currently has a prior
authorization screening procedure for drug classes and
D. PROVISIONS RELATING TO DRUGS home health care.
Benefit Design Prescribing or Dispensing Limitations
Drug Benefit Product Coverage: Products covered with All covered outpatient drugs are reimbursed up to a 34-day
restrictions (i.e., quanity limits): disposable needles and supply and five refills.
syringe combinations used for insulin; blood glucose test Exceptions include:
strips; and urine ketone test strips. Products covered as 1. Antibiotics are covered for a 14-day supply and one
DME: total parenteral nutrition. Prior authorization refill.
required for: prescribed insulin (pens); branded NSAIDs, 2. Opiate agonists (excluding Schedule II drugs),
Retin-A for adults; ED drugs; proton pump inhibitors; analgesics and miscellaneous antipyretics are covered
drugs to treat impotency; most injectable medications; and for 30 days and one refill.
non-preferred drugs. Products not covered: cosmetics; 3. Sedatives and hypnotics are covered for a 30-day
fertility drugs; experimental drugs; and interdialytic supply and one refill.
parenternal nutrition.
Drug Utilization Review
Over-the-Counter Product Coverage: Products covered PRODUR system implemented in March 1995. State
with restrictions (i.e., limited formulary/prescription currently has a DUR Board with a quarterly review.
required): feminine products; topical products; allergy,
asthma, and sinus products; analgesics; cough and cold Pharmacy Payment and Patient Cost Sharing
preparations; and digestive products (non-H2 antagonist). Dispensing Fee: $3.90, effective 1/1/96. For a
Prior authorization for: smoking deterrent products. compounded prescription, an additional $1.00 will be
Products not covered: digestive products (H2 antagonists). added to the dispensing fee. A compound prescription is
defined as any legend medication requiring a combination
Therapeutic Category Coverage: Therapeutic categories of any two or more substances to exclude normal
covered: anabolic steroids; anticonvulsants; anti- reconstitution operations.
depressants; antidiabetic drugs; antilipemic agents;
antihistamine drugs; antipsychotics; anxiolytics, sedatives, Ingredient Reimbursement Basis: EAC = AWP - 12%.
and hypnotics (partial coverage); cardiac drugs;
contraceptives; prescribed cold mediation (partial Prescription Charge Formula: Reimbursement based on
coverage); ENT anti-inflammatory agents; estrogens; the lowest of:
hypotensive agents; and thyroid agents. Therapeutic 1. The estimated acquisition cost (EAC) plus a
categories requiring prior authorization: analgesics, dispensing fee.
antipyretics, NSAIDs; antibiotics; anticoagulants; 2. The maximum allowable cost (MAC) plus a
chemotherapy agents; growth hormones; prescribed dispensing fee.
smoking deterrents; misc. GI drugs; and sympathominetics 3. The usual and customary price charged by the
(adrenergic). Therapeutic categories not covered: pharmacy to the general public including any sale
anorectics; and hair growth products. price that may be in effect on the date of service.
Coverage of Injectables: Injectable medicines Maximum Allowable Cost: State imposes Federal Upper
reimbursable under the Prescription Drug Program when Limits on generic drugs. Override will require physician
used in home health care and extended care facilities, and certification of “Brand Medically Necessary.”
through both the Prescription Drug Program and physician
payment in physician offices; most require prior approval. Incentive Fee: None.
Vaccines: Vaccines reimbursable as part of CHIP and the Patient Cost Sharing: Copayment varies - $0.50 to $2.00.
Vaccines for Children Program. Exclusions include:
Unit Dose: Unit dose packaging reimbursable. 1. Family planning services and supplies.
Formulary/Prior Authorization 2. Prescriptions originating with the Early and Periodic
Screening, Diagnosis and Treatment Program.
Formulary: Closed formulary (as of 1/17/03). Restrictions 3. Nursing home residents.
include preferred products and prior authorization. 4. Children under the age of 18 years.
General exclusions include: legend agents used for Cognitive Services: Does not pay for cognitive services.

2-West Virginia National Pharmaceutical Council


Pharmaceutical Benefits 2002

E. USE OF MANAGED CARE P.O. Box 9511


Morgantown, WV 26506-9511
Approximately 50,000 unduplicated Medicaid recipients T: 800/847-3859
were enrolled in MCOs in 2002. Beneficiares in managed F: 800/531-7787
care receive pharmacy services through the State. E-mail: ssmall@hsc.wvu.edu
Managed Care Organizations Pharmaceutical and Therapeutics Committee
Carelink Health Plans Kevin W. Yingling, R.Ph., M.D.
Michelle Coon Steve R. Matulis, M.D.
Manager of Government Programs Thomas L. Gilligan, D.O.
500 Virginia Street East David Avery, M.D.
Suite 400 John D. Justice, M.D.
Charleston, WV 25326-1711 Teresa Dunsworth, Pharm.D.
T: 304/348-2041 James D. Bartsch, R.Ph.
F: 304/348-3948 Harriett Nottingham, R.Ph.
Kristy H. Lucas, Pharm.D.
The Health Plan of the Upper Ohio Valley Tom Harwood, PA-C
Tom Samol, Director/Government Programs Barbara Koster, M.S.N., R.N.C. – A.N.P.
52160 National Road, East
St. Clairsville, OH 43950 DUR Contact
T: 740/695-3585 Vicki M. Cunningham, R.Ph.
F: 740/695-5297 DUR Coordinator
Bureau for Medical Services
Physician Assured Access System (PAAS) Office of Pharmacy Services
Shelley Baston, Director 350 Capitol Street, Room 251
Office of Medicaid Managed Care Charleston, WV 25301-3707
Bureau for Medical Services T: 304/558-1700
350 Capitol Street, Room 251 F: 304/558-1542
Charleston, WV 25301 E-mail: vickicunningham@wvdhhr.org
T: 304/558-1700
F: 304/558-4398 Medicaid DUR Board
Steven C. Judy, R.Ph.
F. STATE CONTACTS Kevin W. Yingling, M.D.
State Drug Program Administrator David P. Elliott, Pharm.D.
Bernard Lee Smith, R.Ph., M.B.A, M.H.A
Peggy A. King, R.Ph. Patrick M. Regan, R.Ph.
Director, Office of Pharmacy Services Karen Reed, R.Ph. (Chairperson)
WV Department of Human Services Mary Nemeth-Pyles, M.S.N., R.N., C.S.
350 Capitol Street, Rm 251 Mitch Shaver, M.D.
Charleston, WV 25301-3707 Myra Chiang, M.D.
T: 304/558-1700 Matthew Watkins, D.O.
F: 304/558-1542 John R. Vanin, M.D.
E-mail: pking@wvdhhr.org Lester Labus, M.D.
Internet address: www.wvdhhr.org/bma Ernest Miller, D.O.
Christopher Terpening, Pharm.D., Ph.D.
Department of Health & Human Resources James M. Bennett, M.D.
Officials Kerry Sitzinger, R.Ph.
Sandra Joseph, M.D. George Bryant, PA-C
Medical Director Daniel Dickman, M.D.
Division of Medical Care
West Virginia Department of Human Services Prescription Price Updating
350 Capitol St., Rm 251 Becky Garrigan
Charleston, WV 25301-3707 PBM Account Manager
Prior Authorization Contact ACS, Inc.
365 Northridge Rd.
Stephen Small, R.Ph., M.S. Northridge Center One, Suite 400
Director, Rational Drug Therapy Program Atlanta, GA 30350
West Virginia University School of Pharmacy T: 770/352-8592
Robert C. Byrd Health Sciences Center

National Pharmaceutical Council West Virginia-3


Pharmaceutical Benefits 2002

F: 770/730-5198 E-mail: evan@wvsma.com


E-mail: Becky.Garrigan@acs-inc.com Internet address: www.wvsma.com
Medicaid Drug Rebate Contacts
West Virginia Pharmacists Association
Technical: Gail Goodnight, R.Ph., 304/558-1700 Richard D. Stevens, Executive Director
Policy: Peggy A. King, 304/558-1700 2003 Quarrier St.
Rebate: Gail Goodnight, R.Ph., 304/558-1700 Charleston, WV 25311-2212
T: 304/344-5302
Claims Submission Contact F: 304/344-5316
Becky Garrigan E-mail: wvrds@aol.com
770/352-8592
West Virginia Society of Osteopathic Medicine
Medicaid Managed Care Contact Charlotte Ann Cales Pulliam
Shelley Baston Executive Director
304/558-1700 P.O. Box 5266
Charleston, WV 25361-0266
Mail Order Pharmacy Program T: 304/345-9836
None F: 304/345-9865
E-mail: wvdo@wvsominc.org
Disease Management/Patient Educated Programs Internet address: www.wvsominc.org
Disease/Medical State: Diabetes
Program Name: WV Health Initiative Project State Board of Pharmacy
Program Manager: Bureau of Medical Services William T. Douglas, Jr.
Executive Director
Disease Management Initiative/Program Contact 236 Capitol Street
Vicki M. Cunningham, R.Ph. Charleston, WV 25301
304/558-1700 T: 304/558-0558
F: 304/558-0572
Physician-Administered Drug Program Contact E-mail: wdouglass@wvbop.com
Barbara White Internet address: www.wvbop.com/main.htm
West Virginia Department of Human Services
350 Capitol St., Rm 251 West Virginia Hospital Association
Charleston, WV 25301-3707 Steven J. Summer
304/558-1700 President
100 Association Drive
Medical Services Fund Advisory Council Charleston, WV 25311
Violet Burdette T: 304/344-9744
William McFarland, R.Ph F: 304/344-9745
Doug Coffman E-mail: ssummer@wvha.com
John Elliott Internet address: www.wvha.com
Sheryl Kiser
Charles Smith, D.D.S.
John Russell
Scott McClanahan
Mark B. Ayoubi, M.D.
Larry Robertson
G. Anne Cather, M.D.
Chris Cutis
Fred Booth
Executive Officers of State Medical and
Pharmaceutical Societies
West Virginia State Medical Association
Evan Jenkins, Executive Director
4307 MacCorkle Avenue SE
P.O. Box 4106
Charleston, WV 25364
T: 304/925-0342
F: 304/925-0345

4-West Virginia National Pharmaceutical Council


Pharmaceutical Benefits 2002

National Pharmaceutical Council West Virginia-5


Pharmaceutical Benefits 2002

6-West Virginia National Pharmaceutical Council


Pharmaceutical Benefits 2002

WISCONSIN

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        

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients

TOTAL $349,558,072 267,417 $389,373,521 262,238

RECEIVING CASH ASSISTANCE TOTAL $180,127,927 110,356 $195,261,895 107,145


Aged $19,174,287 12,438 $20,208,955 11,879
Blind/Disabled $157,699,143 74,817 $171,261,361 73,646
Child $1,094,362 12,055 $1,321,948 11,038
Adult $2,160,135 11,046 $2,469,631 10,582

MEDICALLY NEEDY, TOTAL $27,283,734 16,284 $29,447,709 16,508


Aged $10,985,233 6,303 $12,300,642 6,621
Blind/Disabled $15,917,838 4,963 $16,741,054 5,048
Child $305,458 4,038 $327,772 3,962
Adult $75,205 980 $78,241 877

POVERTY RELATED, TOTAL $3,699,695 22,860 $7,821,202 24,252


Aged $398,786 596 $392,139 593
Blind/Disabled $1,414,102 756 $4,837,078 1,794
Child $1,447,789 16,197 $2,164,005 17,197
Adult $439,018 5,311 $427,980 4,668

TOTAL OTHER EXPENDITURES/RECIPIENTS* $138,446,716 117,917 $156,842,715 114,333

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

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

National Pharmaceutical Council Wisconsin-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Maximum Allowable Cost: State imposes State-specific


limits on generic drugs. Override requires hand written
State Department of Health and Family Services. “Brand Medically Necessary” by the prescriber.

D. PROVISIONS RELATING TO DRUGS Incentive Fee: None.


Benefit Design
Cognitive Services: Provides an expanded dispensing fee
Formulary: Open formulary. General exclusions include for cognitive services.
progesterone for PMS; topical minoxidil; legend prenatal
vitamins; fertility enhancement drugs; experimental Patient Cost Sharing: All legend drugs are subject to a
drugs; and impotence treatment drugs. $1.00 copay, limited to $5.00 per month maximum per
pharmacy. OTCs are subject to a $0.50 copay.
Prior Authorization: Prior authorization is required on the Disposable medical supplies are subject to a sliding scale
following drugs: Schedule III and IV stimulants; human copayment system. Residents of Skilled Nursing
growth hormone; enteral nutrition products; Cerezyme; Facilities (SNF) or Intermediate Care Facilities (ICF),
Mupirocin; fertility enhancing drugs; anti-obesity drugs; subsidized adoption recipients, children under age 18 and
alitretinoin gel; brand-name ACE inhibitors; brand-name HMO enrollees are exempt from the copayment.
NSADs; and medically necessary drugs with no rebate
agreement. E. USE OF MANAGED CARE
Drug Utilization Review: Implementation of PRODUR Approximately 321,000 Medicaid recipients were
system completed in 2001. enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through managed care plans.
Coverage of Injectables: Injectable medicines (Some mental health plans carve out pharmaceutical
reimbursable through physician payment when used in benefits.)
physician offices. Managed Care Organizations
Vaccines: Vaccines provided plus reimbursement for Atrium Health Plan, Inc.
administrative fee as part of the Vaccines for Children c/o Group Health Cooperative of Eau Claire
Program. P.O. Box 3217
Eau Claire, WI 54702-3217
Unit Dose: Unit dose packaging reimbursable.
Dean Health Plan, Inc.
Prescribing or Dispensing Limitations: P.O. Box 56099
Madison, WI 53705
Quantity of Medication: Pharmacists may not dispense
more than 34-day supply of a legend drug. Certain Group Health Cooperative of Eau Claire
exceptions for some maintenance drugs. P.O. Box 3217
Refills: Maximum of 11 refills during a 12-month period Eau Claire, WI 54702
for non-scheduled medications.
Group Health Cooperative of
Dollar Limits: None. South Central Wisconsin
Pharmacy Payment and Patient Cost Sharing P.O. Box 44971
Madison, WI 53744-4971
Dispensing Fee: $4.88 to a maximum of $40.11, effective
7/1/98. Extra fees for unit dose pharmacies. Incremental Health Tradition HealthPlan
increases based on pharmaceutical care services being P.O. Box 188
provided. Maximum of two dispensing fees per month, LaCrosse, WI 54602-0188
per prescription.
Managed Health Services Insurance Corp.
Ingredient Reimbursement Basis: EAC = AWP–11.25%. 1205 S. 70th Street, Ste. 500
West Allis, WI 53214
Prescription Charge Formula: Reimbursement at the MercyCare Insurance Company
lowest of: P.O. Box 2770
Janesville, WI 53547-2770
AWP-11.25% plus dispensing fee; Maximum Allowable Network Health Services
Cost (MAC) plus dispensing fee; or providers usual and c/o Managed Health Services
customary. 1205 S. 70th Street, Ste. 500
West Allis, WI 53214

2-Wisconsin National Pharmaceutical Council


Pharmaceutical Benefits 2002

Daniel R. Erickson, M.D.


Security Health Plan of Wisconsin, Inc. Barry Hess, R.Ph.
P.O. Box 8000 Nancy E. Ness, M.D.
Marshfield, WI 54449 Pamela Poetz, R.Ph.
Lee C. Vermeulen, Jr., R.Ph., M.S.
United Healthcare Mary Jo Willis, M.S., N.P.
10701 W. Research Drive
Milwaukee, WI 53226 Prescription Price Updating

Unity Health Plans Insurance Corporation First Databank


840 Carolina Street 1111 Bayhill Dr., Ste. 350
San Bruno, CA 94066
Sauk City, WI 53583-1374
T: 800/633-3453
F: 415/588-6867
Valley Health Plan
2270 EastRidge Center Medicaid Drug Rebate Contacts
P.O. Box 3128
Eau Claire, WI 54702-3128 Audits: Barbara Evans, R.N.,608/261-7783
Disputes: Ellen Orsburne, 608/267-7939
Wraparound of Milwaukee Technical: Randy Zirk, 608/266-8532
9501 Watertown Plank Rd. Policy: Rita Hallett, 608/267-0938
Milwaukee, WI 53226 Claims Submission Contact
Mark Gajewski
F. STATE CONTACTS
Account Director
Pharmacy Practices Consultant EDS
6406 Bridge Rd.
Vacant
Madison, WI 53784-0014
Pharmacy Practices Consultant
T: 608/221-4746
Division of Health Care Financing
F: 608/221-4567
Department of Health and Family Services
One West Wilson Street
Medicaid Managed Care Contact
P.O. Box 309
Madison, WI 53701-0309 Angela Dombrowski, Director
T: 608/266-3753 Department of Health and Family Services
F: 608/266-1096 Division of Healthcare Financing
E-mail: Vacant Bureau of Managed Health Care Programs
Agency Internet Address: www.dhfs.state.wi.us/medicaid 1 West Wilson
Madison, WI 53701
Prior Authorization Contact
T: 608/266-1935
Rita Hallett, M.A., R.N. F: 608/261-7792
Department of Health and Family Services
Mail Order Pharmacy Program
One West Wilson Street
P.O. Box 309 None
Madison, WI 53701-0309
Physician-Administered Drug Program Contact
608/267-0938
E-mail: haller@dhfs.state.wi.us Richard Carr, M.D.
Chief Medical Officer
DUR Contact
Division of Healthcare Financing
Michael A. Mergener, R.Ph., Ph.D. One West Wilson Street
Chief Pharmacist Madison, WI 53701
APS Healthcare 608/266-0957
10 East Duty St., Ste. 210
Health and Family Services Department Officials
Madison, WI 53703
T: 608/258-3348 Helene Nelson
F: 608/258-3359 Secretary
Department of Health and Family Services
Wisconsin Drug Utilization Review Committee
State Office Building
Robert M. Breslow, R.Ph. One West Wilson Street
Ward Brown, M.D. Madison, WI 53701
Mark E. Buhler, R.Ph. T: 608/266-8922

National Pharmaceutical Council Wisconsin-3


Pharmaceutical Benefits 2002

F: 608/266-7882 E-mail: sbrenton@wha.org


Internet address: www.wha.org
Mark P. Moody
Administrator Wisconsin Health Care Association
Division of Health Care Financing Thomas P. Moore
One West Wilson Street Executive Director
P.O. Box 309 121 South Pinckney Street, Suite 500
Madison, WI 53701 Madison, WI 53703
T: 608/266-8922 T: 608/257-0125
F: 608/266-1096 F : 608/257-0025
E-mail: tomm@whca.com
Executive Officers of State Medical and
Internet address: www.whca.com
Pharmaceutical Societies
State Medical Society of Wisconsin
John Patchett, J.D.
Executive Vice President
330 East Lakeside, Box 1109
Madison, WI 53701-1109
T: 608/257-6781
F: 608/442-3802
E-mail: johnp@wismed.org
Internet address: wisconsinmedicalsociety.org

Wisconsin Association of Osteopathic Physicians &


Surgeons
Robert J. Finnegan, CAE
Executive Director
34615 Road E.
Oconomowoc, WI 53066-2543
T: 414/567-0520
F: 262/567-0520
E-mail: rfinnegan@wi.rr.com

Wisconsin Pharmacists Association


Christopher J. Decker
Executive Vice President
701 Heartland Trail
Madison, WI 53717
T: 608/827-9200
F: 608/827-9292
E-mail: cdecker@pswi.org

Wisconsin Pharmacy Exam Board


Deanna Zychowski, Director
Bureau of Health Professions
P.O. Box 8935
1400 E. Washington Ave.
Madison, WI 53708
T: 608/266-2812
F: 608/261-7083
E-mail: dorl@drl.state.wi.us
Internet address: www.drl.state.wi.us

Wisconsin Health and Hospital Association


Steve Brenton, CEO
5721 Odana Road
Madison, WI 53719-1289
T: 608/274-1820
F: 608/274-8554

4-Wisconsin National Pharmaceutical Council


Pharmaceutical Benefits 2002

WYOMING

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    

B. EXPENDITURES FOR DRUGS


2000 2001**
Expenditures Recipients Expenditures Recipients
TOTAL $27,233,795 33,342 $31,881,860 36,704

RECEIVING CASH ASSISTANCE, TOTAL $11,778,585 12,682 $12,791,205 12,347


Aged $1,196,354 739 $1,358,763 746
Blind / Disabled $8,433,959 3,956 $8,964,573 3,913
Child $835,376 4,976 $948,764 4,687
Adult $1,312,896 3,011 $1,519,105 3,001

MEDICALLY NEEDY, TOTAL $0 0 $0 0


Aged $0 0 $0 0
Blind / Disabled $0 0 $0 0
Child $0 0 $0 0
Adult $0 0 $0 0

POVERTY RELATED, TOTAL $2,237,285 12,592 $2,817,574 14,975


Aged $11,271 19 $13,038 15
Blind / Disabled $53,863 42 $20,761 28
Child $1,871,910 10,415 $2,437,127 12,689
Adult $300,241 2,116 $346,648 2,243

TOTAL OTHER EXPENDITURES/RECIPIENTS* $13,217,925 8,068 $16,273,081 9,382

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.

Source: CMS, MSIS Report, FY 2000, and FY2001.

National Pharmaceutical Council Wyoming-1


Pharmaceutical Benefits 2002

C. ADMINISTRATION Pharmacy Payment and Patient Cost Sharing


Department of Health, Director’s Office. Dispensing Fee: $5.00, effective 7/01.

D. PROVISIONS RELATING TO DRUGS Ingredient Reimbursement Basis: EAC = AWP – 11%.

Benefit Design Prescription Charge Formula: Payments shall be the


Drug Benefit Product Coverage: Products covered: lowest of:
prescribed insulin, syringe combinations and disposable
needles used for insulin; blood glucose test strips; and 1. The Estimated Acquisition Cost (AWP - 11%) of the
urine ketone test strips. Products covered under DME: ingredient, plus a dispensing fee.
total parenteral nutrition; and interdialytic parenteral
2. Usual and customary charge.
nutrition. Products not covered: cosmetics; fertility drugs;
tobacco cessation products; weight loss products; hair 3. The upper limit established by CMS for multiple
growth products; IQ enhancers and experimental drugs. source drugs or State MAC.

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.

2-Wyoming National Pharmaceutical Council


Pharmaceutical Benefits 2002

Antoinette Brown Leonard Kosirog, R.Ph.


Medicaid Pharmacist 3095 Galloway
Department of Health Riverton, WY 82501
2424 Pioneer Ave., Suite 100 307/856-6993
Cheyenne, WY 82001
T: 307/777-6016 Scott Johnson, M.D.
F: 307/777-7085 P.O. Bos 100
Wright, WY 82732
Department of Health Officials
307/464-0422
Deb Fleming, Ph.D.
Director George Zaharas, R.Ph.
Department of Health Town and Country Pharmacy
117 Hathaway Building 514 S. Greeley
2300 Capitol Ave. Cheyenne, WY 82009
Cheyenne, WY 82002-0710 307/634-6662
T: 307/777-7656
F: 307/777-7439 Stephen Brown, M.D.
2521 E. 15th St.
Roxanne Homar, R.Ph. Casper, WY 82609
307/777-6032 307/234-3638
DUR Contact Michael Carpenter, PA-C
Debra Devereaux, R.Ph. 1121 Washington Blvd.
DUR Coordinator Newcastle, WY 82701
University of Wyoming School of Pharmacy 307/746-3582
P.O. Box 3375
Laramie, WY 82071-3375 William Harrison, M.D.
T: 307/766-6750 Cheyenne Medical Specialists
F: 307/766-2953 5050 Powderhouse Road
E-mail: debdev@concentric.com Cheyenne, WY 82009
307/638-6820
DUR Board
Kendra Grande, R.Ph.
Debra Devereaux, R.Ph. University of Wyoming School of Pharmacy
307/766-6750 Drug Information
P.O. Box 3375
Becky Drnas, R.Ph. Laramie, WY 82071
K-Mart Pharmacy 307/766-6988
2450 Foothill Blvd.
Rock Springs, WY 82901 Richard L. Johnson, R.Ph.
307/362-7990 Emissary Pharmacy
401 East Collins Drive
Dawn Ford, R.Ph. Casper, WY 82601
2022 Reagan Ave. 800/281-2026
Rock Springs, WY 82901
307/382-5437 Cory L. Moss, Pharm.D.
University of Wyoming School of Pharmacy
Roxanne Homar, R.Ph. (ex-officio) P.O. Box 3375
307/777-6032 Laramie, WY 82071
307/766-6128
Kathryn Kohler, M.D.
Women’s Clinic Linda G. Martin, R.Ph. (ex-officio)
204 McCollum Drive, Suite 104 University of Wyoming
Laramie, WY 82070 School of Pharmacy
307/745-8991 P.O. Box 3375
Laramie, WY 82071-3375
307/766-6128

National Pharmaceutical Council Wyoming-3


Pharmaceutical Benefits 2002

Prescription Price Updating State Board of Pharmacy


Jim T. Carder
First DataBank
Executive Director
1111 Bayhill Drive
1720 S. Poplar Street, Suite 4
San Bruno, CA 94066
Casper, WY 82601
T: 800/633-3453
T: 307/234-0294
F: 650/872-4510
F: 307/234-7226
Medicaid Drug Rebate Contacts E-mail: wypharmbd@wercs.com
Internet address: www.pharmacyboard.state.wy.us
Suzie Gambell
ACS Wyoming Hospital Association
P.O. Box 667
Robert C. Kidd II
Cheyenne, WY 82003
President
T: 307/772-8400
2005 Warren Avenue
F: 307/772-8405
Cheyenne, WY 82003
Claims Submission Contact T: 307/632-9344
F: 307/632-9347
ACS E-mail: bob@wyohospitals.com
Northridge Center 1, Suite 400 Internet address: www.wyohospitals.com
365 Northridge Road
Atlanta, GA 30350
T: 866/322-5960
F: 888/335-8459
Disease Management Program/Initiative Contact
Roxanne Homar
307/777-6032
Mail Order Pharmacy Program
None
Physician-Administered Drug Program Contact
Antoinette Brown
307/777-6016
Executive Officers of State Medical and
Pharmaceutical Societies
Wyoming State Medical Society
Stephen Brown, M.D.
President
1920 Evans
P.O. Box 4009
Cheyenne, WY 82003-4009
T: 307/635-2424
F: 307/632-1973
E-mail: prez@wyomed.org
Internet address: www.wyomed.org

Wyoming Pharmacists Association


Keith Sande, R.Ph.
1022 Ponderosa Court
Powell, WY 82435-4100
T: 307/754-4663
F: 307/754-4145
E-mail: ksande@directairnet.com
Internet address: www.wpha.net

4-Wyoming National Pharmaceutical Council


Pharmaceutical Benefits 2002

Appendix A:
State and Federal
Medicaid Contacts

National Pharmaceutical Council A-1


Pharmaceutical Benefits 2002

A-2 National Pharmaceutical Council


Pharmaceutical Benefits 2002

STATE MEDICAID DRUG PROGRAM ADMINISTRATORS, 2002

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

National Pharmaceutical Council A-3


Pharmaceutical Benefits 2002

DISTRICT OF COLUMBIA IDAHO


Donna Bovell, R.Ph. Shawna Kittridge, R.Ph., M.H.S.
Pharmacist Consultant Medicaid Drug Program Supervisor
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE, Fifth Floor 3380 Americana Terrace, Suite 140
Washington, DC 20002 Boise, ID 83720-0036
T: 202/442-5988 T: 208/364-1956
F: 202/442-4790 F: 208/364-1864
E-mail: donna.bovell@dcgov.org E-mail: kittrids@mmis.state.id.us
Internet Address:
ww2.state.id.us/dhw/medicaid/providers/pharmacy.htm
FLORIDA
George Kitchens, Chief
ILLINOIS
Pharmacy Bureau
Agency for Healthcare Administration Services Marvin L. Hazelwood
2727 Mahan Drive, MS 38 Pharmacy and Ancillary Services Programs
Tallahassee, FL 32308 Illinois Department of Public Aid
T: 850/487-4441 Division of Medical Assistance
F: 850/922-0685 1001 N. Walnut St.
E-mail: kitcheng@fdhc.state.fl.us Springfield, IL 62702
Internet Address: www.fdhc.state.fl.us T: 217/782-5565
F: 217/524-7194
E-mail: dpa_webmaster@state.il.us
GEORGIA
Internet Address: www.state.il.us/dpa
Lori S. Garner, R.Ph., M.P.A., M.S.
Director, Pharmacy Services
INDIANA
Department of Community Health-Medicaid Division
2 Peachtree Street, N.W., 37th Floor Marc Shirley, R.Ph.
Atlanta, GA 30303-3159 Pharmacy Program Director
T: 404/656-4044 Office of Medicaid Policy and Planning
F: 404/656-8366 Indiana State Government Center South-Rm. W382
E-mail: lgarner@dch.state.ga.us 402 W. Washington Street
Internet Address: www.dch.state.ga.us Indianapolis, IN 46204-2739
T: 317/232-4343
F: 317/232-7382
HAWAII
E-mail: mshirley@fssa.state.in.us
Lynn Donovan, R.Ph.
Pharmacy Consultant
IOWA
Med-Quest Division
601 Kamokila Boulevard, Room 506B Susan L. Parker, Pharm.D.
P.O. Box 700190 Pharmacy Consultant
Honolulu, HI 96709-0190 Division of Medical Services
T: 808/692-8116 Bureau of Long Term Care
F: 808/692-8131 Hoover State Office Bldg.
Des Moines, IA 50319
T: 515/281-3002
F: 515/281-6230
E-mail: sparker2@dhs.state.ia.us

A-4 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-5


Pharmaceutical Benefits 2002

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

A-6 National Pharmaceutical Council


Pharmaceutical Benefits 2002

NEW YORK OKLAHOMA


Mark-Richard Butt, M.S., R.Ph. Nancy Nesser
Director, Pharmacy Policy and Operations Pharmacy Director
Bureau of Program Guidance Oklahoma Health Care Authority
Office of Medicaid Management 4545 N. Lincoln Boulevard, Suite 124
NYS Department of Health Oklahoma City, OK 73105-9901
99 Washington Ave., Room 606 T: 405/522-7325
Albany, NY 12210 F: 405/522-3240
T: 518/474-9219 E-mail: nessern@ohca.state.ok.us
F: 518/473-5508 Internet Address: www.ohca.state.ok.us
E-mail: mrb01@health.state.ny.us
Internet Address: www.health.state.ny.us OREGON
Thomas Drawbaugh
NORTH CAROLINA
Pharmacy Program Manager
Sharman C. Leinwand Department of Human Resources
Pharmacy Program Manager Office of Medical Assistance Programs
Division of Medical Assistance 500 Summer Street, NE, E-35
Department of Health and Human Services Salem, OR 97301-1077
1985 Umstead Drive T: 503/945-6492
2511 Mail Service Center F: 503/373-7689
Raleigh, NC 27699-2511 E-mail: thomas.drawbaugh@state.or.us
T: 919/857-4034 Internet Address: www.omap.hr.state.or.us
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net
Internet Address: www.dhhs.state.nc.us/dma PENNSYLVANIA
Joseph E. Concino, R.Ph.
NORTH DAKOTA
Chief, Pharmacy Services Section
Brendan K. Joyce, Pharm.D., R.Ph. Office of Medical Assistance Programs
Department of Human Services P.O. Box 8046
600 East Boulevard Avenue Harrisburg, PA 17105
Department 325 T: 717/772-6341
Bismarck, ND 58505-0250 F: 717/772-6366
T: 701/328-4023 E-mail: jconcino@state.pa.us
F: 701/328-1544 Internet Address: www.dpw.state.pa.us/omap
E-mail: sojoyb@state.nd.us
RHODE ISLAND
OHIO
Paula J. Avarista, R.Ph.
Robert P. Reid, R.Ph. Chief of Pharmacy
Administrator, Pharmacy Services Unit Department of Human Services
Ohio Department of Job and Family Services 600 New London Avenue
Bureau of Health Plan Policy Cranston, RI 02920
30 East Broad St., 27th Floor T: 401/462-6390
Columbus, OH 43615-3414 F: 401/462-6336
T: 614/466-6420 E-mail: pavarista@gw.dhs.state.ri.us
F: 614/466-2908
E-mail: reidr@odhs.state.oh.us

National Pharmaceutical Council A-7


Pharmaceutical Benefits 2002

SOUTH CAROLINA UTAH


James M. Assey, R.Ph., Division Director RaeDell Ashley, R.Ph.
Division of Health Services Pharmacy Director
S.C. Department of Health & Human Services Division of Health Care Financing
P.O. Box 8206 Utah Department of Health
Columbia, SC 29202-8206 P.O. Box 143102
T: 803/898-2876 Salt Lake City, UT 84114-3102
F: 803/898-4517 T: 801/538-6495
E-mail: asseyj@dhhs.state.sc.us F: 801/538-6099
Internet Address: www.dhhs.state.sc.us E-mail: rashley@doh.state.ut.us

SOUTH DAKOTA VERMONT


Mark Petersen, R.Ph. Pat House, Operations Manager
Pharmacy Consultant Office of Vermont Health Access
Department of Social Services 103 South Main Street
Office of Medical Services Waterbury, VT 05671-1201
700 Governors Drive T: 802/241-2156
Pierre, SD 57501 F: 802/241-2974
T: 605/773-3495 E-mail: pathouse@wpgate1.ahs.state.vt.us
F: 605/773-5246
E-mail: markp@state.sd.us VIRGINIA
David B. Shepherd, R.Ph.
TENNESSEE
Pharmacy Consultant
H. Leo Sullivan, D.Ph. Division of Program Operations
Director of Pharmacy Services Department of Medical Assistance Services
Bureau of TennCare 600 East Broad Street, Ste 1300
729 Church Street Richmond, VA 23219
Nashville, TN 37247-6501 T: 804/786-2196
T: 615/741-0213 F: 804/786-0973
F: 615/253-5481 E-mail: dshepher@dmas.state.va.us
E-mail: leo.sullivan@state.tn.us Internet Address: www.dmas.state.va.us
Internet Address: www.state.tn.us/health/tenncare
WASHINGTON
TEXAS
Siri A. Childs, Pharm D.
Curtis Burch, R.Ph. Pharmacy Research Specialist/Manager
Director, Vendor Drug Program Medical Assistance Administration, DSHS
Texas Health and Human Services Commission 805 Plum Street, SE
1100 W. 49th Street P.O. Box 45506
Austin, TX 78756-3174 Olympia, WA 98504-5506
T: 512/338-6992 T: 360/725-1564
F: 512/794-5190 F: 360/586-2262
E-mail: curtis.burch@hhsc.state.tx.us E-mail: childsa@dshs.wa.gov
Internet Address: Internet Address: wws2.wa.gov/dshs/maa
www.hhsc.state.tx.us/hcf/vdp/vdpstart.html

A-8 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-9


Pharmaceutical Benefits 2002

DUR CONTACT INFORMATION, 2002


State Contact Contractor
Louise F. Jones Not Available
Pharmacy Program Manager
Alabama Medicaid Agency
501 Dexter Avenue
ALABAMA
P.O. Box 5624
Contracted DUR
Montgomery, AL 36103-5624
T: 334/242-5039
F: 334/353-7014
E-mail: lljones@medicaid.state.al.us

State Contact Contractor


Dave Campana, R.Ph. Not Available
Pharmacy Program Manager
Division of Medical Assistance
ALASKA 4501 Business Park Blvd., Ste. 24
Contracted DUR Anchorage, AK 99503
T: 907/334-2425
F: 907/561-1684
E-mail: david_campana@health.state.ak.us

Within Federal and State guidelines,


ARIZONA individual managed care and pharmacy
DUR is conducted at benefit management organizations make
the plan level. formulary/drug decisions.

State Contact Contractor


Pamela Ford Cherly Avants
Pharmacist II Director, Retrospective DUR
Arkansas Department of Human Services Health Information Design
Division of Medical Services 1550 Pumphrey Avenue
ARKANSAS
Pharmacy Program Auburn, AL 36832
Contracted DUR
P.O. Box 147, Slot 415 T: 205/402-9530
Little Rock, AR 72203 F: 205/402-9531
T: 501/683-4120 E-mail: clavants@aol.com
F: 501/683-4124
E-mail: pamela.ford@medicaid.state.ar.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

A-10 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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 Contractor


James Zakszewski, R.Ph. Michelle Lester-Bradley
Pharmacy Consultant Account Manager
Department of Social Services ACS State Healthcare
CONNECTICUT
25 Sigourney Street 866/322-5960 Ext. 5139
Contracted DUR
Hartford, CT 06106 E-mail:
T: 860/424-5150 michelle.lester-bradley@acs-inc.com
F: 860/424-5206
E-mail: james.zakszewski@po.state.ct.us

State Contact Contractor


Cynthia Denemark Cynthia Denemark
Pharmacist Consultant Pharmacist Consultant
EDS EDS
DELAWARE
248 Chapman Road, Suite 200
Contracted DUR
Newark, DE 197029720
T: 302/453-8453
F: 302/454-7603
E-mail: cynthia.denemark@eds.com

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 Contractor


Jerry F. Wells Rita Brown
Pharmacy Program Manager DUR Coordinator
Agency for Health Care Administration Florida Pharmacy Association
FLORIDA
2727 Mahan Drive, MS 38 610 N. Adams Street
Contracted DUR
Tallahassee, FL 32308 Tallahassee, FL 32301
T: 850/487-4441 T: 850/222-2400
F: 850/922-0685 F: 850/561-6758
E-mail: wellssj@fdhc.state.fl.us

National Pharmaceutical Council A-11


Pharmaceutical Benefits 2002

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 Contractor


Tamara Eide, Pharm.D., BCPS, FASHP Vaughn Culbertson, Pharm.D.
Pharmacy Services Specialist DUR Coordinator
IDAHO Department of Health and Welfare Idaho State U. - College of Pharmacy
Contracted DUR Division of Medicaid Campus Box 8356
3380 Americana Terrace, Suite 140 Pocatello, ID 83209-8356
Boise, ID 83720-0036 T: 208/236-4385
208/364-1821 F: 208/236-4482
E-mail: eidet@mmis.state.id.us E-mail: Vculb@otc.isu.edu
State Contact
Marvin L. Hazelwood, Manager
Pharmacy and Ancillary Services Program
Illinois Department of Public Aid
ILLINOIS Division of Medical Assistance
In-House DUR 1001 N. Walnut Street
Springfield, IL 62702
T: 217/524-5565
F: 217/524-7194

State Contact Contractor


Karen Clifton ACS
DUR Board Secretary E-mail: david.george@acs-inc.com
Office of Medicaid Policy and Planning
Indiana State Government Center
INDIANA
South-Room W382
Contracted DUR
402 West Washington Street
Indianapolis, IN 46204
T: 317/232-4391
F: 317/232-7382
E-mail: kclifton@fssa.state.in.us

A-12 National Pharmaceutical Council


Pharmaceutical Benefits 2002

State Contact Contractor


Julie Kuhle, R.Ph. Julie Kuhle, R.Ph.
DUR Coordinator DUR Coordinator
IOWA Iowa Pharmacy Association Iowa Pharmacy Association
Contracted DUR 8515 Douglas, Ste. 16
Des Moines, IA 50322
T: 515/270-0713
F: 515/270-2979

State Contact Contractor


Mary H. Obley New Contract Pending
Pharmacist
Health Care Policy Division
Kansas Department of Social and
KANSAS Rehabilitation Services
Contracted DUR Docking State Office Building
915 SW Harris, Room 651-South
Topeka, KS 66612-1570
T: 785/296-8406
F: 785/296-4813
E-mail: mho@srskansas.org

State Contact Contractor


Debra Bahr, R.Ph. In-house DUR with data obtained from
Pharmacy Services Program Manager outside vendor - Unisys
Department for Medicaid Services
KENTUCKY CHR Building, 6 W-A
In-House DUR 275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: Debra.Bahr@mail.state.ky.us

State Contact Contractor


Mary J. Terrebonne, Pharm.D. Dan Scholl
Pharmaceutical Program Director Pharmacy Director
Department of Health and Hospitals Unisys
LOUISIANA 1201 Capitol Access Road, 6th Floor 8591 United Plaza Blvd., Ste.300
Contracted DUR P.O. Box 91030 Baton Rouge, LA 70809
Baton Rouge, LA 70821 T: 225/237-3208
T: 225/342-9768 F: 225/237-3334
F: 225/342-1980 E-mail: dan.scholl@unisys.com
E-mail: mterrebo@dhh.state.la.us

National Pharmaceutical Council A-13


Pharmaceutical Benefits 2002

State Contact Contractor


Vacant GHS Data Management
Director of Pharmacy P.O. Box 1090
DHS – Bureau of Medical Services Augusta, ME 04332
MAINE
442 Civic Center Drive T: 207/622-7153
Contracted DUR
Augusta, ME 04333-0011 F: 207/623-5125
T: 207/287-4018
F: 207/287-8601

State Contact Contractor


Judy Geisler Contact Judy Geisler
Pharmacist Consultant Pharmacist Consultant
DHMH-Office of Health Services
MARYLAND Division of Pharmacy and Clinical Services
Contracted DUR 201 W. Preston St., Rm. 208A
Baltimore, MD 21201
T: 410/787-1455
F: 410/333-7049
E-mail: Geislerj@dhmh.state.md.us

State Contact Contractor


Paul Jeffrey Paul L. Jeffrey
Director of Pharmacy Director of Pharmacy
Division of Medical Assistance
MASSACHUSETTS
600 Washington Street, 5th Floor
Contracted DUR
Boston, MA 02111
T: 617/210-5319
F: 617/210-5865
E-mail: pjeffrey@nt.state.ma.us

State Contact Contractor


Mary Sandusky, R.Ph. First Health Services Corp.
Pharmacist Consultant 4300 Cox Rd.
MDCH/Medical Services Administration Glen Allen, VA 23060
MICHIGAN
400 S. Pine Street
Contracted DUR
Lansing, MI 48933
T: 517/335-5280
F: 517/335-7813
E-mail: sanduskym@state.mi.us

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

A-14 National Pharmaceutical Council


Pharmaceutical Benefits 2002

State Contact Contractor


Rickey R. Malloy Tyrone Gibson, President
Pharmacy Bureau Director Heritage Information Design
Division of Medicaid 1550 Pumphrey Avenue
MISSISSIPPI Robert E. Lee Building Auburn, AL 36832
Contracted DUR 239 North Lamar St., Ste. 801 334/502-3262
Jackson, MS 39201-1399
T: 601/359-6296
F: 601/359-9555
E-mail: phrrm@medicaid.state.ms.us

State Contact Contractor


Jayne Zemmer Not Available
DUR Coordinator
Div. of Medical Services
MISSOURI P.O. Box 6500
Contracted DUR Jefferson City, MO 65102-6500
T: 573/751-6963
F: 573/526-4650
E-mail:
jaynezemmer@mail.medicaid.state.mo.us

State Contact Contractor


Mark Eichler, R.Ph. Mark Eichler, R.Ph.
DUR Coordinator Mountain-Pacific Quality Health
Mountain-Pacific Quality Health Foundation Foundation
MONTANA
3404 Cooney Drive
Contracted DUR
Helena, MT 59602
T: 406/443-4020
F: 406/443-4585
E-mail: meichler@mpqhf.org

State Contact Contractor


Beth Wilson Beth Wilson
DUR Director DUR Director
Nebraska Pharmacists Association Nebraska Pharmacists Association
NEBRASKA
6221 South 58th, Ste. A 6221 South 58th, Ste. A
Contracted DUR
Lincoln, NE 68516 Lincoln, NE 68516
T: 402/420-1500 T: 402/420-1500
F: 402/420-1406 F: 402/420-1406
E-mail: beth@npharm.org E-mail: beth@npharm.org

National Pharmaceutical Council A-15


Pharmaceutical Benefits 2002

State Contact Contractor


Dionne Coston, R.N. Steve Espy, R.Ph.
Medical Services Specialist Health Info Design
Division of Health Care Financing and Policy Auburn, AL
NEVADA Pharmacy Program 800/748-0130
Contracted DUR 1100 E. Williams Street
Carson City, NV 89701
T: 775/684-3775
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us

State Contact Contractor


Lisè Ferrand, R.Ph. Clinical Manager
Pharmaceutical Services Specialist First Health Services Corp.
Office of Health Planning & Medicaid 17 Chenell Drive
NEW HAMPSHIRE
129 Pleasant Street, Annex Concord, NH 03301
Contracted DUR
Concord, NH 03301-3857 T: 603/224/2083
T: 603/271-4419 F : 603/224/6690
F: 603/271-8701
E-mail: lfarrand@dhhs.state.nh.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 Contractor


Neal Solomon, M.P.H., R. Ph. UNM College of Pharmacy
Drug Program Administrator
NEW MEXICO Medical Assistance Bureau
In-House and P.O. Box 2348
Contracted DUR Sante Fe, NM 87504-2348
T: 505/827-3174
F: 505/827-3185
E-mail: neal.solomon@state.nm.us

A-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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 Contractor


Sharman C. Leinwand Sharon Greeson, R.Ph.
Pharmacy Program Manager Pharmacy Program Manager
Division of Medical Assistance EDS
Department of Human Resources 4905 Waters Edge Drive
NORTH CAROLINA
1985 Umstead Drive Raleigh, NC 27606
Contacted DUR
2511 Mail Services Center T: 919-816-4475
Raleigh, NC 27699-2511 F: 919/816-4399
T: 919/857-4034 E-mail: sharon.greeson@eds.com
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net

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 Contractor


Nancy Nesser Ronald Graham, Pharm.D.
Medicaid Pharmacy Director Manager, Operations/DUR
Oklahoma Health Care Authority University of Oklahoma
OKLAHOMA 4545 N. Lincoln Blvd. Ste 124 College of Pharmacy
Contracted DUR Oklahoma City, OK 73105-9901 P.O. Box 26801
T: 405/522-7325 Oklahoma City, OK 73109
F: 405/522-3240 T: 405/271-6614
E-mail: nessern@ohca.state.ok.us F: 405/271-2615
E-mail: ronald-graham@ouhsc.edu

National Pharmaceutical Council A-17


Pharmaceutical Benefits 2002

State Contact Contractor


Mariellen Rich, R.Ph. Mariellen Rich, R.Ph.
Pharmacist Account Manager First Health Services Corporation
First Health Service Corporation
OREGON
565 Union St., NE, Suite 205
Contracted DUR
Salem, OR 97310
T: 503/391-1980
F: 503/391-1979
E-mail: merich@fhsc.com

State Contact Contractor


Office of Medical Assistance Programs PRODUR: EDS
PENNSYLVANIA P.O. Box 8046 RETRODUR: University of Maryland
Contracted DUR Harrisburg, PA 17105
T: 717/772-6341
F: 717/772-6366

State Contact Contractor


Paula Avarista, R.Ph. Not Available
Chief of Pharmacy
Departrment of Human Services
RHODE ISLAND
600 New Loudon Avenue
Contracted DUR
Cranston, RI 02920
T: 401/462-6390
F: 401/462-6336
E-mail: pavarist@gw.dhs.state.ri.us

State Contact Contractor


Caroline Y. Sojourner, R.Ph. First Health Services Corporation
Deptartment Head, Pharmacy Services 4300 Cox Road
S.C. Department of Health & Human Glen Allen, VA 23060
SOUTH CAROLINA
Services T: 800/884-2822
In-House and
P.O. Box 8206 F: 804/273-6961
Contracted DUR
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/255-8353
E-mail: sojourne@dhhs.state.sc.us

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

A-18 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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 Contractor


Gloria Jacobs EDS
Operations Administrator Fiscal Agent
Office of VT Health Access 312 Hurrican Lane, Suite 101
VERMONT
103 S. Main St. Williston, VT 05495
Contracted DUR
Waterbury, VT 05671 T: 802/879-4450
T: 802/241-2763 F: 802/878-3440
F: 802/241-2974
E-mail: gloriaj@wpgate1.ahs.state.vt.us

National Pharmaceutical Council A-19


Pharmaceutical Benefits 2002

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

State Contact Contractor


Vicki M. Cunningham, R.Ph. Robert Berringer, Pharm.D.
DUR Coordinator Account Manager
Bureau for Medical Services Heritage Information Systems
WEST VIRGINIA Office of Pharmacy Services 410 West Franklin St.
Contracted DUR 350 Capitol Street, Room 251 Richmond, VA 23220
Charleston, WV 25301-3707 T: 804/644-8707
T: 304/558-1700 F: 804/644-8709
F: 304/558-1542 E-mail: robertb@heritage-info.com
E-mail: vickicunningham@wvdhhr.org

State Contact Contractor


Michael Mergener, R.Ph., Ph.D. Same as State contact
Chief Pharmacist
APS Healthcare
WISCONSIN
10 East Doty St., Suite 210
Contracted DUR
Madison, WI 53703
T: 608/258-3348
F: 608/258-3359

State Contact Contractor


Debra Devereaux, R.Ph. Same as State contact
DUR Coordinator,
University of Wyoming-School of Pharmacy
WYOMING
P.O. Box 3375
Contracted DUR
Laramie, WY 82071-3375
T: 307/766-6750
F: 307/766-2953
E-mail: debdev@concentric.net

A-20 National Pharmaceutical Council


Pharmaceutical Benefits 2002

CLAIMS SUBMISSION CONTACTS, 2002

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

ARKANSAS DISTRICT OF COLUMBIA


John Herzog Contact not provided
Account Manager
EDS Federal Corp
500 President Clinton Ave., Suite 400 FLORIDA
Little Rock, AR 72201
T: 501/374-6608 Kevin Whittington
F: 501/372-2971 Clinical Program Coordinator
E-mail: john.herzog@medicaid.state.ar.us ACS
2308 Killearn Center Blvd.
Tallahassee, FL 32308
CALIFORNIA 850/201-1418
EDS Federal Corp.
P.O. Box 31029
Sacramento, CA 95813-4029
916/636-1000
Internet Address: www.medi-cal.ca.gov

National Pharmaceutical Council A-21


Pharmaceutical Benefits 2002

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

A-22 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-23


Pharmaceutical Benefits 2002

NORTH CAROLINA PENNSYLVANIA


Sharon Greeson, R.Ph. EDS
Pharmacy Program Manager 275 Grandview Avenue
EDS Camp Hill, PA 17011
4905 Waters Edge Dr. (Calls to contractor must be
Raleigh, NC 27606 made through State agency.)
T: 919/816-4475
F: 919/816-4399 RHODE ISLAND
E-mail: sharon.greeson@eds.com
EDS
401/784-3879
NORTH DAKOTA
Brendan K. Joyce, Pharm. D., R.Ph. SOUTH CAROLINA
North Dakota Department of Human Services
600 East Boulevard Avenue Rod Davis
Department 325 Bureau Chief, Bureau of Information Systems
Bismarck, ND 58505-0250 S.C. Department of Health & Human Services
T: 701/328-4023 P.O. Box 8206
F: 701/328-1544 Columbia, SC 29202-8206
E-mail: sojoyb.@state.nd.us 803/898-2610
E-mail: davisr@dhhs.state.sc.us
OHIO
SOUTH DAKOTA
First Health Services Corp.
4300 Cox Rd. Meredith Heerman
Glen Allen, VA 23060 SD Dept. of Social Services
T: 800/884-2822 Claims Processing Supervisor
F: 800/884-7682 700 Governors Dr.
Pierre, SD 57501
T: 605/773-3495
OKLAHOMA
F: 605/773-5246
Chris Shearier E-mail: meredith_heerman@state.sd.us
EDS
2401 N.W. 63rd Street, Suite 11 TENNESSEE
Oklahoma City, OK 73107
405/416-6794 Becky Garrigan
PBM Account Manager
ACS, Inc.
OREGON
Northridge Center One, Suite 400
Mariellen Rich, R.Ph. 365 Northridge Road
Pharmacist Account Manager Atlanta, GA 30350
First Health Services Corporation T: 800/334-5979
565 Union St., NE, Suite 205 F: 800/793-2305
Salem, OR 97301 E-mail: becky.garrigan@acs-inc.com
T: 503/391-1980
F: 503/391-1979
E-mail: merich@fhsc.com

A-24 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-25


Pharmaceutical Benefits 2002

PRESCRIPTION PRICE UPDATING CONTACTS, 2002

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

National Pharmaceutical Council A-26


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-27


Pharmaceutical Benefits 2002

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

MINNESOTA NEW HAMPSHIRE


First DataBank Farah Jiwa
1111 Bay Hill Drive, Suite 350 Account Manager
San Bruno, CA 94066 First Health Services Corp.
T: 650/588-5454 17 Chenell Drive
F: 650/588-4003 Concord, NH 03301
T: 603/224-2083
MISSISSIPPI E-mail: JiwaFa@fhsc.com

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

A-28 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-29


Pharmaceutical Benefits 2002

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

A-30 National Pharmaceutical Council


Pharmaceutical Benefits 2002

MEDICAID DRUG REBATE CONTACTS, 2002

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

National Pharmaceutical Council A-31


Pharmaceutical Benefits 2002

DISTRICT OF COLUMBIA IDAHO


Donna Bovell Carl Jeffrey, Pharm.D.
Pharmacist Consultant Pharmacy Services Specialist
Department of Health Department of Health and Welfare
Medical Assistance Administration Division of Medicaid
825 North Capitol Street, NE Bureau of Care Management
5th Floor 3380 Americana Terrace, Suite 140
Washington, DC 20002 Boise, ID 83720-0036
T: 202/442-5988 T: 208/364-1832
F: 202/442-4790 E-mail: jeffreyc@mmis.state.id.us
E-mail: donna.bovell@dcgov.org
ILLINOIS
FLORIDA
Bradley Wallner
Jason Ottinger Manager
Agency for Health Care Administration Illinois Department of Public Aid
2727 Mahan Dr. 2200 Churchill Road
Tallahassee, FL 32308 Springfield, IL 62704
T: 850/922-7794 217/785-6114
F: 850/922-0685 E-mail: dpa_webmaster@state.il.us
E-mail: ottingej@fdhc.state.fl.us
INDIANA
GEORGIA
ACS
Patricia Zeigler Jeter, M.P.A., R.Ph. E-mail: david.george@acs-inc.com
Pharmacist
Pharmacy Services Unit, Program Policy Section IOWA
Division of Medical Assistance
2 Peachtree St., NW, 37th Floor Rocco Russo
Atlanta, GA 30303 Third Party Liability Manager
T: 404/657-9181 ACS
F: 404/656-8366 P.O. Box 14422
E-mail: pjeter@dch.state.ga.us Des Moines, IA 50306-3422
T: 515/327-0950 Ext. 1114
F: 515/327-0945
HAWAII
Lynn Donovan, R.Ph. KANSAS
Medicaid Pharmacy Consultant
Med-Quest Division Mary H. Obley
601 Kamokila Boulevard, Room 506B Pharmacist
P.O. Box 700190 Health Care Policy Division
Kapolei, HI 96709-0190 KS Dept of Social and Rehabilitation Services
T: 808/692-8116 Docking State Office Building
F: 808/692-8131 915 SW Harrison, Room 651-South
Topeka, KS 66612-1570
T: 785/296-8406
F: 785/296-4813
E-mail: mho@srskansas.org

A-32 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

National Pharmaceutical Council A-33


Pharmaceutical Benefits 2002

MISSOURI NEW HAMPHSHIRE


Lynn Hebenheimer Glen Hutchinson
Drug Rebate Unit Supervisor First Health Services Corp.
Division of Medical Services 4300 Cox Road
P.O. Box 6500 Glen Allen, VA 23060
Jefferson City, MO 65102 T: 800/884-2822
T: 573/526-5778 F: 804/965-7647
F: 573/522-2594 E-mail: hutchig@fhsc.com
E-mail:
lynnhebenheimer@mail.medicaid.state.mo.us NEW JERSEY
Carl D. Tepper, R.Ph.
MONTANA
Chief, Pharmaceutical Services
Betty DeVaney Department of Human Services
Drug Rebate Coordinator Division of Medical Assistance and Health Services
Dept. of Public Health and Human Services P.O. Box 712, Bldg 11-A
Medicaid Services Bureau Trenton, NJ 08625
1400 Broadway T: 609/588-2744
P.O. Box 202951 F: 609/588-3889
Helena, MT 59620-2951 E-mail: cdtepper@dhs.state.nj.us
T: 406/444-3457
F: 406/444-1861 NEW MEXICO
E-mail: bdevaney@state.mt.us
Sonya Miera
Drug Rebate Program Administration
NEBRASKA
Medical Assistance Division
Karen Jaques P.O. Box 2348
Accountant II Santa Fe, NM 87504-2348
HHSS-Finance and Support T: 505/827-7777
301 Centennial Mall South F: 505-827-3185
NSOB, 5th Floor
P.O. Box 95026 NEW YORK
Lincoln, NE 68509-5026
F: 402/471-9397 Mark-Richard Butt, M.S., R.Ph.
E-mail: karen.jaques@hhss.state.ne.us Director, Pharmacy Policy and Operations
Bureau of Program Guidance
Office of Medicaid Management
NEVADA
NYS Department of Health
Dionne Coston, R.N. 99 Washington Ave., Room 606
Medicaid Services Specialist Albany, NY 12210
Nevada Medicaid Office T: 518/474-9219
Pharmacy Program F: 518/473-5508
1100 E. Williams Street E-mail: mrb01@health.state.ny.us
Carson City, NV 89701
T: 775/684-3775
F: 775/684-3762
E-mail: dcpstpm@dhcfp.state.nv.us

A-34 National Pharmaceutical Council


Pharmaceutical Benefits 2002

NORTH CAROLINA OREGON


Sharon Greeson, R.Ph. Becky Smith
Pharmacy Program Manager Rebate Analyst
EDS First Health Services Corporation
4905 Waters Edge Dr. 565 Union St. NE, Suite 205
Raleigh, NC 27606 Salem, OR 97301
T: 919/816-4475 T: 503/391-1981
F: 919/816-4399 F: 503/391-1979
E-mail: sharon.greeson@eds.com E-mail: rssmith@fhsc.com

NORTH DAKOTA PENNSYLVANIA


Brendan K. Joyce, Pharm.D., R.Ph. Louis J. Cappello
Department of Human Services Dispute Resolution Coordinator
600 East Boulevard Ave. Office of Medical Assistance Programs
Department 325 701 Crosby Street, Suite A
Bismarck, ND 58505-0250 Chester, PA 19013
T: 701/328-4023 T: 610/447-5385
F: 701/328-1544 F: 610/447-5385
E-mail: sojoyb@state.nd.us E-mail: lcappello@state.pa.us

OHIO RHODE ISLAND


Robert P. Reid, R.Ph. Paula Avarista, R.Ph.
Administrator, Pharmacy Services Unit Chief of Pharmacy
Ohio Department of Job and Family Services Department of Human Services
Bureau of Health Plan Policy 600 New London Avenue
30 East Broad Street, 27th Floor Cranston, RI 02920
Columbus, OH 43215-3414 T: 401/462-6390
T: 614/466-6420 F: 401/462-6336
F: 614/466-2908 E-mail: pavarist@gw.dhs.state.ri.us
E-mail: reidr@odjfs.state.oh.us
SOUTH CAROLINA
OKLAHOMA
Caroline Y. Sojurner, R.Ph.
Tom Simonson Department Head
Drug Rebate Program Manager Department of Pharmacy Services
Oklahoma Health Care Authority S.C. Department of Health & Human Services
4545 N. Lincoln Blvd, Suite 124 P.O. Box 8206
Oklahoma City, OK 73105-9901 Columbia, SC 29202-8206
T: 405/522-7327 T: 803/898-2876
F: 405/522-3236 F: 803/255-8353
E-mail: simonsoT@ohca.state.ok.us E-mail: sojurne@dhhs.state.sc.us

National Pharmaceutical Council A-35


Pharmaceutical Benefits 2002

SOUTH DAKOTA VIRGINIA


Helen Rokusek David B. Shepherd, R. Ph.
Rebate Coordinator Pharmacy Consultant
SD Dept. of Social Services Department of Medical Assistance Services
700 Governors Drive 600 East Broad Street, Suite 1300
Pierre, SD 57501 Richmond, VA 23219
605/773-3653 T: 804/786-8056
F: 804/786-0414
TENNESSEE E-mail: dsheper@dmas.state.va.us

H. Leo Sullivan, D.Ph.


Director of Pharmacy Services WASHINGTON
Bureau of TennCare Connie Riddle
729 Church Street Medical Assistance Administration, DSHS
Nashville, TN 37247-6501 P.O. Box 45503
T: 615/741-0213 Olympia, WA 98504-5503
F: 615/253-5481 360/725-1243
E-mail: leo.sullivan@state.tn.us
WEST VIRGINIA
TEXAS
Gail Goodnight, R.Ph.
Heather Murphy Rebate Coordinator
Manager, Pharmacy Rebates Bureau for Medical Services
Vendor Drug Program Contracts and Rebates Office of Pharmacy Services
Texas Health and Human Services Commission 350 Capitol Street, Room 251
1100 West 49th Street Charleston, WV 25301-3707
Austin, TX 78756-3174 T: 304/558-1700
T: 512/338-6963 F: 304/558-1542
F: 512/338-6910 E-mail: gailgoodnight@wvdhhr.org
E-mail: heather.murphy@hhsc.state.tx.us
WISCONSIN
UTAH
Ellen Orsburne
Raedell Ashley, R.Ph. Medicaid Systems Analyst
Pharmacy Director Division of Health Care Financing
Division of Health Care Financing Department of Health and Family Services
P.O. Box 143102 One West Wilson Street
Salt Lake City, UT 84114-3102 P.O. Box 309
T: 801/538-6495 Madison, WI 53701-0309
F: 801/538-6099 T: 608/267-7939
E-mail: rashley@doh.state.ut.us F: 608/261-7793
E-mail: orsbuer@dhfs.state.wi.us
VERMONT
Christine Dapkiewicz WYOMING
Drug Rebate Coordinator Suzie Gambell
EDS ACS
312 Hurricane Lane, Suite 101 P.O. Box 667
Williston, VT 05495 Cheyenne, WY 82003
T: 802/879-4450 T: 307/772-8400
F: 802/878-3440 F: 307/772-8405

A-36 National Pharmaceutical Council


Pharmaceutical Benefits 2002

STATE OFFICIALS, 2003

ALABAMA ALASKA ARIZONA


Governor Governor Governor
Honorable Bob Riley Honorable Frank Murkowski Honorable Janet Napolitano
State Capitol P.O. Box 110001 State Capitol
600 Dexter Avenue Juneau, AK 99811-0001 1700 W. Washington
Montgomery, AL 36103 T: 907/465-3500 Phoenix, AZ 85007
T: 334/242-7100 F: 907/465-3532 T: 602/542-4331
F: 334/353-0004 E-mail: governor@gov.state.ak.us F: 602/542-1381
E-mail: Internet address: E-mail: azgov@azgov.state.az.us
governor@governor.state.al.us www.gov.state.ak.us Internet address:
Internet address: www.governor.state.az.us
www.governor.state.al.us Single State Agency Director
Mr. Joel Gilbertson, Commissioner Single State Agency Director
Single State Agency Director Department of Health and Social Ms. Phyllis Beidess, Director
Mr. Mike Lewis, Commissioner Services Arizona Health Care Cost
Alabama Medicaid Agency P.O. Box 110601 Containment System
501 Dexter Avenue Juneau, AK 99811-0601 80l East Jefferson Street
P.O. Box 5624 T: 907/465-3030 Phoenix, AZ 85034
Montgomery, AL 36103-5624 F: 907/465-3068 T: 602/417-4680
T: 334/242-5010 E-mail: F: 602/252-6536
F: 334/242-0556 joel_gilbertson@health.state.ak.us E-mail:
E-mail: Internet address: PXBiedess@ahccs.state.az.us
ALmedicaid@medicaid.state.al.us www.hss.state.ak.us Internet address:
www.ahcccs.state.az.us
Medicaid Director Medicaid Director
Mr. Mike Lewis, Commissioner Mr. Bob Labbe, Director Medicaid Director
Alabama Medicaid Agency Division of Medical Assistance Ms. Phyllis Beidess, Director
501 Dexter Avenue Department of Health and Social Arizona Health Care Cost
P.O. Box 5624 Services Containment System
Montgomery, AL 36103-5624 P.O. Box 110660 801 East Jefferson Street
T: 334/242-5600 Juneau, AK 99811-0660 Phoenix, AZ 85034
F: 334/242-0556 T: 907/465-3355 T: 602/417-4680
E-mail: F: 907/465-2204 F: 602/252-6536
Almedicaid@medicaid.state.al.us E-mail: Blabbe@health.state.ak.us E-mail:
Internet address: PXBiedess@ahcccs.state.az.us
www.hss.state.ak.us/dma Internet address:
www.ahcccs.state.az.us

National Pharmaceutical Council A-37


Pharmaceutical Benefits 2002

ARKANSAS CALIFORNIA COLORADO


Governor Governor Governor
Honorable Mike Huckabee Honorable Gray Davis Honorable Bill Owens
State Capitol Building State Capitol, First Floor State Capitol
Little Rock, AR 72201 Sacramento, CA 958l4 Room 136
T: 501/682-2345 T: 916/445-2841 Denver, CO 80203
F: 501/682-1382 F: 916/445-4633 T: 303/866-2471
E-mail: mike.huckabee@state.ar.us E-mail: governor@governor.ca.gov F: 303/866-2003
Internet address: Internet address: E-mail: governorowens@state.co.us
www.state.ar.us/governor/staff.html www.governor.ca.gov/state/govsite/ Internet address:
gov_hompage.jsp www.state.co.us/gov_dir/governor_
Single State Agency Director office.html
Mr. Kurt Knickrehm, Director Single State Agency Director
Department of Human Services Ms. Diana M. Bonta, Director Single State Agency Director
P.O. Box 1437, Slot 329 Medical Care Services Ms. Marva Livingston Hammons
Little Rock, AR 72203-1437 Department of Health Services Executive Director
T: 501/682-8650 714 P Street, Room 1253 Department of Human Services
F: 501/682-6836 Sacramento, CA 95814 l575 Sherman Street
E-mail: kurt.knickrehm@state.ar.us T: 916/657-1425 Denver, CO 80203-1714
Internet address: F: 916/657-5183 T: 303/866-5096
www.accessarkansas.org/dhs E-mail: dbonta@dhs.ca.gov F: 303/866-4740
Internet address: E-mail:
Medicaid Director www.dhs.cahwnet.gov Marva.hammons@state.co.us
Mr. Ray Hanley, Director Internet address:
Division of Medical Services, Dept. Medicaid Director www.cdhs.state.co.us
of Human Services Mr. Stan Rosenstein, Deputy
P.O. Box 1437, Slot 1100 Director Medicaid Director
Little Rock, AR 72203-1437 Medical Care Services Mr. Richard Allen
T: 50l/682-8292 Department of Health Services Executive Director
F: 501/682-1197 714 P Street, Room 1253 Department of Health Care Policy
E-mail: Sacramento, CA 95814 and Financing
Ray.Hanley@medicaid.state.ar.us T: 916/654-0391 1575 Sherman Street
Internet address: F: 916/657-1156 Denver, CO 80203-1714
www.accessarkansas.org/dhs E-mail: srosenst@dhs.ca.gov T: 303/866-2859
Internet address: www.medi- F: 303/866-2803
cal.ca.gov TDD: 303/866-3883
E-mail: Richard.allen@state.co.us
Internet address:
www.chcpf.state.co.us

A-38 National Pharmaceutical Council


Pharmaceutical Benefits 2002

CONNECTICUT DELAWARE DISTRICT OF COLUMBIA


Governor Governor Mayor
Honorable John G. Rowland Honorable Ruth Ann Minner Honorable Anthony A. Williams
State Capitol, Room 202 Tatnall Building John A. Wilson Building
Hartford, CT 06l06 William Penn Street 1350 Pennsylvania Avenue, NW
T: 860/566-4840 Dover, DE 19901 Washington, DC 20004
F: 820/524-7395 T: 302/739-4101 T: 202/727-2980
E-mail: F: 302/739-2775 F: 202/727-6561
governor.rowland@po.state.ct.us E-mail: gminner@state.de.us E-mail: mayor@dc.gov
Internet address: Internet address: Internet address: www.dc.gov
www.state.ct.us/governor www.state.de.us/governor/index.htm
Single State Agency Director
Single State Agency Director Single State Agency Director Mr. James A. Buford, Director
Ms. Patricia Wilson-Coker, Mr. Vincent P. Meconi, Secretary Department of Health
Commissioner Department of Health and Social 825 North Capitol Street, NE
Department of Social Services Services Fourth Floor
25 Sigourney Street 1901 North DuPont Highway Washington, DC 20002
Hartford, CT 06106-5033 New Castle, DE l9720 T: 202/442-5999
T: 860/424-5008 T: 302/421-6705 F: 202/442-4788
F: 860/566-2022 F: 302/255-4429 E-mail: james.buford@dc.gov
E-mail: pat.wilson- E-mail: vmeconi@state.de.us Internet address:
coker@po.state.ct.us Internet address: www.dchealth.dc.gov
Internet address: www.state.de.us/dhss/index.html
www.dss.state.us.ct Medicaid Director
Medicaid Director Ms. Wanda R. Tucker, Interim
Medicaid Director Mr. Philip Soulé Director
Mr. David Parella, Deputy Deputy Director/Medicaid Medical Assistance Administration
Commissioner Department of Health and Social Department of Health
Department of Social Services Services 825 North Capitol Street, NE
25 Sigourney Street 1901 North DuPont Highway Fifth Floor
Hartford, CT 06106-5116 New Castle, DE 19720 Washington, DC 20002
T: 860/424-5116 T: 302/255-9501 T: 202/442-5988
F: 860/424-5114 F: 302/255-4425 F: 202/442-4790
E-mail: E-mail: wanda.tucker@dc.gov
david.parrella@po.state.ct.us Internet address:
Internet address: www.dchealth.dc.gov
www.dss.state.ct.us

National Pharmaceutical Council A-39


Pharmaceutical Benefits 2002

FLORIDA GEORGIA GUAM


Governor Governor Governor
Honorable Jeb Bush Honorable Sonny Purdue Honorable Felix Comacho
The State Capitol 203 State Capitol Adelup Complex
Tallahassee, FL 32399-0001 Atlanta, GA 30334 P.O. Box 2950
T: 850/488-4441 T: 404/656-l776 Agana, GU 96932
F: 850/487-0801 F: 404/657-7332 T: 671/479-2002
E-mail: governor@myflorida.com E-mail: governor@gov.state.ga.us F: 671/479-2009
Internet address: Internet address: E-mail: governor@mail.gov.gu
www.myflorida.com/b_eog/owa/b_ www.gagovernor.org Internet address:
eog_www.html.main_page www.gov.gu/webtax/govoff.html
Single State Agency Director
Single State Agency Director Mr. Gary Redding, Commissioner Single State Agency Director
Dr. Rhonda Medows, Secretary Department of Community of Health Mr. Peter John B. Comacho,
Agency for Health Care 2 Peachtree Street, NW Administrator
Administration Suite 4043 Dept. of Public Health and Social
2727 Mahan Drive, Mail Stop 1 Atlanta, GA 30303-3159 Services
Tallahassee, FL 32308 T: 404/656-4507 P.O. Box 2816
T: 850/922-3809 F: 404/651-6880 Agana, GU 96932
F: 850/488-0043 E-mail: gredding@dma.state.ga.us T: 671/735-7102
E-mail: Internet address: F: 671/734-5910
AHCAcontact@fdhc.state.fl.us www.dch.state.ga.us E: mail:
Internet address: director@dphss.govguam.net
www.fdhc.state.fl.us Medicaid Director
Mr. Mark Trail, Director Medicaid Director
Medicaid Director Department of Community Health Ms. Ma Theresa Arcangel, Acting
Mr. Bob Sharpe, Deputy Secretary Medical Assistance Division Administrator
Agency for Health Care 2 Peachtree Street, NW Bureau of Health Care Financing
Administration Suite 4043 Department of Public Health and
2727 Mahan Drive, Mail Stop 8 Atlanta, GA 30303-3159 Social Services
Tallahassee, FL 32308 T: 404/656-4496 P.O. Box 28l6
T: 850/488-3560 F: 404/651-6880 Agana, GU 96910
F: 850/488-0043 E-mail: mtrail@dma.state.ga.us T: 671/735-7282
E-mail: Internet address: F: 671/734-5910
AHCAcontact@fdhc.state.fl.us www.dch.state.ga.us
Internet address:
www.fdhc.state.fl.us

A-40 National Pharmaceutical Council


Pharmaceutical Benefits 2002

HAWAII IDAHO ILLINOIS


Governor Governor Governor
Honorable Linda Lingle Honorable Dirk Kempthorne Honorable Rod Blagojevich
State Capitol P.O. Box 83720 207 Capitol Building
415 S. Beretania Street Boise, ID 83720-0034 State Capitol
Honolulu, HI 968l3 T: 208/334-2100 Springfield, IL 62706
T: 808/586-0034 F: 208/334-3454 T: 2l7/782-6830
F: 808/586-0006 E-mail: governer@gov.state.id.us F: 217/782-1853
E-mail: gov@gov.state.hi.us Internet address: E-mail: governor@state.il.us
Internet address: www2.id.us/gov/index.htm Internet address:
www.gov.state.hi.us www.state.il.us/gov
Single State Agency Director
Single State Agency Director Mr. Karl Kurtz, Director Single State Agency Director
Ms. Lillian B. Koller Department of Health and Welfare Mr. Barry Maram, Director
Department of Human Services 450 West State Street Department of Public Aid
1390 Miller Street, Room 209 Boise, ID 83720-0036 201 South Grand Avenue, East,
Honolulu, HI 96813 T: 208/334-5500 Third Floor
808/586-4997 F: 208/334-6558 Springfield, IL 62794
E-Mail: lillian.b.koller@hawaii.gov E-mail: dhwinfo@idhw.state.id.us T: 2l7/782-1200
Internet address: Internet address: F: 217/524-7120
www.state.hi.us/dhs www2.state.id.us/dhw E-mail:
directordpa@mail.idpa.state.il.us
Medicaid Director Medicaid Director Internet address:
Ms. Aileen Hiramastu, Mr. Joe Brunson, Administrator www.state.il.us/dpa
Administrator Division of Medicaid
Med-Quest Division Department of Health and Welfare Medicaid Director (Medical
Department of Human Services Americana Building Operations)
P.O. Box 399 P.O. Box 83720 Mr. A. George Hovanec,
Honolulu, HI 96809-0339 Boise, ID 83720-0036 Administrator
T: 808/692-8050 T: 208/364-5747 Division of Medical Programs
F: 808/586-4890 F: 208/334-1811 Department of Public Aid
E-mail: E-mail: Allynkp@mmis.state.id.us 20l South Grand Avenue, East,
AHiramatsu@medicaid.dhs.state.hi. Internet address: Third Floor
us www2.state.id.us/dhw Springfield, IL 62763-0001
Internet address: T: 2l7/782-2570
www.state.hi.us/dhs F: 217/524-7979
E-mail:
directordpa@mail.idpa.state.il.us
Internet address:
www.state.il.us/dpa

National Pharmaceutical Council A-41


Pharmaceutical Benefits 2002

INDIANA IOWA KANSAS


Governor Governor Governor
Honorable Frank O’Bannon Honorable Thomas J. Vilsack Honorable Kathleen Sebelius
State House, Room 206 State Capitol Building 2nd Floor
200 W. Washington Street Des Moines, IA 503l9 State Capitol Building
Indianapolis, IN 46204 T: 5l5/28l-0561 Topeka, KS 66612-1590
T: 3l7/232-4567 F: 515/281-6611 T: 785/296-3232
F: 317/232-3443 E-mail: gen.office@igov.state.ia.us F: 785/296-7973
E-mail: fobannon@gov.state.in.us Internet address: E-mail: governor@ink.org
Internet address: www.in.gov/gov www.state.ia.us/governor Internet address:
www.accesskansas.org/governor
Single State Agency Director Single State Agency Director
Mr. John Hamilton, Secretary Mr. Kevin Concannon, Director Single State Agency Director
Family and Social Services Department of Human Services Ms. Janet Schalansky, Secretary
Administration Hoover State Office Building Kansas Department of Social and
Room 461, Mail Stop 25 Fifth Floor Rehabilitation Services
P.O. Box 7083 Des Moines, IA 503l9-0114 Docking State Office Building
402 W. Washington Street T: 5l5/28l-5452 915 SW Harrison Street
Indianapolis, IN 46207-7083 F: 515/281-4980 Topeka, KS 66612
T: 317/233-4690 E-mail: kconcannon@dhs.state.ia.us T: 785/296-3271
F: 317/233-4693 Internet address: www.dhs.state.ia.us F: 785/296-2173
E-Mail: Jhamilton@fssa.state.in.us E-mail: JKS@srskansas.org
Internet address: Medicaid Director Internet address:
www.state.in.us/fssa Ms. Sally Titus Cunningham, www.srskansas.org
Interim Director
Medicaid Director Division of Medical Services Medicaid Director
Ms. Melanie Bella, Assistant Department of Human Services Mr. Robert Day, Commissioner
Secretary Hoover State Office Building Adult and Medical Services
Medicaid Policy and Planning Fifth Floor Department of Social and
Family and Social Services Des Moines, IA 503l9-0114 Rehabilitation Services
Administration T: 5l5/281-5452 Docking State Office Building
402 W. Washington Street, Room F: 515/281-7791 915 SW Harrison Street, Room 651
W382 E-mail: scunnin@dhs.state.ia.us South
Indianapolis, IN 46204-2739 Internet address: www.dhs.state.ia.us Topeka, KS 66612
T: 317/233-4455 T: 785/296-3981
F: 317/232-7382 F: 785/296-4813
E-mail: mbella@fssa.state.in.us E-mail: rmd@srskansas.org
Internet address: Internet address:
www.state.in.us/fssa www.srskansas.org

A-42 National Pharmaceutical Council


Pharmaceutical Benefits 2002

KENTUCKY LOUISIANA MAINE


Governor Governor Governor
Honorable Paul E. Patton Honorable M. J. “Mike” Foster Honorable John Baldacci
State Capitol Building State Capitol 1 State House Station
700 Capitol Avenue P.O. Box 94004 Augusta, Maine 04333-0001
Frankfort, KY 4060l Baton Rouge, LA 70804 T: 207/287-3531
T: 502/564-2611 T: 225/342-7015 F: 207/287-1034
F: 502/564-2517 F: 225/342-7099 E-mail: governor@state.me.us
E-mail: governor@mail.state.ky.us E-mail: Internet address:
Internet address: www.gov.state.la.us/gov_email.html www.state.me.us/governor.index
www.gov.state.ky.us Internet address: .html
www.gov.state.la.us
Single State Agency Director Single State Agency Director
Ms. Marcia Morgan, Secretary Single State Agency Director Mr. Peter Walsh
Cabinet for Health Services Mr. David W. Hood, Secretary Acting Commissioner
275 East Main Street, 5C-A Department of Health and Hospitals Department of Human Services
Frankfort, KY 40621 P.O. Box 629, Bin #2 State House Station 11
T: 502/564-6786 Baton Rouge, LA 70821-0629 Augusta, ME 04333-0011
F: 502/564-0274 T: 225/342-9500 T: 207/287-2736
E-mail: F: 225/342-9508 F: 207/287-3005
brandyp.cantor@mail.state.ky.us E-mail: bgulotta@dhh.state.la.us E-mail: peter.e.walsh@maine.gov
Internet address: Internet address: Internet address:
www.chs.state.ky.us www.dhh.state.la.us www.state.me.us/dhs/wecolme_to_
dhs.htm
Medicaid Director Medicaid Director
Mr. Mike Robinson, Commissioner Mr. Ben Bearden, Director Medicaid Director
Department for Medicaid Services Bureau of Health Services Financing Mr. Eugene Gessow, Director
Sixth Floor Department of Health and Hospitals Bureau of Medical Services
275 East Main Street P.O. Box 91030 Department of Human Services
Frankfort, KY 40621 Baton Rouge, LA 70821-9030 State House Station 11
T: 502/564-4321 T: 225/342-3891 Augusta, ME 04333-0011
F: 502/564-0509 F: 225/342-9508 T: 207/287-2674
E-mail: E-mail: BBearden@dhhmail.dhh- F: 207/287-2675
mike.robinson@mail.state.ky.us state.la.us E-mail: gene.gessow@state.me.us
Internet address: Internet address:
www.chs.ky.us/dms/default.htm www.dhh.state.la.us/MEDICAID/
index.htm

National Pharmaceutical Council A-43


Pharmaceutical Benefits 2002

MARYLAND MASSACHUSETTS MICHIGAN


Governor Governor Governor
Honorable Robert Ehrlich Honorable Mitt Romney Honorable Jennifer Granholm
State House Executive Office, State House P.O. Box 30013
Annapolis, MD 21401 Room 360 Lansing, MI 48909
T: 410/974-3901 Boston, MA 02133 T: 5l7/335-7858
F : 410/974-3275 T: 617/727-6250 F: 517/335-6863
E-mail: governor@gov.state.md.us F: 617/727-9725 E-mail: wwwimichigan.gov/gov
Internet address: E-mail: goffice@state.ma.us Internet address:
www.gov.state.md.us www.michigan.gov/gov
Single State Agency Director
Single State Agency Director Mr. Ronald Preston, Secretary Single State Agency Director
Mr. Nelson J. Sabatini Health and Human Services Ms. Janet Olszewski
Secretary Executive Office Director
Department of Health & Mental One Ashburton Place, Room 1109 Michigan Department of
Hygiene Boston, MA 02108 Community Health
Herbert R. O'Connor Building T: 617/727-0077 Lewis Cass Building
201 West Preston Street F: 617/727-5134 320 South Walnut Street
Fifth Floor E-mail: ronald.preston@state.ma.us Lansing, MI 48913
Baltimore, MD 21201 Internet address: www.masscare.org T: 517/335-0267
T: 410/225-6500 F: 517/373-4288
F: 410/161-6489 Medicaid Director E-mail: norris@michigan.gov
E-mail: Mr. Wendy Warring, Commissioner Internet address:
nsabatini@dhmh.state.md.us Division of Medical Assistance www.michigan.gov/mdch
Internet address: 600 Washington Street
www.dhmh.state.md.us Boston, MA 02111 Medicaid Director
T: 617/210-5690 Mr. Patrick Barrie
Medicaid Director T: 617/210-5000 Deputy Director
Ms. Debbie Chang F: 617/210-5697 Health Programs Administration
Deputy Secretary for Health Care E-mail: Michigan Department of
Financing Wwarring@nt.dma.state.ma.us Community Health
Department of Health & Mental 400 S. Pine Street
Hygiene Lansing, MI 48909
201 West Preston Street T: 517/335-5001
Baltimore, MD 21201 F: 517/335-5007
T: 410/767-4664 E-mail: barriep@michigan.gov
F: 410/333-7687 Internet address:
E-mail: Dchang@dhmh.md.state.us www.michigan.gov/mdch
Internet address:
www.dhmh.state.md.us

A-44 National Pharmaceutical Council


Pharmaceutical Benefits 2002

MINNESOTA MISSISSIPPI MISSOURI


Governor Governor Governor
Honorable Tim Pawlenty Honorable Ronnie Musgrove Honorable Bob Holden
130 State Capitol State Capitol State Capitol Building, Room 218
St. Paul, MN 55155-1099 P.O. Box 139 P.O. Box 720
T: 651/296-3391 Jackson, MS 39205 Jefferson City, MO 65102-0720
F: 651/296-0674 60l/359-3150 T: 573/751-3222
E-mail: tim.pawlenty@state.mn.us E-mail: F: 573/751-1495
Internet address: www.governor.state.ms.us/abouttheg E-mail:
www.governor.state.mn.us ov/writetoindex.html www.gov.state.mo.us/mail1.html
Internet address: Internet address:
Single State Agency Director www.governor.state.ms.us www.gov.state.mo.us
Mr. Kevin Goodno,
Commissioner Single State Agency Director Single State Agency Director
Minnesota Department of Human Ms. Thelma Brittain Mr. Dana Katherine Martin,
Services Executive Director Director
444 Lafayette Road North Department of Human Services Department of Social Services
St. Paul, MN 55155-3815 750 North State Street P.O. Box 1527
T: 651/296-2701 Jackson, MS 39201-1399 Jefferson City, MO 65102
F: 651/297-3230 T: 601/359-4500 T: 573/751-4815
E-mail: F: 601/359-4910 F: 573/751-3203
commissioner.dhs@state.mn.us E-mail: tbrittain@mdhs.state.ms.us E-mail: dlorts@mail.dss.state.mo.us
Internet address: Internet address: Internet address:
www.dhs.state.mn.us www.mdhs.state.ms.us www.dss.state.mo.us

Medicaid Director Medicaid Director Medicaid Director


Ms. Mary B. Kennedy, Medicaid Ms. Rica Lewis Payton Mr. Gregory A. Vadner
Director Executive Director Division of Medical Services
Assistant Commissioner Health Division of Medicaid Department of Social Services
Care Suite 801, Robert E. Lee Building 615 Howerton Court
Minnesota Department of Human 239 North Lamar Street P.O. Box 6500
Services Jackson, MS 39201 Jefferson City, MO 65102-6500
444 Lafayette Road T: 601/359-6050 T: 573/751-3425
St. Paul, MN 55l55-3852 F: 601/359-6048 F: 573/751-6564
T: 651/297-7515 E-mail: E-mail: gvadner@mail.state.mo.us
F: 651/297-3230 exfmp@medicaid.state.ms.us
E-mail: mary.kennedy@state.mn.us Internet address:
Internet address: www.mdhs.state.ms.us
www.dhs.state.mn.us

National Pharmaceutical Council A-45


Pharmaceutical Benefits 2002

MONTANA NEBRASKA NEVADA


Governor Governor Governor
Honorable Judy Martz Honorable Mike Johanns Honorable Kenny C. Guinn
State Capitol P.O. Box 94848 State Capitol
Helena, MT 59620-0801 Lincoln, NE 68509-4848 Carson City, NV 89710
T: 406/444-3111 T: 402/471-2244 T: 702/687-5670
F: 406/444-4151 F: 402/471-6031 F: 775/684-5683
E-mail: E-mail: jodee@mail.state.ne.us E-mail:
www.discoveringmontana.com/gov/ Internet address: www.gov.nol.org www.gov.state.nv.us/mail.gov.htm
contact.tm Internet address:
Internet address: Single State Agency Director www.gov.state.nv.us
www.state.mt.us/governor/css/defa Mr. Stephen Curtiss, Director
ult.asp Nebraska Department of Health and Single State Agency Director
Human Services Mr. Mike Wilden, Director
Single State Agency Director Finance and Support Department of Human Resources
Dr. Gail Gray, Director P.O. Box 95026 505 East King Street, Room 600
Department of Public Health and Lincoln, NE 68509-5026 Carson City, NV 89710
Human Services T: 402/471-8533 T: 775/684-4000
P.O. Box 4210 F: 402/471-9449 F: 775/684-4010
111 N. Sanders E-mail: E-mail: slindsey@dhr.state.nv.us
Helena, MT 59604-4210 Kelly.ostrander@hhss.state.ne.us Internet address:
T: 406/444-5622 Internet address: www.hr.state.nv.us
F: 406/444-1970 www.hhs.state.ne.us/fin/finindex.htm
E-mail: ggray@state.mt.us Medicaid Director
Internet address: Medicaid Director Mr. Chuck Duarte, Administrator
www.dphhs.state.mt.us Mr. Bob Seiffert, Administrator Division of Health Care Financing
Medicaid Division and Policy
Medicaid Director Nebraska Department of HHS 1100 East William Street, Suite 116
Ms. Margaret A. Bullock, Finance and Support Carson City, NV 89710
Administrator P.O. Box 95026 T: 775/684-3676
Division of Health Policy and 301 Centennial Mall South, 5th Floor F: 775/684-8792
Services Lincoln, NE 68509-5026 E-mail:
Department of Public Health and T: 402/471-9147 cduarte@govmail.state.nv.us
Human Services F: 402/471-9092 Internet address:
1400 Broadway E-mail: bob.seiffert@hhss.state.ne.us www.dhcfp.state.nv.us
Helena, MT 59601 Internet address:
T: 406/444-4141 www.hhs.state.ne.us/med/medindex.
F: 406/444-1861 htm
E-mail: Mbullock@state.mt.us
Internet address:
www.dphhs.state.mt.us/hpsd/index.
htm

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Pharmaceutical Benefits 2002

NEW HAMPSHIRE NEW JERSEY NEW MEXICO


Governor Governor Governor
Honorable Craig Benson Honorable Jim McGreevey Honorable Bill Richardson
State House 125 West State Street Office of The Governor
Room 208 State House CN-001 State Capitol
107 North Main Street Trenton, NJ 08625 Suite 400
Concord, NH 03301-4990 T: 609/292-6000 Santa Fe, NM 87503
T: 603/271-2121 F: 609/292-3454 T: 505/827-3000
F: 603/271-5686 E-mail: F: 505/476-2226
E-mail: www.state.nh.us/governor/ www.state.nj.us/governor/govmail. E-mail: gov@gov.state.nm.us
comment.html html Internet address:
Internet address: Internet address: www.governor.state.nm.us
www.state.nh.us/governor www.state.nj.us/governor
Single State Agency Director
Single State Agency Director Single State Agency Director Ms. Pamela Hyde, Secretary
Mr. Nicholas Vailas, Commissioner Ms. Gwendolyn L. Harris, New Mexico Human Services
Department of Health and Human Commissioner Department
Services Department of Human Services P.O. Box 2348
129 Pleasant Street Capitol Place One CN-700, Fifth Santa Fe, NM 87504-2348
Concord, NH 03301-3857 Floor T: 505/827-7750
T: 603/271-4331 222 South Warren Street F: 505/827-6286
F: 603/271-4912 Trenton, NJ 08625 E-mail: pam.hyde@state.nm.us
E-mail: khenders@dhhs.state.us T: 609/292-3717 Internet address:
Internet address: F: 609/292-3824 www.state.nm.us/hsd
www.dhhs.state.nh.us/DHHS/ E-mail: webmaster@dhs.state.nj.us
DHHS/SITE/default.htm Internet address: Medicaid Director
www.state.nj.us/humanservices Ms. Carolyn Ingram, Director
Medicaid Director Medical Assistance Division
Ms. Lori Read, Director Medicaid Director New Mexico Human Services
Office of Health Planning & Ms. Kathryn A. Plant, Director Department
Medicaid Division of Medical Assistance and P.O. Box 2348
Department of Health and Human Health Services Santa Fe, NM 87504-2348
Services Department of Human Services T: 505/827-3106
129 Pleasant Street P.O. Box 712 F: 505/827-3185
Concord, NH 03301-3857 Trenton, NJ 08625-0712 E-mail:
T: 603/271-5254 T: 609/588-2600 carolyn.ingram@state.nm.us
F: 603/271-8431 F: 609/588-3583 Internet address:
Internet address: E-mail: www.state.nm.us/hsd/mad/index
www.dhhs.state.nh.us/DHHS/ Kathryn.plant@dhs.state.nj.us
OHPM/default.htm Internet address:
www.state.nj.us/humanservices/
dmahs/index.html

National Pharmaceutical Council A-47


Pharmaceutical Benefits 2002

NEW YORK NORTH CAROLINA NORTH DAKOTA


Governor Governor Governor
Honorable George E. Pataki Honorable Mike Easley Honorable John Hoeven
Executive Chamber Office of the Governor Department 101
State Capitol 116 West Jones Street 600 East Boulevard Avenue
Albany, NY 12224 20301 Mail Service Center Bismarck, ND 58505-0001
T: 5l8/474-8390 Raleigh, NC 27699-0301 T: 701/328-2200
F: 518/474-3767 T: 919/733-4240 F: 701/328-2205
E-mail: F: 919/733-2120 E-mail: governor@state.nd.us
gov.pataki@chamber.state.ny.us E-mail: Internet address:
Internet address: www.governor.state.nc.us/email.asp? www.governor.state.nd.us
www.state.ny.us/governor to=1
Internet address: Single State Agency Director
Single State Agency Director www.governor.state.nc.us Ms. Carol Olson, Executive
Antonio C. Novello, M.D., M.P.H., Director
Commissioner Single State Agency Director Department of Human Services
NYS Department of Health Ms. Carmen Hooker Odom, 600 East Boulevard Avenue,
ESP, Corning Tower Building Secretary Dept. 325
Albany, NY 12237 Department of Health and Human Bismarck, ND 58505-0250
T: 518/474-2011 Services T: 701/328-2538
F: 518/474-5450 2001 Mail Service Center F: 701/328-2359
E-mail: acn01@health.state.ny.us Raleigh, NC 27699-2001 E-mail: dhseo@state.nd.us
Internet address: T: 919/733-4534 Internet address:
www.health.state.ny.us/homens6. F: 919/715-4645 www.lnotes.state.nd.us/dhs/dhsweb.
html E-mail: nsf
carmen.hookerodom@ncmail.net
Medicaid Director Internet address: Medicaid Director
Ms. Kathryn Kuhmerker, Deputy www.dhhs.state.nc.us Mr. David J. Zentner, Director
Director Division of Medical Assistance
NYS Department of Health Medicaid Director Department of Human Services
Office of Medicaid Management Mr. Gary Fuquay, Acting Director 600 East Boulevard Avenue,
Empire State Plaza Division of Medical Assistance Dept. 325
Room 1466, Corning Tower Department of Health and Human Bismarck, ND 58505-0261
Building Services T: 701/328-2321
Albany, NY 12237 2501 Mail Service Center F: 701/328-1544
T: 518/474-3018 Raleigh, NC 27699-2501 E-mail: sozend@state.nd.us
F: 518/486-6852 T: 919/857-4011 Internet address:
E-mail: kk03@health.state.ny.us F: 919/733-6608 www.lnotes.state.nd.us/dhs/dhsweb.
E-mail: gary.fuquay@ncmail.net nsf
Internet address:
www.dhhs.state.nc.us/dma

A-48 National Pharmaceutical Council


Pharmaceutical Benefits 2002

NORTHERN MARIANA OHIO OKLAHOMA


ISLANDS Governor
Governor
Governor Honorable Bob Taft Honorable Brad Henry
Honorable Juan N. Babauta 77 South High Street, 30th Floor 212 State Capitol
Commonwealth of the Northern Columbus, OH 43215-6117 Oklahoma City, OK 73105
Mariana Islands T: 614/466-3555 T: 405/521-2342
Caller Box 10007 F: 614/466-9354 F: 405/521-3353
Capitol Hill E-mail: E-mail: governor@gov.state.ok.us
Saipan, MP 96950 governor.taft@das.state.oh.us Internet address:
670/322-5091 Internet address: www.governor.state.ok.us
www.state.oh.us/gov
Single State Agency Director Single State Agency Director
Dr. James Hofschneider Single State Agency Director Mike Fogarty, J.D.
Secretary for Health Services Mr. Tom Hayes, Director Chief Executive Officer
Department of Public Health and Ohio Department of Job and Family Oklahoma Health Care Authority
Environmental Services Services 4545 North Lincoln Boulevard
Commonwealth of the Northern 30 East Broad Street, 32nd Floor Suite 124
Mariana Islands Columbus, OH 43215-3414 Oklahoma City, OK 73105
P.O. Box 409 CK 614/466-6282 T: 405/522-7300
Saipan, MP 96950 F: 405/522-7187
670/234-8950 Medicaid Director E-mail: fogartym@ohca.state.ok.us
Ms. Barbara Edwards, Deputy Internet address:
Medicaid Director Director www.ohca.state.oh.us
Ms. Maria Sablan, Medical Office of Medicaid
Administrator Ohio Department of Job and Family Medicaid Director
Department of Public Health and Services Lynn Mitchell, M.D.
Environmental Services 30 East Broad Street, 31st Floor Oklahoma Health Care Authority
Commonwealth of the Northern Columbus, OH 43215-3414 4545 North Lincoln Boulevard
Mariana Islands T: 614/466-4443 Suite 124
P.O. Box 409 CK F: 614/752-3986 Oklahoma City, OK 73105
Saipan, MP 96950 E-mail: Medicaid@odhs.state.oh.us T: 405/522-7365
T: 670/664-4880 F: 405/530-3218
F: 670/664-4885 E-mail: mitchelll@ohca.state.ok.us
E-mail: gov.frosario@saipan.com Internet address:
(info officer) www.ohca.state.ok.us

National Pharmaceutical Council A-49


Pharmaceutical Benefits 2002

OREGON PENNSYLVANIA PUERTO RICO


Governor Governor Governor
Honorable Ted Kulongoski Honorable Ed Rendell Honorable Sila Maria Calderon
State Capitol 25 Main Capitol Building La Fortaleza
900 Court Street NE Harrisburg, PA 17120 P.O. Box 82
Salem, OR 97310-4047 T: 717/787-2500 San Juan, PR 00901
T: 503/378-3111 F: 717/772-8284 809/721-7000
F: 503/378-4863 E-mail:
E-mail: www.state.pa.us/pa_exec/governor/ Single State Agency Director
representative.citizen@state.or.us govmail.html John Rullan, M.D.
Internet address: Internet address: Secretary
www.governor.state.or.us www.state.pa.us/governor/site/ Department of Health
default.asp G.P.O. Box 70184
Single State Agency Director San Juan, PR 00936
Ms. Jean Thorne, Director Single State Agency Director 787/7274-7676
Department of Human Resources Ms. Estelle B. Richman, Acting
500 Summer Street, NE Secretary Medicaid Director
Human Resources Building Department of Public Welfare Mr. William Gonzalez, Director
Salem, OR 97301 Health and Welfare Building Medical Assistance Program
T: 503/945-5944 P.O. Box 2675 Department of Health
F: 503/378-2897 Harrisburg, PA 17105-2675 G.P.O. Box 70184
E-mail: jean.i.thorne@state.or.us T: 717/787-2600 San Juan, PR 00936
Internet address: www.hr.state.or.us F: 717/772-2062 T: 787/765-1230, ext. 201
E-mail: ra-dpwsecretarynet F: 787/250-0990
Medicaid Director @state.pa.us
Ms. Lynn Read, Director Internet address:
Office of Medical Assistance www.dpw.state.pa/us/default.html
Programs
Department of Human Services Medicaid Director
500 Summer Street, NE Ms. Carole Rebert
Salem, OR 97301 Office in Charge
T: 503/945-5772 Office of Medical Assistance
F: 503/373-7689 Programs
E-mail: lynn.read@state.or.us Department of Public Welfare
Internet address: Health and Welfare Building, Room
www.omap.state.or.us 515
P.O. Box 2675
Harrisburg, PA 17105-2675
T: 717/787-1870
F: 717/787-4639
E-mail:
pamedicaid2@dpw.state.pa.us
Internet address:
www.dpw.state.pa.us/omap/dpwoma
p.asp

A-50 National Pharmaceutical Council


Pharmaceutical Benefits 2002

RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA


Governor Governor Governor
Honorable Don Carcieri Honorable Mark Sanford Honorable Mike Rounds
222 State House P.O. Box 11829 500 East Capitol
Providence, RI 02903-1196 Columbia, SC 29211 Pierre, SD 57501
T: 401/222-2080 T: 803/734-9400 T: 605/773-3212
F: 401/861-5894 F: 803/734-9413 F: 605/773-4711
E-mail: rigov@gov.state.ri.us E-mail: E-mail: sdgov@gov.state.sd.us
Internet address: governor@govoepp.state.sc.us Internet address:
www.governor.state.ri.us Internet address: www.state.sd.us/state/executive/
www.state.sc.us/governor governor/governor.htm
Single State Agency Director
Ms. Jane Hayward, Director Single State Agency Director Single State Agency Director
Department of Human Services Mr. Robert C. Toomey, Director Mr. James W. Ellenbecker,
600 New London Avenue Department of Health and Human Secretary
Cranston, RI 02920 Services Department of Social Services
T: 401/462-2121 1801 Main Street Richard F. Kneip Building
F: 401/462-3677 P.O. Box 8206 700 Governors Drive
E-mail: Columbia, SC 29202-8206 Pierre, SD 57501-2291
jhayward@gw.dhs.state.ri.us T: 803/898-2504 T: 605/773-3165
Internet address: F: 803/898-4515 F: 605/773-4855
www.dhs.state.ri.us E-mail: btoomey@gov.sc.gov E-mail: info@dss.state.sd.us
Internet address: Internet address:
Medicaid Director www.dhhs.state.sc.us www.state.sd.us/social
Mr. John Young, C.P.M.
Associate Director Medicaid Director Medicaid Director
Division of Medical Services Mr. Robert C. Toomey, Director Mr. Damian Prunty, Adninistrator
Department of Human Services Department of Health and Human Medical Services
600 New London Avenue Services Department of Social Services
Cranston, RI 02920 P.O. Box 8206 Richard F. Kneip Building
T: 401/462-3575 1801 Main Street 700 Governors Drive
F: 401/462-6338 Columbia, SC 29202-8206 Pierre, SD 57501-2291
E-mail: Jyoung@gw.dhs.state.ri.us T: 803/898-2504 T: 605/773-3495
Internet address: F: 803/898-4515 F: 605/773-5246
www.dhs.state.ri.us E-mail: btoomey@gov.sc.gov E-mail: medicaid@dss.state.sd.us
Internet address: Internet address:
www.dhhs.state.sc.us www.state.sd.us/social

National Pharmaceutical Council A-51


Pharmaceutical Benefits 2002

TENNESSEE TEXAS UTAH


Governor Governor Governor
Honorable Phil Brendsen Honorable Rick Perry Honorable Michael O. Leavitt
State Capitol, First Floor State Capitol 210 State Capitol
Nashville, TN 37243-0001 P.O. Box 12428 Salt Lake City, UT 84114
T: 615/741-2001 Austin, TX 78711 T: 801/538-1000
F: 615/532-9711 T: 5l2/463-2000 F: 801/538-1528
E-mail: phil.brendsen@state.tn.us F: 512/463-1849 E-mail: governor@utah.gov
Internet address: E-mail: Internet address:
www.state.tn.us/governor www.governor.state.tx.us/contact_ www.utah.gov/governor
email.htm
Single State Agency Director Internet address: Single State Agency Director
Mr. Dave Goetz, Commissioner ww.governor.state.tx.us Mr. Rod Betit, Executive Director
Department of Finance and Department of Health
Administration Single State Agency Director P.O. Box 141000
1st Floor, State Capitol Mr. Albert Hawkins, Commissioner Salt Lake City, UT 84114-1000
Nashville, TN 37219 Health and Human Services T: 801/538-6111
T: 615/741-2401 Commission F: 801/538-6306
F: 615/741-9872 4900 N. Lamar Boulevard E-mail: rodbet.t@utah.gov
E-mail: brenda.tune@state.tn.us P.O. Box 13247 Internet address:
Internet address: Austin, TX 78711 www.hlunix.hl.state.ut.us
www.state.tn.us/finance T: 5l2/424-6502
F: 512/424-6587 Medicaid Director
Medicaid Director E-mail contact@hhsc.state.tx.us Mr. Michael Deily, Director
Mr. Manny Martins Internet address: Department of Health
Deputy Commissioner www.hhsc.state.tx.us Division of Health Care Financing
Department of Finance and P.O. Box 14301
Administration Medicaid Director Salt Lake City, UT 84114-1000
729 Church Street Mr. Jason Cooke T: 801/538-6406
Nashville, TN 37247-6501 State Medicaid Director F: 801/538-6099
T: 615/741-0213 Health and Human Services E-mail: mdeily@utah.gov
F: 615/741-0882 Commission Internet address: www.hlunix.
E-mail: many.martins@state.tn.us 4900 N. Lamar Boulevard Ex.state.ut.us/medicaid
Internet address: P.O. Box 13247
www.state.tn.us/tenncare Austin, TX 78711
T: 512/424-6517
F: 512/424-6587
E-mail: medicaid@hhsc.state.tx.us
Internet address:
www.hhsc.tx.us/medicaid/index.html

A-52 National Pharmaceutical Council


Pharmaceutical Benefits 2002

VERMONT VIRGINIA VIRGIN ISLANDS


Governor Governor Governor
Honorable James Douglas Honorable Mark Warner Honorable Charles Turnbull
109 State Street State Capitol Building, Third Floor Government House
Montpelier, VT 05609 Richmond, VA 232l9 21-22 Kongens Gada Street
T: 802/828-3333 T: 804/786-2211 Charlotte Amalie
F: 802/828-3339 F: 804/692-0121 St. Thomas, VI 00802
Internet address: E-mail: T: 340/774-0001
www.gov.state.vt.us www.governor.state.va.us/contact/ F: 340/776-4912
email_form.html E-mail: rcanton@govhouse.gov.vi
Single State Agency Director Internet address: Internet address: www.gov.vi
Mr. Charles Smith, Secretary www.governor.state.va.us
Agency of Human Services Single State Agency Director
103 South Main Street Single State Agency Director Mavis Matthew, M.D.
Waterbury, VT 05671-0201 Ms. Jane H. Woods, Secretary Commissioner of Health
T: 802/241-2220 Health and Human Resources Virgin Islands Department of
F: 802/241-2979 Secretariat Health
E-mail: Ninth Street Office Building 48 Sugar Estate
charles@wpgate1.aah.state.vt.us 202 N. Ninth Street, Suite 622 St. Thomas, VI 00802
Internet address: P.O. Box 1475 T: 340/774-0117
www.ahs.state.vt.us Richmond, VA 23219 F: 340/777-4001
T: 804/786-7765 E-mail:vimchftx@viaccess.net
Medicaid Director F: 804/371-6984
Mr. Paul Wallace-Brodeur, E-mail: shhr@gov.state.va.us Medicaid Director
Medicaid Director Ms. Priscilla Berry-Quetel,
Department of Prevention, Medicaid Director Executive Director
Transition, and Health Access Mr. Patrick Finnerty, Director Bureau of Health Insurance and
103 South Main Street Department of Medical Assistance Medical Assistance
Waterbury, VT 05676 Services Department of Health
T: 802/241-3985 600 East Broad Street 210-3A Altona, Suite 302 Frostco
F: 802/241-2897 Suite 1300 Center
E-mail: Paulw@path.state.vt.us Richmond, VA 23219 Charlotte Amalie
Internet address: T: 804/786-4231 St. Thomas, VI 00802
www.dsw.state.vt.us F: 804/225-4512 T: 340/774-4624
E-mail: pfinnert@dmas.state.va.us F: 340/774-4918
Internet address: E-mail: prisene@viaccess.net
www.dms.state.va.us

National Pharmaceutical Council A-53


Pharmaceutical Benefits 2002

WASHINGTON WEST VIRGINIA WISCONSIN


Governor Governor Governor
Honorable Gary Locke Honorable Bob Wise Honorable Jim Doyle
Office of the Governor State Capitol Office of The Governor
P.O. Box 40002 Charleston, WV 25305-0370 115 East State Capitol
Olympia, WA 98504-0002 T: 304/558-2000 Madison, WI 53702
T: 360/902-4111 F: 304/342-7025 T: 608/266-1212
F: 360-753-4110 E-mail: governor@state.wv.us F: 608/267-8983
E-mail: Internet address: E-mail: wisgov@gov.state.wi.us
www.governor.wa.gov/contact.gov www.state.wv.us/governor Internet address:
email.htm www.wisgov.state.wi.us
Single State Agency Director
Single State Agency Director Mr. Paul Nusbaum, Secretary Single State Agency Director
Mr. Dennis Braddock, Secretary Department of Health and Human Ms. Helene Nelson, Secretary
Department of Social and Health Resources Department of Health and Family
Services Building 3, State Capitol Complex Services
P.O. Box 45010 Room 206 One West Wilson Street, Room 650
Olympia, WA 98504-5010 Charleston, WV 25305 Madison, WI 53702
T: 360/902-7800 T: 304/558-0684 T: 608/266-9622
F: 360/902-7848 F: 304/558-1130 F: 608/266-7882
E-mail: braddd.dshs.wa.gov E-mail: E-mail:
Internet address: www.wa.gov/dshs wvdhhrsecretary@wvdhhr.org webmaster@dhfs.state.wi.us
Internet address: www.wvd.hhr.org Internett address:
Medicaid Director www.dhfs.state.wi.us
Mr. Doug Porter, Assistant Medicaid Director
Secretary Ms. Nancy Atkins, Commissioner Medicaid Director
Medical Assistance Administration Bureau for Medical Services Mr. Mark B. Moody, Administrator
P.O. Box 45080 Department of Health and Human Division of Health Care Financing
Olympia, WA 98504-5080 Resources One West Wilson Street, Room 350
T: 360/902-1863 7012 MacCorkle Avenue, SE Madison, WI 53701-0309
F: 360/902-7855 Charleston, WV 25304 T: 608/266-2522
E-mail: portejd@dshs.wa.gov T: 304/558-1700 F: 608/266-1096
Internet address: F: 304/926-1833 E-mail:
www.fortress.wa.gov/dshs/maa E-mail: nancyatkins@wvdhhr.org webmaster@dhfs.state.wi.us
Internet address: Internet address:
www.wvdhhr.org/bms www.dhfs.state.wi.us

A-54 National Pharmaceutical Council


Pharmaceutical Benefits 2002

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

Single State Agency Director


Ms. Deb Fleming, Ph.D., Director
Department of Health
117 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7656
F: 307/777-7439
Internet address: wdhfs.state.wy.us

Medicaid Director
Ms. Iris Oleske,
State Medicaid Agent
Department of Health
147 Hathaway Building
Cheyenne, WY 82002
T: 307/777-7531
F: 307/777-6964
E-mail: iolesk@state.wy.us
Internet address: wdhfs.state.wy.us

National Pharmaceutical Council A-55


Pharmaceutical Benefits 2002

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


REGIONAL OFFICES
ASSOCIATE REGIONAL ADMINISTRATORS - MEDICAID

Region I Vacant Connecticut, Maine, Massachusetts,


Boston Regional Office John F. Kennedy Federal Bldg. New Hampshire, Rhode Island,
Government Center, Room 2325 Vermont
Boston, MA 02203-0003
617/565-1223
Region II Sue Kelly New Jersey, New York, Puerto Rico,
New York Regional Office 26 Federal Plaza Virgin Islands
Room 3811
New York, NY 10278-0063
212/264-2058
Region III Mary McSorley Delaware, District of Columbia,
Philadelphia Regional Office Suite 216, The Public Ledger Building Maryland, Pennsylvania, Virginia,
150 South Independence Mall West West Virginia
Philadelphia, PA 19106
215/861-4261
Region IV Rhonda Cottrell Alabama, Florida, Georgia, Kentucky,
Atlanta Regional Office Atlanta Federal Center Mississippi, North Carolina, South
61 Forsyth Street, S.W., Suite 4T20 Carolina, Tennessee
Atlanta, GA 30303-8909
404/562-7175
Region V Cheryl Harris Illinois, Indiana, Michigan,
Chicago Regional Office 233 North Michigan Avenue Minnesota, Ohio, Wisconsin
Suite 600
Chicago, IL 60601-5519
312/353-2702
Region VI Andrew Fredrickson Arkansas, Louisiana, New Mexico,
Dallas Regional Office 1301 Young Street, Room 714 Oklahoma, Texas
Dallas, TX 75202
214/767-6385
Region VII Tom Lenz Iowa, Kansas, Missouri, Nebraska
Kansas City Regional Office Richard Bolling Federal Building
601 East 12th Street, Room 235
Kansas City, MO 64106-2808
816/426-5925
Region VIII Mark Gilbert Colorado, Montana, North Dakota,
Denver Regional Office Colorado State Bank Building South Dakota, Utah, Wyoming
1600 Broadway, Suite 700
Denver, CO 80202-4367
303/844-7055
Region IX Linda Minamoto Arizona, California, Hawaii, Guam
San Francisco Regional Office 75 Hawthorne Street, 4th & 5th Floors Nevada, and Pacific Islands
San Francisco, CA 94105-3901
415/744-3568
Region X Karen O’Connor Alaska, Idaho, Oregon, Washington
Seattle Regional Office 2201 6th Avenue
Mail Stop RX-40
Seattle, WA 98121-2500
206/615-2330

Source: CMS, Regional Office Contacts, February 2003.

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Pharmaceutical Benefits 2002

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


NATIONAL ACCOUNT REPRESENTATIVES

STATE CENTRAL OFFICE REGIONAL OFFICE

Alabama Bill Lasowski Jay Gavens


Director Financial Analyst
Division of Financial Management Atlanta Federal Center
Finance, Systems and Quality Group 61 Forsyth Street, SW
Center for Medicaid and State Operations 4th Floor, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7430
Baltimore, MD 21244-1850 E-mail: Jgavens@cms.hhs.gov
T: 410/786-2003
E-mail: wlasowski@cms.hhs.gov

Alaska Richard Strauss Elizabeth Trias


Deputy Director Health Insurance Specialist
Division of Financial Management Medicaid Branch, Region X
Finance, Systems and Quality Group 2201 Sixth Avenue
Center for Medicaid and State Operations MS/RX-40
Mail Stop S2-26-12 Seattle, WA 98121
7500 Security Boulevard T: 206/615-2400
Baltimore, MD 21244-1850 E-mail: etrias@cms.hhs.gov
T: 410/786-2019
E-mail: rstrauss@cms.hhs.gov

American Samoa Linda Murphy Mary Rydell


Health Insurance Specialist Pacific Area Representative
Division of Quality System Management Finance, P.O. Box 50081
Systems and Quality Group 300 Ala Moana Blvd. 6-225
Center for Medicaid and State Operations Honolulu, HI 96850
Mail Stop S2-26-12 T: 808/541-2732
7500 Security Boulevard E-mail: mrydell@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0435
E-mail: lmurphy@cms.hhs.gov

Arizona Rhonda Rhodes Ronald Reepen


Deputy Director Health Insurance Specialist
Division of Integrated Health Services 75 Hawthorne Street
Family and Children's Health Programs Group 4th Floor, Rom 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3601
7500 Security Boulevard E-mail: rreepen@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1848
E-mail: rrhodes@cms.hhs.gov

National Pharmaceutical Council A-57


Pharmaceutical Benefits 2002

Arkansas Marty Svolos J. P. Peters


Director Health Insurance Specialist
Division of Eligibility, Enrollment and Outreach Medicaid Fraud & Abuse Liaison
Family and Children's Health Program Group Medicaid Alliance for Program Safeguards
Center for Medicaid and State Operations 1301 Young Street, RM 714
Mail Stop S2-26-12 Dallas, TX 75202
7500 Security Boulevard T: 214/767-26284461
Baltimore, MD 21244-1850 E-mail: jpeters@cms.hhs.gov
T: 410/786-4582
E-mail: msvolos@cms.hhs.gov

California Richard Chambers Pat Daley


Director Health Insurance Specialist
Family and Children's Health Program Group 75 Hawthorne Street
Center for Medicaid and State Operations 4th Floor, Room 408
Mail Stop S2-26-12 San Francisco, CA 94105
7500 Security Boulevard T: 415/744-3592
Baltimore, MD 21244-1850 E-mail: pdaley@cms.hhs.gov
T: 410/786-5647
E-mail: rchambers@cms.hhs.gov

Colorado Todd Lawson Penny Finnegan


Budget Staff Director State Program Coordinator
Survey and Certification Group Office of the Regional Administrator
Center for Medicaid and State Operations Colorado State Bank Bldg.
Mail Stop S2-26-12 1600 Broadway, Suite 700
7500 Security Boulevard Denver, CO 80202-4367
Baltimore, MD 21244-1850 T: 303/844-7117
T: 410/786-5366 E-mail: pfinnegan@cms.hhs.gov
E-mail: tlawson1@cms.hhs.gov

Connecticut Angela Brice-Smith Elena Nicolella


Deputy Director Health Insurance Specialist
Survey and Certification Group JFK Federal Building
Center for Medicaid and State Operations RM 2325
Mail Stop S2-26-12 Boston, MA 02203-0003
7500 Security Boulevard T: 617/565-1243
Baltimore, MD 21244-1850 E-mail: enicolella@cms.hhs.gov
T: 410/786-4340
E-mail: abricesmith@cms.hhs.gov

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Pharmaceutical Benefits 2002

Delaware Mike Goldman Elizabeth Wheeler


Chief Health Insurance Specialist
Nursing Homes Branch Section II The Public Ledger Building
Division of Nursing Homes and Continuing Care 150 S. Independence Mall West, Suite 116
Services Philadelphia, PA 19106
Center for Medicaid and State Operations T: 215/861-4190
Mail Stop S2-26-12 E-mail: ewheeler@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-6813
E-mail: mgoldman@cms.hhs.gov

District of Rick Fenton Marguerite Clark


Columbia Deputy Director Health Insurance Specialist
Family & Children's Health Programs Group The Public Ledger Building
Center for Medicaid and State Operations 150 S. Independence Mall West, Suite 116
Mail Stop S2-26-12 Philadelphia, PA 19106
7500 Security Boulevard T: 215/861-4199
Baltimore, MD 21244-1850 E-mail: mclark2@cms.hhs.gov
T: 410/786-5920
E-mail: rfenton@cms.hhs.gov

Florida Jim Frizzera Eugene Grasser, ARA


Co-Lead, National Institutional Reimbursement Team Division of Medicaid and State Operations
Center for Medicaid and State Operations Atlanta Federal Center, 4th Floor
Mail Stop S2-26-12 61Forsyth Street, SW, Suite 4T20
7500 Security Boulevard Atlanta, GA 30303-8909
Baltimore, MD 21244-1850 T: 404/562-7401
T: 410/786-9535 E-mail: egrasser2@cms.hhs.gov
E-mail: jfrizzera@cms.hhs.gov

Georgia Linda Strumsky Hugh Webster, Chief


Deputy Director Medicaid Financial
Private Health Insurance Group Management Branch
Center for Medicaid and State Operations Atlanta Federal Center
Mail Stop S2-26-12 61 Forsyth Street, SW
7500 Security Boulevard 4th Floor, Suite 4T20
Baltimore, MD 21244-1850 Atlanta, GA 30303-8909
T: 410/786-3255 T: 404/562-7432
E-mail: lstrumsky@cms.hhs.gov E-mail: hwebster@cms.hhs.gov

National Pharmaceutical Council A-59


Pharmaceutical Benefits 2002

Guam Maria Friedman Eddie Martin


Technical Director Accountant
Division of Quality Improvement and Training 75 Hawthorne Street
Finance, Systems and Quality Group 4th Floor, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3567
7500 Security Boulevard E-mail: emartin@cms.hhs.gov
Baltimore, MD 21244-1850
T: 202/401-3561
E-mail: mfriedman@cms.hhs.gov

Hawaii Larry Reed Susan Castleberry


Co-Lead, Pharmacy Team Health Insurance Specialist
Family and Children's Health Program Group 75 Hawthorne Street
Center for Medicaid and State Operations 4th Floor, Room 408
Mail Stop S2-26-12 San Francisco, CA 94105-3901
7500 Security Boulevard T: 415/744-3599
Baltimore, MD 21244-1850 E-mail: scastleberry@cms.hhs.gov
T: 410/786-3325
E-mail: lreed@cms.hhs.gov

Idaho Georgia Johnson David Meacham


Technical Director Health Insurance Specialist
Continuing Care Providers Branch 2201 Sixth Avenue
Survey and Certification Group MS/RX 40
Center for Medicaid and State Operations Seattle, WA 98121
Mail Stop S2-26-12 T: 206/615-2356
7500 Security Boulevard E-mail: dmeacham@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6859
E-mail: gjohnson4@cms.hhs.gov

Illinois Mary Beth Hance Vera Drivalas


Director 233 N. Michigan Avenue
Policy Coordination and Planning Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/886-0792
7500 Security Boulevard E-mail: vdrivalas@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4299
E-mail: mhance@cms.hhs.gov

A-60 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Indiana Regina Fletcher Jean Hall


Special Assistant 233 N. Michigan Avenue
Family and Children's Health Program Group Suite 600
Center for Medicaid and State Operations Chicago, IL 6061
Mail Stop S2-26-12 T: 312/352-3746
7500 Security Boulevard E-mail: jhall@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3293
E-mail: rfletcher@cms.hhs.gov

Iowa Mary Jean Duckett Brenda Jackson


Director Health Insurance Specialist
Division of Benefits, Coverage and Payment Richard Bolling Federal Building
Disabled and Elderly Health Programs Group 601 East 12th Street
Center for Medicaid and State Operations Room 227
Mail Stop S2-26-12 Kansas City, MO 64106-2808
7500 Security Boulevard T: 816/426-3406 Ext. 3307
Baltimore, MD 21244-1850 E-mail: bjackson1@cms.hhs.gov
T: 410/786-3294
E-mail: mduckett@cms.hhs.gov

Kansas Frank Sokolik Jackie Glaze


Deputy Director Health Insurance Speicalist
Survey and Certification Group Richard Bolling Federal Building
Center for Medicaid and State Operations 601 East 12th Street
Mail Stop S2-26-12 Room 227
7500 Security Boulevard Kansas City, MO 64106-2808
Baltimore, MD 21244-1850 T: 816/426-3406 Ext. 3318
T: 410/786-7089 E-mail: jglaze@cms.hhs.gov
E-mail: fsokolik@cms.hhs.gov

Kentucky Jack Williams Renard Murray


Director, Division of National Systems Atlanta Federal Center
Finance Systems and Quality Group 61 Forsyth Street, SW
Center for Medicaid and State Operations 4th Floor, Suite 4T20
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7417
Baltimore, MD 21244-1850 E-mail: rmurray@cms.hhs.gov
T: 410/786-6743
E-mail: jwilliams@cms.hhs.gov

National Pharmaceutical Council A-61


Pharmaceutical Benefits 2002

Louisiana Wayne Smith Joe Reeder


Deputy Director Health Insurance Specialist
Finance, Systems and Quality Group 1301 Young Street
Center for Medicaid and State Operations Room 714
Mail Stop S2-26-12 Dallas, TX 75202
7500 Security Boulevard T: 214/767-4419
Baltimore, MD 21244-1850 E-mail: jreeder@cms.hhs.gov
T: 410/786-2583
E-mail: wsmith1@cms.hhs.gov

Maine Roger Buchanan Irvin Rich


Director JFK Federal Building
Division of Informational Analysis and Technical Room 2325
Assistance Boston, MA 02203-0003
Finance, Systems and Quality Group T: 617/565-1247
Center for Medicaid and State Operations E-mail: irich@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-0780
E-mail: rbuchanan@cms.hhs.gov

Maryland Kathy Rama James Hake


Technical Director Health Insurance Specialist
Division of Advocacy and Special Issues The Public Ledger Building
Disabled and Elderly Health Programs Group 150 S. Independence Mall West, Suite 216
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4196
7500 Security Boulevard E-mail: jhake@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6659
E-mail: krama@cms.hhs.gov

Massachusetts Tom Hamilton Patricia Hitz McKnight


Director Health Insurance specialist
Disabled and Elderly Health Programs Group Division of Medicaid and State Operations
Center for Medicaid and State Operations JFK Federal Building
Mail Stop S2-26-12 Room 2275
7500 Security Boulevard Boston, MA 02203-0003
Baltimore, MD 21244-1850 T: 617/565-1268
T: 410/786-6763 E-mail: phitzmcknight@cms.hhs.gov
E-mail: thamilton@cms.hhs.gov

A-62 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Michigan Lillian Gibbons Ruth Hughes


Senior Advisor 233 N. Michigan Avenue
Children’s Health Programs and Policies Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-1670
7500 Security Boulevard E-mail: rhughes@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-8705
E-mail: lgibbons@cms.hhs.gov

Minnesota Terry Pratt Doris Ross


Director Michigan/Minnesota/Wisconsin Branch
Division of Integrated Health Systems Division of Medicaid and Children's
Disabled and Elderly Health Programs Group Oversight
Center for Medicaid and State Operations 233 N. Michigan Avenue, Suite 600
Mail Stop S2-26-12 Chicago, IL 60601
7500 Security Boulevard T: 312/353-9843
Baltimore, MD 21244-1850 E-mail: dross2@cms.hhs.gov
T: 410/786-9499
E-mail: tpratt@cms.hhs.gov

Mississippi Pam Vocke Selwyn White


Director Atlanta Federal Center
Division of Quality Improvement and Training 4th Floor, Suite 4T20
Finance, Systems and Quality Group 61 Forsyth Street, SW
Finance, Systems and Quality Group Atlanta, GA 30303-8909
Center for Medicaid and State Operations T: 404/562-7427
Mail Stop S2-26-12 E-mail: swhite3@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3486
E-mail: pvocke@cms.hhs.gov

Missouri Steven Pelovits Judith Flynn


Director Health Insurance Specialist
Survey and Certification Group Richard Bolling Federal Building
Finance, Systems and Quality Group 601 East 12th Street, Room 227
Center for Medicaid and State Operations Kansas City, MO 64106-2808
Mail Stop S2-26-12 T: 816/426-3406 Ext. 3308
7500 Security Boulevard E-Mail: jflynn2@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3160
E-mail: spelvotz@cms.hhs.gov

National Pharmaceutical Council A-63


Pharmaceutical Benefits 2002

Montana Helene Fredeking Robert Lyon


Technical Director Colorado State Bank
Division of Nursing Homes and Continuing Care Building
Services 1600 Broadway, Suite 700
Survey and Certification Group Denver, CO 80202-4367
Center for Medicaid and State Operations T: 303/844-7114
Mail Stop S2-26-12 E-mail: rylon@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-7304
E-mail: hfredeking@cms.hhs.gov

Nebraska Dave Witt Sharon Taggart


Technical Director Health Insurance Specialist
Division of Eligibility, Enrollment and Outreach Richard Bolling Federal Building
Disabled and Elderly Health Programs Group 601 East 12th Street, Room 227
Center for Medicaid and State Operations Kansas City, MO 64106-2808
Mail Stop S2-26-12 T: 816/426-3406 Ext. 3320
7500 Security Boulevard E-mail: staggart@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5600
E-mail: dwitt@cms.hhs.gov

Nevada Judy Yost Lee Netzer


Director Health Insurance Specialist
Div. of Laboratories and Acute Care Services 75th Hawthorne Street
Survey and Certification Group 4th Floor, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3595
7500 Security Boulevard E-mail: lnetzer@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3407
E-mail: jyost@cms.hhs.gov

New Hampshire Jan Tarantino Harold Finn


Special Assistant JFK Federal Building
Survey and Certification Group Boston, MA 02203-0003
Center for Medicaid and State Operations T: 617/565-1225
Mail Stop S2-26-12 E-mail: hfinn@cms.hhs.gov
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-0905
E-mail: jtarantino@cms.hhs.gov

A-64 National Pharmaceutical Council


Pharmaceutical Benefits 2002

New Jersey Fred Gladden Julie Alberino


Chief 26 Federal Plaza
Nursing Homes Branch Section I Room 3800
Division of Nursing Homes and Continuing Care New York, NY 10278-0063
Services T: 212/264-3904
Survey and Certification Group E-mail: jalberino@cms.hhs.gov
Center for Medicaid and State Operations
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-3033
E-mail: fgladden@cms.hhs.gov

New Mexico Susan Cuerdon Jack Allen


Policy Advisor Health Insurance Specialist
Office of the Director 1301 Young street
Center for Medicaid and State Operations Room 827
Mail Stop S2-26-12 Dallas, TX 75202
7500 Security Boulevard T: 214/767-4425
Baltimore, MD 21244-1850 E-mail: jallen@cms.hhs.gov
T: 410/786-1146
E-mail: scuerdon@cms.hhs.gov

New York Charlene Brown Sue Kelly


Deputy Director 26 Federal Plaza
Center for Medicaid and State Operations Room 3800
Mail Stop S2-26-12 New York, NY 10278-0063
7500 Security Boulevard T: 212/264-2058
Baltimore, MD 21244-1850 E-Mail: skelly@cms.hhs.gov
T: 410/786-3230
E-mail: cbrown@cms.hhs.gov

North Carolina Joe Razes Donna Cross


Technical Director State Representative for North Carolina
Division of Advocacy and Special Issues Atlanta Federal Center
Disabled and Elderly Health Programs Group 4th Floor, suite 4T20
Center for Medicaid and State Operations 61 Forsyth Street, SW
Mail Stop S2-26-12 Atlanta, GA 30303-8909
7500 Security Boulevard T: 404/562-7406
Baltimore, MD 21244-1850 E-mail: dcross@cms.hhs.gov
T: 410/786-6126
E-mail: jrazes@cms.hhs.gov

National Pharmaceutical Council A-65


Pharmaceutical Benefits 2002

North Dakota James Merrill Bernadette Quevedo-Mendoza


Life Safety Code Specialist State Program Coordinator
Nursing Homes Branch Section 1 Office of the Regional Administrator,
Division of Nursing Homes and Continuing Care CMS
Services Colorado State Bank Building
Center for Medicaid and State Operations 1600 Broadway, Suite 700
Mail Stop S2-26-12 Denver, CO 80202-4367
7500 Security Boulevard T: 303/844-7121
Baltimore, MD 21244-1850 E-mail: bquevedo-mendoza@cms.gov
T: 410/786-6998
E-mail: jmerrill@cms.hhs.gov

Northern Randy Graydon H. Stephen Deering


Mariana Islands Deputy Director Deputy Regional Administrator
Division of Advocacy and Special Issues 75 Hawthorne Street
Disabled and Elderly Health Programs Group 4th Floor, Room 408
Center for Medicaid and State Operations San Francisco, CA 94105-3901
Mail Stop S2-26-12 T: 415/744-3501
7500 Security Boulevard E-mail: sdeering@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-1357
E-mail: rgraydon@cms.hhs.gov

Ohio Deirdre Duzor Gwendolyn Sampson


Co-Lead, Pharmacy Team 233 N. Michigan Avenue
Finance, Systems and Quality Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-9861
7500 Security Boulevard E-mail: gsampson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4626
E-mail: dduzor@cms.hhs.gov

Oklahoma Melissa Hulbert Ford Blunt


Chief Health Insurance Specialist
Continuing Care Providers Branch 1301 Young Street
Division of Nursing Homes and Continuing Care Room 827
Services Dallas, TX 75202
Survey and Certification Group T: 214/767-6381
Center for Medicaid and State Operations E-mail: fblunt@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-6568
E-mail: mhulbert@cms.hhs.gov

A-66 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Oregon Alissa DeBoy Randy Poulsen


Special Assistant Health Insurance Specialist
Disabled and Elderly Health Programs Group Medicaid Branch, Region X
Center for Medicaid and State Operations 2201 Sixth Avenue
Mail Stop S2-26-12 MS/RX -43
7500 Security Boulevard Seattle, WA 98121
Baltimore, MD 21244-1850 T: 206/615-2390
T: 410/786-6041 E-mail: rpoulsen@cms.hhs.gov
E-mail: adeboy@cms.hhs.gov

Pennsylvania Cheryl Austein-Casnoff Michael Cruse


Director Health Insurance Specialist
Division of Benefits, Coverage and Payment The Public Ledger Building
Family and Children's Health Program Group 150 S. Independence Mall West, Suite 216
Center for Medicaid and State Operations Philadelphia, PA 19106
Mail Stop S2-26-12 T: 215/861-4216
7500 Security Boulevard E-mail: mcruse@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-4196
E-mail: causteincasnoff@cms.hhs.gov

Puerto Rico Cindy Melanson Frank Fournier


Health Program Evaluator La Torre de Plaza Las
Survey and Certification Group Americas
Center for Medicaid and State Operations Suite 1116
Mail Stop S2-26-12 525 F. SD. Roosevelt Ave.
7500 Security Boulevard San Juan, PR 000919-8024
Baltimore, MD 21244-1850 T: 787/771-3687
T: 410/786-0310 E-mail: ffournier@cms.hhs.gov
E-mail: cmelanson@cms.hhs.gov

Rhode Island Rick Friedman Richard Pecorella


Director JFK Federal Build9ng
Division of State Systems Boston, MA 02203-0003
Finance, Systems and Quality Group T: 617/565-1244
Center for Medicaid and State Operations E-mail: rpecorella@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-4451
E-mail: rfriedman2@cms.hhs.gov

National Pharmaceutical Council A-67


Pharmaceutical Benefits 2002

South Carolina Helaine Jeffers Jessie Spillers


Accreditation Staff Director 61 Forsyth Street, SW
Survey and Certification Group 4th Floor, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7418
7500 Security Boulevard E-mail: jspillers@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-5648
E-mail: hjeffers@cms.hhs.gov

South Dakota David Eddinger Cynthia Myers


Technical Director State Program Coordinator
Division of Laboratories and Acute Care Services Colorado State Bank Building
Survey and Certification Group 1600 Broadway, Suite 700
Center for Medicaid and State Operations Denver, CO 80202-4367
Mail Stop S2-26-12 T: 303/844-7116
7500 Security Boulevard E-mail: cmyers2@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3429
E-mail: deddingert@cms.hhs.gov

Tennessee Mike Fiore Dorothy Smith


Director Health Insurance Specialist
Division of integrated Health Systems Atlanta Federal Center
Family and Children's Health Programs Group 4th Floor, Suite 4T20
Center for Medicaid and State Operations Atlanta, GA 30303-8909
Mail Stop S2-26-12 T: 404/562-7159
7500 Security Boulevard E-mail: dsmith5@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-0623
E-mail: mfiore@cms.hhs.gov

Texas Dave McNally Shirley Glaspie


Deputy Director Health Insurance Specialist
Finance, Systems and Quality Group 1301 Young Street
Center for Medicaid and State Operations Room 714
Mail Stop S2-26-12 Dallas, TX 75202
7500 Security Boulevard T: 214/767-6407
Baltimore, MD 21244-1850 E-mail: sglaspie@cms.hhs.gov
T: 410/786-3292
E-mail: dmcnally@cms.hhs.gov

A-68 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Utah Aaron Blight Tilly Rollin


Special Assistant Utah State Program
Office of the Director Coordinator
Center for Medicaid and State Operations CMS
Mail Stop S2-26-12 Colorado State Bank Building
7500 Security Boulevard 1600 Broadway, Suite 700
Baltimore, MD 21244-1850 Denver, CO 80202-4367
T: 410/786-5239 T: 303/844-7111
E-mail: ablight@cms.hhs.gov E-mail: trolln@cms.hhs.gov

Vermont Clarke Cagey Allen P. Bryan


Special Assistant Health Insurance Specialist
Office of the Director Room 2275
Center for Medicaid and State Operations Boston, MA 02203-0003
Mail Stop S2-26-12 T: 617/565-1246
7500 Security Boulevard E-mail: abryan@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-3135
E-mail: ccagey@cms.hhs.gov

Virginia Ginni Hain Jake Hubik


Director Health Insurance specialist
Division of Eligibility, Enrollment and Outreach The Public Ledger Building
Disabled and Elderly Health Programs Group 150 S. Independence Mall West
Center for Medicaid and State Operations Suite 216
Mail Stop S2-26-12 Philadelphia, PA 19106
7500 Security Boulevard T: 215/861-4181
Baltimore, MD 21244-1850 E-mail: jhubik@cms.hhs.gov
T: 410/786-6036
E-mail: ghain@cms.hhs.gov

Virgin Islands Cindy Granunke Ricardo Holligan


Acting Director 26 Federal Plaza
Division of Nursing Homes and Continuing Care Room 3811
Services New York, NY 10278-0063
Survey and Certification Group T: 212/264-3978
Center for Medicaid and State Operations E-mail: rholligan@cms.hhs.gov
Mail Stop S2-26-12
7500 Security Boulevard
Baltimore, MD 21244-1850
T: 410/786-6782
E-mail: cgraunke@cms.hhs.gov

National Pharmaceutical Council A-69


Pharmaceutical Benefits 2002

Washington Gale Arden Carol Crimi


Director Health Insurance Specialist
Private Health Insurance Group Medicaid Branch
Center for Medicaid and State Operations Division of Medicaid and State
Mail Stop S2-26-12 Operations
7500 Security Boulevard 2201 Sixth Avenue
Baltimore, MD 21244-1850 MS/RX-43
T: 410/786-6810 Seattle, WA 98121
E-mail: garden@cms.hhs.gov T: 206/615-2515
E-mail: ccrimi@cms.hhs.gov

West Virginia Joan Simmons Ted Gallagher


Deputy Director Health Insurance Specialist
Division of Laboratories and Acute Care Services The Public Ledger Building
Survey and Certification Group 150 S. Independence Mall West
Center for Medicaid and State Operations Suite 216
Mail Stop S2-26-12 Philadelphia, PA 19106
7500 Security Boulevard T: 215/861-4275
Baltimore, MD 21244-1850 E-mail: tgallagher@cms.hhs.gov
T: 410/786-3409
E-mail: jsimmons1@cms.hhs.gov

Wisconsin Glenn Stanton Pam Carson


Deputy Director 233 N. Michigan Avenue
Disabled and Elderly Health Programs Group Suite 600
Center for Medicaid and State Operations Chicago, IL 60601
Mail Stop S2-26-12 T: 312/353-0108
7500 Security Boulevard E-mail: pcarson@cms.hhs.gov
Baltimore, MD 21244-1850
T: 410/786-6768
E-mail: gstanton@cms.hhs.gov

Wyoming Marjorie Eddinger Robert Tonsberg


Technical Director Epidemiologist, Sr. Health Services
Division of Laboratories and Acute Care Services Office Manager
Survey and Certification Group Office of the Regional Administrator,
Center for Medicaid and State Operations CMS
Mail Stop S2-26-12 Colorado State Bank Bldg.
7500 Security Boulevard 1600 Broadway, Suite 700
Baltimore, MD 21244-1850 Denver, CO 80202-4367
T: 410/786-0375 T: 303/844-1981
E-mail: meddinger@cms.hhs.gov E-mail: rtonsberg@cms.hhs.gov

Source: CMS website, http://www.cms.hhs.gov/states/natreps.pdf. Accessed on December 31, 2002.

A-70 National Pharmaceutical Council


Pharmaceutical Benefits 2001

CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS)


CENTER FOR MEDICAID AND STATE OPERATIONS
CENTRAL OFFICE STAFF
7500 Security Boulevard
Baltimore, MD 21244-1850
410/786-3000
Director Deputy Director Financial Advisor
Dennis Smith Charlene Brown Bill Lasowski
410/786-3870 410/786-3870 410/786-3870

Appeals and Grievances Drug Utilization Review


Tim Roe (Managed Care) Christina Lyon
410/786-2006 410/786-3332
Bob Tomlinson (Fee for Service) Carl Tepper
410/786-4463 410/786-2137

Assignment of Rights to Benefits Eligibility


Cheryl Camillo Marty Svolos (Families & Children)
410/786-1068 410/786-4582
Roy Trudel (Disabled/Elderly)
Budget Information for State Agencies 410/786-3417
Miles McDermott
410/786-3722 Family/Children 1915(b) Waivers; 1115 Demonstrations;
And the Health Insurance Flexibility & Accountability
Children’s Health Insurance Initiative (HIFA)
Cheryl Austein Casnoff Mike Fiore
410/786-6614 410/786-0623

Coordination of Benefits HCFA 2082 Statistical Report


Ginni Hain (Disabled & Elderly) Cindy Foltz
410/786-6036 410/786-0253
Marty Svolos (Families & Children)
Home and Community Based Waiver Program Reviews;
Data Inquiries Independence Plus Initiative
Marilyn McMillan Mary Jean Duckett
410/786-4623 410/786-3294

Department Appeals Board Decisions Investigational/Experimental Drugs


Ed Davis Tami Bruce
410/786-3280 410/786-1519

Disabled/Elderly 1915(b) Waivers; 1115 Demonstrations; Managed Care Enrollment Report


And PACE Program Carolyn Lawson
Terri Pratt 410/786-0704
410/786-5831
Medicaid Statistical Information System (MSIS)
Drug Rebate Agreement/Data Ron North
Judy Allison 410/786-5651
410/786-3330 rmacy Issues

(Coverage, Payment & Rebate Program)


Larry Reed
Source: CMS Central Office, CMSO, February 2003. 410/786-3325
Dierde Duzor
410/786-4626

National Pharmaceutical Council A-71


Pharmaceutical Benefits 2002

A-72 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Appendix B:
Medicaid Program Statistics --
CMS MSIS Tables

National Pharmaceutical Council B-1


Pharmaceutical Benefits 2002

B-2 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Program Statistics -- MSIS Report

The CMS MSIS Report is an annual report designed to collect State-reported


statistical summary data on eligibles, recipients, services, and expenditures
during a Federal fiscal year (i.e., October l through September 30). The data
reported for a given year represent recipients of service and the amount of
payments for claims adjudicated during the year. The data reflect bills
adjudicated during the year rather than the services used during the year.

Historically, States summarized and reported the data processed through their
Medicaid claims processing and payment operations unless they opted to
participate in the Medicaid Statistical Information System (MSIS) project. Prior
to Federal fiscal year 1999, MSIS was a voluntary program and those States
participating in the MSIS project provide data tapes from their claims processing
systems to HCFA in lieu of HCFA-2082 tables. However, in accordance with
the Balanced Budget Act of 1997, all claims processed on or after January 1,
1999, must be submitted electronically in the MSIS format.

The MSIS Report is the primary CMS source on recipients’ use of services and
the associated payments for these services. However, the new reporting
requirements have resulted in a lag in the timely release of MSIS summary
tables. The most recent MSIS service utilization information available from
CMS for all states is for FY 2000, too old for inclusion in the main body of this
year’s Compilation. Hence in many sections of this year’s Compilation, we have
used data from other, more current sources. MSIS data for FY 2001 have been
released for some states, and partial data are included in this Appendix where
appropriate. Please note these data are preliminary and subject to change.

In an effort to provide more recent recipient information as well as to maintain


continuity with previous version of the Compilation, we have compiled ten
tables from the MSIS data system for inclusion in this Appendix. The first two
tables provide national level summary information on total expenditures and
total number of recipients by type of service for FY 1999 and FY 2000. The
remaining tables present State-by-State and national level data, including some
trend information, on total Medicaid recipients, total Medicaid payments,
number of prescription drug recipients, and Medicaid prescription drug
payments. Partial tables with the incomplete FY 2001 data are also included for
the state-by-state data where appropriate. Additionally, there are three partial
tables at the end of the Appendix that correspond to FY 2000 tables presented in
Section 2.

National Pharmaceutical Council B-3


Pharmaceutical Benefits 2002

B-4 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Total U.S. Medical Assistance Recipients


By Type of Service
Service FY 1999** Percent of Total* FY 2000*** Percent of Total* Percent Change 1999-2000
Capitated Payment Services 20,686,648 51.5% 21,261,218 49.7% 2.8%
Pharmaceuticals 19,854,953 49.4% 20,516,882 48.0% 3.3%
Physicians 18,373,483 45.7% 19,103,558 44.7% 4.0%
Hospital Outpatient 12,417,078 30.9% 13,226,305 30.9% 6.5%
Lab/X-ray 10,194,096 25.4% 11,395,712 26.6% 11.8%
Other Care 8,571,677 21.3% 9,036,596 21.1% 5.4%
Clinic 6,746,062 16.8% 7,666,977 17.9% 13.7%
Dental 5,621,824 14.0% 5,891,733 13.8% 4.8%
PCCM Services 3,890,455 9.7% 5,560,441 13.0% 42.9%
Hospital Inpatient 4,497,189 11.2% 4,933,277 11.5% 10.0%
Other Practitioners 3,985,501 9.9% 4,735,427 11.1% 18.8%
Personal Support Services 4,076,883 10.1% 4,549,488 10.6% 11.6%
Nursing Facility 1,616,663 4.0% 1,702,885 4.0% 5.3%
Home Health Care 813,631 2.0% 994,801 2.3% 22.3%
ICF-Mentally Retarded 122,082 0.3% 118,171 0.3% -3.2%
Mental Health Facility 97,146 0.2% 99,342 0.2% 2.3%
Total Unduplicated Recipients* 40,184,407 42,763,233 6.4%

*Sum of percentages will exceed 100% due to recipients' use of multiple services. Puerto Rico and the U.S. Territories are not included in these national
totals.
**New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting.
***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals.

Source: CMS, MSIS Report, FY 1999 and FY 2000.

National Pharmaceutical Council B-5


Pharmaceutical Benefits 2002

Total U.S. Medical Assistance Payments


By Type of Service
Service FY 1999** Percent of Total* FY 2000*** Percent of Total* Percent Change 1999-2000
Nursing Facility $33,113,405,994 21.7% $34,432,018,376 20.5% 4.0%
Capitated Payment Services $21,114,777,944 13.8% $24,412,582,129 14.5% 15.6%
Hospital Inpatient $22,182,314,066 14.5% $24,265,794,997 14.4% 9.4%
Pharmaceuticals $16,566,787,283 10.9% $20,013,770,558 11.9% 20.8%
Other Care $13,088,047,530 8.6% $14,808,103,169 8.8% 13.1%
Personal Support Services $10,498,771,251 6.9% $11,567,367,970 6.9% 10.2%
ICF-Mentally Retarded $9,326,234,901 6.1% $9,374,506,773 5.6% 0.5%
Hospital Outpatient $6,060,585,731 4.0% $7,053,041,842 4.2% 16.4%
Physicians $6,496,562,916 4.3% $6,805,694,595 4.0% 4.8%
Clinic $5,777,756,292 3.8% $6,174,164,021 3.7% 6.9%
Home Health Care $2,898,409,629 1.9% $3,118,966,203 1.9% 7.6%
Mental Health Facility $1,757,605,519 1.2% $1,768,270,710 1.1% 0.6%
Dental $1,202,573,063 0.8% $1,404,498,611 0.8% 16.8%
Lab/X-Ray $1,146,792,397 0.8% $1,288,213,313 0.8% 12.3%
Unknown $468,963,299 0.3% $997,460,227 0.6% 112.7%
Other Practitioners $466,810,030 0.3% $658,455,027 0.4% 41.1%
PCCM Services $463,066,148 0.3% $164,562,061 0.1% -64.5%
Total Payments $152,629,463,993 $168,307,398,582 10.3%

*Percentages may not add to 100% due to rounding. Puerto Rico and the U.S. Territories are not included in these national totals.
**New York did not provide Quarter 1, FY 1999. MSIS data and was included based on totals estimated from State hard-copy reporting.
***Hawaii did not report for FY 2000. Their FY 1999 data are included in the FY 2000 totals.

Source: CMS, MSIS Report, FY 1999 and FY 2000.

B-6 National Pharmaceutical Council


Pharmaceutical Benefits 2002

2000 Baseline Data

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

Source: CMS, MSIS Report, FY 2000.

National Pharmaceutical Council B-7


Pharmaceutical Benefits 2002

2001 Baseline Data*

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.

Source: CMS, MSIS Report, FY 2001.

B-8 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Medicaid Payments and Recipients, 2000


State Total Payments Total Recipients Payments Per Recipient
National Total* $168,307,231,426 42,763,233 $3,936
Alabama $2,391,194,897 619,480 $3,860
Alaska $470,249,823 96,432 $4,876
Arizona $2,111,769,849 681,258 $3,100
Arkansas $1,510,079,842 489,325 $3,086
California $17,060,494,184 7,915,450 $2,155
Colorado $1,808,569,210 380,964 $4,747
Connecticut $2,839,310,317 419,890 $6,762
Delaware $528,339,689 115,267 $4,584
District of Columbia $792,584,432 138,677 $5,715
Florida $7,350,363,024 2,360,417 $3,114
Georgia $3,577,903,288 1,289,795 $2,774
Hawaii** $535,162,729 203,763 $2,626
Idaho $593,750,993 131,077 $4,530
Illinois $7,807,447,335 1,516,082 $5,150
Indiana $2,976,177,145 704,624 $4,224
Iowa $1,476,340,040 313,648 $4,707
Kansas $1,226,210,559 262,557 $4,670
Kentucky $2,912,792,289 770,536 $3,780
Louisiana $2,630,563,430 761,248 $3,456
Maine $1,306,809,473 191,624 $6,820
Maryland $3,585,781,047 664,576 $5,396
Massachusetts $5,397,153,356 1,047,440 $5,153
Michigan $4,880,769,009 1,351,650 $3,611
Minnesota $3,277,014,103 559,463 $5,857
Mississippi $1,807,391,891 605,077 $2,987
Missouri $3,270,152,458 890,318 $3,673
Montana $433,207,577 103,821 $4,173
Nebraska $958,490,235 229,038 $4,185
Nevada $515,444,377 138,069 $3,733
New Hampshire $650,594,289 96,935 $6,712
New Jersey $4,706,928,703 822,369 $5,724
New Mexico $1,248,764,305 375,585 $3,325
New York $26,147,613,087 3,419,893 $7,646
North Carolina $4,830,025,832 1,208,789 $3,996
North Dakota $356,184,829 60,864 $5,852
Ohio $7,090,395,763 1,304,886 $5,434
Oklahoma $1,603,788,998 507,059 $3,163
Oregon $1,700,408,573 542,392 $3,135
Pennsylvania $6,365,806,031 1,492,352 $4,266
Rhode Island $1,069,994,225 178,859 $5,982
South Carolina $2,672,145,530 685,104 $3,900
South Dakota $401,175,221 101,951 $3,935
Tennessee $3,490,956,581 1,568,318 $2,226
Texas $9,075,305,586 2,602,616 $3,487
Utah $959,100,396 224,268 $4,277
Vermont $479,258,616 138,862 $3,451
Virginia $2,483,930,711 627,214 $3,960
Washington $2,432,050,117 895,279 $2,717
West Virginia $1,391,731,163 335,014 $4,154
Wisconsin $2,905,598,526 576,636 $5,039
Wyoming $213,957,743 46,422 $4,609

*Puerto Rico and the U.S. Territories are not included in the national totals.
** Hawaii data is for FY1999

Source: CMS, MSIS Report, FY 2000.

National Pharmaceutical Council B-9


Pharmaceutical Benefits 2002

Medicaid Payments and Recipients, 2001*


State Total Payments Total Recipients Payments Per Recipient
National Total
Alabama
Alaska $557,398,672 105,464 $5,285
Arizona $2,453,184,175 763,422 $3,213
Arkansas $1,684,717,766 531,533 $3,170
California $19,824,989,448 8,596,862 $2,306
Colorado $1,952,708,545 393,195 $4,966
Connecticut $2,962,088,094 684,717 $4,326
Delaware $601,182,212 122,948 $4,890
District of Columbia $830,258,078 140,720 $5,900
Florida $8,398,159,525 2,458,609 $3,416
Georgia $3,815,267,274 1,256,990 $3,035
Hawaii
Idaho $713,433,025 157,121 $4,541
Illinois $14,838,487,574 1,655,837 $8,961
Indiana $3,355,995,714 771,785 $4,348
Iowa $1,660,864,098 319,741 $5,194
Kansas $1,370,248,183 272,783 $5,023
Kentucky $3,235,072,953 807,435 $4,007
Louisiana $2,779,206,115 740,730 $3,752
Maine
Maryland $3,855,002,531 634,273 $6,078
Massachusetts $5,765,107,723 1,039,979 $5,543
Michigan $5,316,248,739 1,352,418 $3,931
Minnesota $3,766,604,923 609,314 $6,182
Mississippi $2,180,662,071 707,899 $3,080
Missouri $3,626,212,602 978,546 $3,706
Montana $482,543,436 107,708 $4,480
Nebraska $1,089,787,848 242,901 $4,487
Nevada $565,299,853 133,103 $4,247
New Hampshire $691,195,787 97,062 $7,121
New Jersey $5,011,794,888 898,685 $5,577
New Mexico $1,476,537,827 379,207 $3,894
New York $27,497,918,486 3,039,436 $9,047
North Carolina $5,499,093,501 1,304,684 $4,215
North Dakota
Ohio $7,772,738,205 1,413,925 $5,497
Oklahoma $2,004,799,211 570,671 $3,513
Oregon
Pennsylvania
Rhode Island
South Carolina $3,096,853,528 760,797 $4,071
South Dakota $426,633,598 109,461 $3,898
Tennessee $4,059,332,053 1,602,027 $2,534
Texas $9,644,600,358 2,659,682 $3,626
Utah $1,059,729,740 232,520 $4,558
Vermont $541,283,084 149,262 $3,626
Virginia $2,715,962,318 618,395 $4,392
Washington
West Virginia $1,565,008,585 349,229 $4,481
Wisconsin $3,029,722,940 633,463 $4,783
Wyoming $241,187,030 51,068 $4,723

*2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.

Source: CMS, MSIS Report, FY 2001.

B-10 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drug Payments and Recipients, 2000


State Total Drug Payments Total Drug Recipients Drug Payments per Recipient
National Total* $20,013,770,558 20,516,882 $975
Alabama $331,574,388 438,529 $756
Alaska $51,196,685 60,273 $849
Arizona $1,952,231 7,034 $278
Arkansas $209,933,612 290,749 $722
California $2,316,135,493 2,487,875 $931
Colorado $152,478,786 160,264 $951
Connecticut $264,641,409 113,089 $2,340
Delaware $66,263,771 78,167 $848
District of Columbia $55,092,178 38,129 $1,445
Florida $1,366,193,807 1,072,082 $1,274
Georgia $580,612,920 847,730 $685
Hawaii** $44,849,664 35,687 $1,257
Idaho $83,525,730 92,776 $900
Illinois $847,001,431 1,013,254 $836
Indiana $464,982,829 420,041 $1,107
Iowa $193,832,443 212,178 $914
Kansas $167,216,488 158,334 $1,056
Kentucky $465,178,958 427,514 $1,088
Louisiana $476,400,908 581,356 $819
Maine $175,938,952 148,049 $1,188
Maryland $374,121,433 409,511 $914
Massachusetts $682,519,910 666,627 $1,024
Michigan $374,334,359 435,654 $859
Minnesota $221,682,000 180,104 $1,231
Mississippi $370,355,016 415,925 $890
Missouri $600,484,118 447,062 $1,343
Montana $58,634,278 58,899 $996
Nebraska $135,355,734 165,891 $816
Nevada $51,682,326 51,169 $1,010
New Hampshire $80,562,181 73,313 $1,099
New Jersey $584,533,211 298,450 $1,959
New Mexico $57,502,713 67,238 $855
New York $2,366,900,006 2,173,791 $1,089
North Carolina $794,550,074 827,039 $961
North Dakota $38,076,519 38,957 $977
Ohio $882,579,749 777,632 $1,135
Oklahoma $178,254,361 221,984 $803
Oregon $163,263,562 191,901 $851
Pennsylvania $533,527,373 416,498 $1,281
Rhode Island $89,482,143 49,809 $1,797
South Carolina $334,740,332 474,465 $706
South Dakota $44,650,518 53,666 $832
Tennessee $0 0 $0
Texas $1,125,238,856 1,852,801 $607
Utah $100,794,076 133,164 $757
Vermont $91,724,918 103,228 $889
Virginia $382,471,744 347,251 $1,101
Washington $387,877,281 339,440 $1,143
West Virginia $216,077,217 261,544 $826
Wisconsin $349,558,072 267,417 $1,307
Wyoming $27,233,795 33,342 $817
*Puerto Rico and the U.S. Territories are not included in the national totals.
** Hawaii data is for FY1999

Source: CMS, MSIS Report, FY 2000.

National Pharmaceutical Council B-11


Pharmaceutical Benefits 2002

Drug Payments and Recipients, 2001*


State Total Drug Payments Total Drug Recipients Drug Payments per Recipient
National Total
Alabama
Alaska $64,923,574 65,278 $995
Arizona $4,254,191 9,761 $436
Arkansas $248,392,084 321,920 $772
California $2,808,298,437 2,486,910 $1,129
Colorado $177,115,553 143,169 $1,237
Connecticut $304,470,534 116,755 $2,608
Delaware $81,623,058 85,351 $956
District of Columbia $62,292,004 35,324 $1,763
Florida $1,487,935,645 1,159,155 $1,284
Georgia $655,515,772 856,797 $765
Hawaii
Idaho $105,473,425 112,357 $939
Illinois $975,308,665 1,068,512 $913
Indiana $562,120,344 464,879 $1,209
Iowa $230,430,967 221,691 $1,039
Kansas $189,290,260 158,515 $1,194
Kentucky $598,093,343 475,365 $1,258
Louisiana $547,731,897 594,364 $922
Maine
Maryland $417,080,496 413,755 $1,008
Massachusetts $795,309,302 664,891 $1,196
Michigan $604,759,491 551,593 $1,096
Minnesota $265,240,353 188,566 $1,407
Mississippi $494,805,247 478,404 $1,034
Missouri $680,574,899 472,624 $1,440
Montana $69,552,397 63,338 $1,098
Nebraska $161,577,499 178,365 $906
Nevada $62,849,319 55,580 $1,131
New Hampshire $90,927,579 73,489 $1,237
New Jersey $649,274,352 307,798 $2,109
New Mexico $70,147,344 75,669 $927
New York $2,779,026,904 2,283,293 $1,217
North Carolina $971,066,103 907,413 $1,070
North Dakota
Ohio $1,087,552,923 904,380 $1,203
Oklahoma $215,717,760 249,678 $864
Oregon
Pennsylvania
Rhode Island
South Carolina $438,498,935 542,764 $808
South Dakota $52,608,524 58,203 $904
Tennessee $0 0 $0
Texas $1,327,222,456 1,917,351 $692
Utah $117,101,302 136,682 $857
Vermont $105,673,417 109,328 $967
Virginia $419,133,293 333,880 $1,255
Washington
West Virginia $256,395,319 269,174 $953
Wisconsin $389,373,521 262,238 $1,485
Wyoming $31,881,860 36,704 $869
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.

Source: CMS, MSIS Report, FY 2001.

B-12 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drug Payment Trends, Percent Change 1999-2000


State 1999 2000 Percent Change
National Total* $16,566,787,283 $20,013,770,558 20.8%
Alabama $281,017,085 $331,574,388 18.0%
Alaska $39,414,646 $51,196,685 29.9%
Arizona $1,458,590 $1,952,231 33.8%
Arkansas $182,862,001 $209,933,612 14.8%
California $1,883,865,448 $2,316,135,493 22.9%
Colorado $130,546,904 $152,478,786 16.8%
Connecticut $220,556,702 $264,641,409 20.0%
Delaware $53,443,101 $66,263,771 24.0%
District of Columbia $44,963,481 $55,092,178 22.5%
Florida $1,092,855,918 $1,366,193,807 25.0%
Georgia $462,992,436 $580,612,920 25.4%
Hawaii** $44,849,664 -
Idaho $68,618,868 $83,525,730 21.7%
Illinois $670,336,480 $847,001,431 26.4%
Indiana $375,534,082 $464,982,829 23.8%
Iowa $169,142,312 $193,832,443 14.6%
Kansas $139,664,907 $167,216,488 19.7%
Kentucky $359,671,170 $465,178,958 29.3%
Louisiana $405,754,264 $476,400,908 17.4%
Maine $145,653,294 $175,938,952 20.8%
Maryland $291,435,049 $374,121,433 28.4%
Massachusetts $594,321,506 $682,519,910 14.8%
Michigan $320,544,345 $374,334,359 16.8%
Minnesota $184,423,517 $221,682,000 20.2%
Mississippi $274,594,293 $370,355,016 34.9%
Missouri $482,087,676 $600,484,118 24.6%
Montana $47,841,127 $58,634,278 22.6%
Nebraska $115,303,037 $135,355,734 17.4%
Nevada $40,265,800 $51,682,326 28.4%
New Hampshire $64,895,522 $80,562,181 24.1%
New Jersey $491,431,380 $584,533,211 18.9%
New Mexico $46,998,841 $57,502,713 22.3%
New York*** $1,972,517,591 $2,366,900,006 20.0%
North Carolina $611,309,477 $794,550,074 30.0%
North Dakota $31,584,648 $38,076,519 20.6%
Ohio $761,987,389 $882,579,749 15.8%
Oklahoma $167,704,485 $178,254,361 6.3%
Oregon $123,806,352 $163,263,562 31.9%
Pennsylvania $605,729,789 $533,527,373 -11.9%
Rhode Island $75,139,107 $89,482,143 19.1%
South Carolina $268,317,914 $334,740,332 24.8%
South Dakota $37,044,912 $44,650,518 20.5%
Tennessee $0 $0 0.0%
Texas $952,419,862 $1,125,238,856 18.1%
Utah $83,321,189 $100,794,076 21.0%
Vermont $66,833,720 $91,724,918 37.2%
Virginia $327,518,802 $382,471,744 16.8%
Washington $303,391,865 $387,877,281 27.8%
West Virginia $195,644,951 $216,077,217 10.4%
Wisconsin $277,770,270 $349,558,072 25.8%
Wyoming $22,251,178 $27,233,795 22.4%

* Puerto Rico and the U.S. Trust Territories are not included in the national totals.
** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000.
CMS included their FY 1999 data in the FY 2000 MSIS Report.
*** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting.

Source: CMS, MSIS Report, FY 1999 and 2000.

National Pharmaceutical Council B-13


Pharmaceutical Benefits 2002

Drug Payment Trends, Percent Change 2000-2001*


State 2000 2001 Percent Change
National Total** $20,013,770,558
Alabama $331,574,388
Alaska $51,196,685 $64,923,574 26.81%
Arizona $1,952,231 $4,254,191 117.91%
Arkansas $209,933,612 $248,392,084 18.32%
California $2,316,135,493 $2,808,298,437 21.25%
Colorado $152,478,786 $177,115,553 16.16%
Connecticut $264,641,409 $304,470,534 15.05%
Delaware $66,263,771 $81,623,058 23.18%
District of Columbia $55,092,178 $62,292,004 13.07%
Florida $1,366,193,807 $1,487,935,645 8.91%
Georgia $580,612,920 $655,515,772 12.90%
Hawaii
Idaho $83,525,730 $105,473,425 26.28%
Illinois $847,001,431 $975,308,665 15.15%
Indiana $464,982,829 $562,120,344 20.89%
Iowa $193,832,443 $230,430,967 18.88%
Kansas $167,216,488 $189,290,260 13.20%
Kentucky $465,178,958 $598,093,343 28.57%
Louisiana $476,400,908 $547,731,897 14.97%
Maine $175,938,952
Maryland $374,121,433 $417,080,496 11.48%
Massachusetts $682,519,910 $795,309,302 16.53%
Michigan $374,334,359 $604,759,491 61.56%
Minnesota $221,682,000 $265,240,353 19.65%
Mississippi $370,355,016 $494,805,247 33.60%
Missouri $600,484,118 $680,574,899 13.34%
Montana $58,634,278 $69,552,397 18.62%
Nebraska $135,355,734 $161,577,499 19.37%
Nevada $51,682,326 $62,849,319 21.61%
New Hampshire $80,562,181 $90,927,579 12.87%
New Jersey $584,533,211 $649,274,352 11.08%
New Mexico $57,502,713 $70,147,344 21.99%
New York $2,366,900,006 $2,779,026,904 17.41%
North Carolina $794,550,074 $971,066,103 22.22%
North Dakota $38,076,519
Ohio $882,579,749 $1,087,552,923 23.22%
Oklahoma $178,254,361 $215,717,760 21.02%
Oregon $163,263,562
Pennsylvania $533,527,373
Rhode Island $89,482,143
South Carolina $334,740,332 $438,498,935 31.00%
South Dakota $44,650,518 $52,608,524 17.82%
Tennessee $0 $0 0.00%
Texas $1,125,238,856 $1,327,222,456 17.95%
Utah $100,794,076 $117,101,302 16.18%
Vermont $91,724,918 $105,673,417 15.21%
Virginia $382,471,744 $419,133,293 9.59%
Washington $387,877,281
West Virginia $216,077,217 $256,395,319 18.66%
Wisconsin $349,558,072 $389,373,521 11.39%
Wyoming $27,233,795 $31,881,860 17.07%

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
** Puerto Rico and the U.S. Trust Territories are not included in the national totals.

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

B-14 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Rankings Based on Drug Payments


State 2000 Payments 2000 % of 2000 Total Medicaid 1999 Payments 1999
Ranking Drug Payments Ranking
New York*** $2,366,900,006 1 11.83% $1,972,517,591 1
California $2,316,135,493 2 11.57% $1,883,865,448 2
Florida $1,366,193,807 3 6.83% $1,092,855,918 3
Texas $1,125,238,856 4 5.62% $952,419,862 4
Ohio $882,579,749 5 4.41% $761,987,389 5
Illinois $847,001,431 6 4.23% $670,336,480 6
North Carolina $794,550,074 7 3.97% $611,309,477 7
Massachusetts $682,519,910 8 3.41% $594,321,506 9
Missouri $600,484,118 9 3.00% $482,087,676 11
New Jersey $584,533,211 10 2.92% $491,431,380 10
Georgia $580,612,920 11 2.90% $462,992,436 12
Pennsylvania $533,527,373 12 2.67% $605,729,789 8
Louisiana $476,400,908 13 2.38% $405,754,264 13
Kentucky $465,178,958 14 2.32% $359,671,170 15
Indiana $464,982,829 15 2.32% $375,534,082 14
Washington $387,877,281 16 1.94% $303,391,865 18
Virginia $382,471,744 17 1.91% $327,518,802 16
Michigan $374,334,359 18 1.87% $320,544,345 17
Maryland $374,121,433 19 1.87% $291,435,049 19
Mississippi $370,355,016 20 1.85% $274,594,293 22
Wisconsin $349,558,072 21 1.75% $277,770,270 21
South Carolina $334,740,332 22 1.67% $268,317,914 23
Alabama $331,574,388 23 1.66% $281,017,085 20
Connecticut $264,641,409 24 1.32% $220,556,702 24
Minnesota $221,682,000 25 1.11% $184,423,517 26
West Virginia $216,077,217 26 1.08% $195,644,951 25
Arkansas $209,933,612 27 1.05% $182,862,001 27
Iowa $193,832,443 28 0.97% $169,142,312 28
Oklahoma $178,254,361 29 0.89% 167704485 29
Maine $175,938,952 30 0.88% $145,653,294 30
Kansas $167,216,488 31 0.84% $139,664,907 31
Oregon $163,263,562 32 0.82% $123,806,352 33
Colorado $152,478,786 33 0.76% $130,546,904 32
Nebraska $135,355,734 34 0.68% $115,303,037 34
Utah $100,794,076 35 0.50% $83,321,189 35
Vermont $91,724,918 36 0.46% $66,833,720 38
Rhode Island $89,482,143 37 0.45% $75,139,107 36
Idaho $83,525,730 38 0.42% $68,618,868 37
New Hampshire $80,562,181 39 0.40% $64,895,522 39
Delaware $66,263,771 40 0.33% $53,443,101 40
Montana $58,634,278 41 0.29% $47,841,127 41
New Mexico $57,502,713 42 0.29% $46,998,841 42
District of Columbia $55,092,178 43 0.28% $44,963,481 43
Nevada $51,682,326 44 0.26% $40,265,800 44
Alaska $51,196,685 45 0.26% $39,414,646 45
Hawaii** $44,849,664 46 0.22% - -
South Dakota $44,650,518 47 0.22% $37,044,912 46
North Dakota $38,076,519 48 0.19% $31,584,648 47
Wyoming $27,233,795 49 0.14% $22,251,178 48
Arizona $1,952,231 50 0.01% $1,458,590 49
Tennessee $0 51 - $0 50

** Hawaii did not report for FY 1999 in FY 1999 and is not included in the national totals for that year. Hawaii also did not report for FY 2000. CMS
included their FY 1999 data in the FY 2000 MSIS Report.
*** New York did not provide Quarter 1 data for FY 1999 and was included based on totals estimated from State hard-copy reporting.

Source: CMS, MSIS Report, FY 1999 and 2000.

National Pharmaceutical Council B-15


Pharmaceutical Benefits 2002

Drugs as a Percentage of Total Payments, 2000


State Drug Payments Total Payments Percent of Total Payments
National Total* $20,013,770,558 $168,307,231,426 11.9%
Alabama $331,574,388 $2,391,194,897 13.9%
Alaska $51,196,685 $470,249,823 10.9%
Arizona $1,952,231 $2,111,769,849 0.1%
Arkansas $209,933,612 $1,510,079,842 13.9%
California $2,316,135,493 $17,060,494,184 13.6%
Colorado $152,478,786 $1,808,569,210 8.4%
Connecticut $264,641,409 $2,839,310,317 9.3%
Delaware $66,263,771 $528,339,689 12.5%
District of Columbia $55,092,178 $792,584,432 7.0%
Florida $1,366,193,807 $7,350,363,024 18.6%
Georgia $580,612,920 $3,577,903,288 16.2%
Hawaii** $44,849,664 $535,162,729 8.4%
Idaho $83,525,730 $593,750,993 14.1%
Illinois $847,001,431 $7,807,447,335 10.8%
Indiana $464,982,829 $2,976,177,145 15.6%
Iowa $193,832,443 $1,476,340,040 13.1%
Kansas $167,216,488 $1,226,210,559 13.6%
Kentucky $465,178,958 $2,912,792,289 16.0%
Louisiana $476,400,908 $2,630,563,430 18.1%
Maine $175,938,952 $1,306,809,473 13.5%
Maryland $374,121,433 $3,585,781,047 10.4%
Massachusetts $682,519,910 $5,397,153,356 12.6%
Michigan $374,334,359 $4,880,769,009 7.7%
Minnesota $221,682,000 $3,277,014,103 6.8%
Mississippi $370,355,016 $1,807,391,891 20.5%
Missouri $600,484,118 $3,270,152,458 18.4%
Montana $58,634,278 $433,207,577 13.5%
Nebraska $135,355,734 $958,490,235 14.1%
Nevada $51,682,326 $515,444,377 10.0%
New Hampshire $80,562,181 $650,594,289 12.4%
New Jersey $584,533,211 $4,706,928,703 12.4%
New Mexico $57,502,713 $1,248,764,305 4.6%
New York $2,366,900,006 $26,147,613,087 9.1%
North Carolina $794,550,074 $4,830,025,832 16.5%
North Dakota $38,076,519 $356,184,829 10.7%
Ohio $882,579,749 $7,090,395,763 12.4%
Oklahoma $178,254,361 $1,603,788,998 11.1%
Oregon $163,263,562 $1,700,408,573 9.6%
Pennsylvania $533,527,373 $6,365,806,031 8.4%
Rhode Island $89,482,143 $1,069,994,225 8.4%
South Carolina $334,740,332 $2,672,145,530 12.5%
South Dakota $44,650,518 $401,175,221 11.1%
Tennessee $0 $3,490,956,581 -
Texas $1,125,238,856 $9,075,305,586 12.4%
Utah $100,794,076 $959,100,396 10.5%
Vermont $91,724,918 $479,258,616 19.1%
Virginia $382,471,744 $2,483,930,711 15.4%
Washington $387,877,281 $2,432,050,117 15.9%
West Virginia $216,077,217 $1,391,731,163 15.5%
Wisconsin $349,558,072 $2,905,598,526 12.0%
Wyoming $27,233,795 $213,957,743 12.7%

*Puerto Rico and the U.S. Territories are not included in the national totals.
**Hawaii data is for FY 1999.

Source: CMS, MSIS Report, FY 2000

B-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Drugs as a Percentage of Total Payments, 2001*


State Drug Payments Total Payments Percent of Total Payments
National Total
Alabama
Alaska $64,923,574 $557,398,672 11.6%
Arizona $4,254,191 $2,453,184,175 0.2%
Arkansas $248,392,084 $1,684,717,766 14.7%
California $2,808,298,437 $19,824,989,448 14.2%
Colorado $177,115,553 $1,952,708,545 9.1%
Connecticut $304,470,534 $2,962,088,094 10.3%
Delaware $81,623,058 $601,182,212 13.6%
District of Columbia $62,292,004 $830,258,078 7.5%
Florida $1,487,935,645 $8,398,159,525 17.7%
Georgia $655,515,772 $3,815,267,274 17.2%
Hawaii
Idaho $105,473,425 $713,433,025 14.8%
Illinois $975,308,665 $14,838,487,574 6.6%
Indiana $562,120,344 $3,355,995,714 16.7%
Iowa $230,430,967 $1,660,864,098 13.9%
Kansas $189,290,260 $1,370,248,183 13.8%
Kentucky $598,093,343 $3,235,072,953 18.5%
Louisiana $547,731,897 $2,779,206,115 19.7%
Maine
Maryland $417,080,496 $3,855,002,531 10.8%
Massachusetts $795,309,302 $5,765,107,723 13.8%
Michigan $604,759,491 $5,316,248,739 11.4%
Minnesota $265,240,353 $3,766,604,923 7.0%
Mississippi $494,805,247 $2,180,662,071 22.7%
Missouri $680,574,899 $3,626,212,602 18.8%
Montana $69,552,397 $482,543,436 14.4%
Nebraska $161,577,499 $1,089,787,848 14.8%
Nevada $62,849,319 $565,299,853 11.1%
New Hampshire $90,927,579 $691,195,787 13.2%
New Jersey $649,274,352 $5,011,794,888 13.0%
New Mexico $70,147,344 $1,476,537,827 4.8%
New York $2,779,026,904 $27,497,918,486 10.1%
North Carolina $971,066,103 $5,499,093,501 17.7%
North Dakota
Ohio $1,087,552,923 $7,772,738,205 14.0%
Oklahoma $215,717,760 $2,004,799,211 10.8%
Oregon
Pennsylvania
Rhode Island
South Carolina $438,498,935 $3,096,853,528 14.2%
South Dakota $52,608,524 $426,633,598 12.3%
Tennessee $0 $4,059,332,053 0.0%
Texas $1,327,222,456 $9,644,600,358 13.8%
Utah $117,101,302 $1,059,729,740 11.1%
Vermont $105,673,417 $541,283,084 19.5%
Virginia $419,133,293 $2,715,962,318 15.4%
Washington
West Virginia $256,395,319 $1,565,008,585 16.4%
Wisconsin $389,373,521 $3,029,722,940 12.9%
Wyoming $31,881,860 $241,187,030 13.2%

* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.

Source: CMS, MSIS Report, FY 2001

National Pharmaceutical Council B-17


Pharmaceutical Benefits 2002

Drugs as a Percentage of Total Payments, 1996 - 2001


State 1996 1997 1998 1999 2000 2001*
National Total** 8.8% 9.7% 9.5% 10.9% 11.9%
Alabama 13.9% 14.4% 12.4% 16.6% 13.9%
Alaska 7.8% 8.8% 10.0% 9.9% 10.9% 11.6%
Arizona 1.2% 0.8% 0.1% 0.1% 0.1% 0.2%
Arkansas 9.4% 10.4% 11.0% 13.4% 13.9% 14.7%
California 11.0% 11.7% 10.9% 12.2% 13.6% 14.2%
Colorado 8.0% 8.6% 7.7% 8.0% 8.4% 9.1%
Connecticut 7.2% 8.3% 7.7% 8.3% 9.3% 10.3%
Delaware 9.0% 12.6% 9.9% 11.6% 12.5% 13.6%
District of Columbia 4.6% 5.4% 5.6% 5.9% 7.0% 7.5%
Florida 14.1% 15.8% 16.4% 17.0% 18.6% 17.7%
Georgia 10.3% 11.0% 12.3% 14.3% 16.2% 17.2%
Hawaii*** 10.1% - 7.8% - 8.4%
Idaho 10.1% 10.4% 12.9% 13.2% 14.1% 14.8%
Illinois 8.3% 9.1% 9.4% 10.6% 10.8% 6.6%
Indiana 11.0% 12.3% 12.7% 13.7% 15.6% 16.7%
Iowa 10.2% 11.4% 11.4% 12.4% 13.1% 13.9%
Kansas 10.5% 11.4% 13.0% 12.7% 13.6% 13.8%
Kentucky 14.1% 13.9% 13.2% 13.8% 16.0% 18.5%
Louisiana 12.1% 13.5% 14.8% 16.0% 18.1% 19.7%
Maine 11.6% 13.2% 16.3% 12.1% 13.5%
Maryland 7.6% 7.8% 6.0% 9.6% 10.4% 10.8%
Massachusetts 8.0% 10.3% 10.8% 12.0% 12.6% 13.8%
Michigan 10.5% 10.2% 8.6% 6.8% 7.7% 11.4%
Minnesota 6.2% 6.6% 5.9% 6.1% 6.8% 7.0%
Mississippi 13.2% 14.6% 16.1% 17.2% 20.5% 22.7%
Missouri 14.0% 15.3% 14.9% 17.2% 18.4% 18.8%
Montana 9.3% 11.2% 11.7% 13.1% 13.5% 14.4%
Nebraska 10.5% 11.5% 12.3% 13.2% 14.1% 14.8%
Nevada 6.7% 7.1% 7.5% 8.8% 10.0% 11.1%
New Hampshire 7.7% 8.2% 9.1% 12.3% 12.4% 13.2%
New Jersey 10.0% 10.4% 10.1% 11.2% 12.4% 13.0%
New Mexico 7.0% 7.7% 4.8% 4.2% 4.6% 4.8%
New York**** 4.1% 5.1% 5.6% 7.8% 9.1% 10.1%
North Carolina 9.4% 10.7% 11.6% 14.3% 16.5% 17.7%
North Dakota 7.0% 7.7% 8.1% 9.1% 10.7%
Ohio 9.4% 9.9% 10.5% 12.0% 12.4% 14.0%
Oklahoma***** 9.6% 10.7% - 11.7% 11.1% 10.8%
Oregon 5.1% 5.0% 6.4% 7.8% 9.6%
Pennsylvania 11.5% 11.8% 8.6% 9.9% 8.4%
Rhode Island 6.7% 7.1% 6.7% 8.5% 8.4%
South Carolina 9.4% 9.9% 11.1% 10.9% 12.5% 14.2%
South Dakota 7.6% 8.7% 8.7% 10.0% 11.1% 12.3%
Tennessee 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Texas 9.7% 10.2% 11.5% 11.7% 12.4% 13.8%
Utah 11.4% 12.0% 11.1% 10.5% 10.5% 11.1%
Vermont 12.1% 14.4% 12.4% 15.9% 19.1% 19.5%
Virginia 12.5% 13.4% 13.4% 14.8% 15.4% 15.4%
Washington 12.4% 14.7% 12.0% 11.8% 15.9%
West Virginia 11.1% 10.6% 12.0% 14.6% 15.5% 16.4%
Wisconsin 10.8% 10.9% 10.5% 12.4% 12.0% 12.9%
Wyoming 7.5% 8.1% 8.9% 11.2% 12.7% 13.2%
* FY 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota,
Oregon, Pennsylvania, Rhode Island, and Washington.
**Puerto Rico and the U.S. Territories are not included in the national totals.
***Hawaii did not report on time for FY 1997 and FY 1999 and was excluded from the national totals for those years. Hawaii also did not
report for FY 2000. CMS included their FY 1999 data in the FY 2000 MSIS Report.
****New York did not provide Quarter 1 MSIS data for FY 1999 and was included based on totals estimated from State hard-copy reporting.
*****Oklahoma did not report for FY 1998 and was excluded from the national total for that year.

Source: CMS, HCFA-2082 Reports, FY 1996-FY 1998 and MSIS Reports, FY 1999-2001.

B-18 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Total Drug Recipients ‡


State 1996 1997 1998 1999 2000 2001*
National Total** 22,575,656 20,943,872 19,324,605 19,854,953 20,516,082
Alabama 412,511 412,739 395,290 405,338 438,529
Alaska 40,839 42,174 43,734 52,086 60,273 65,278
Arizona 63,103 80,450 56,796 5,545 7,034 9,761
Arkansas 255,211 254,079 262,907 280,573 290,749 321,920
California 3,565,667 3,158,386 2,644,430 2,264,942 2,487,875 2,486,910
Colorado 173,707 156,631 147,033 151,581 160,264 143,169
Connecticut 209,557 120,522 108,331 108,753 113,089 116,755
Delaware 61,380 68,672 69,027 73,093 78,167 85,351
District of Columbia 66,349 64,494 57,733 37,862 38,129 35,324
Florida 1,079,467 1,024,555 1,014,372 1,079,997 1,072,082 1,159,155
Georgia 891,335 846,963 805,923 841,024 847,730 856,797
Hawaii*** 29,657 - 32,222 35,687 35,687
Idaho 84,553 79,961 86,775 81,943 92,776 112,357
Illinois 1,028,753 1,008,740 959,472 965,747 1,013,254 1,068,512
Indiana 401,042 352,814 323,811 361,784 420,041 464,879
Iowa 230,749 221,061 215,173 213,161 212,178 221,691
Kansas 179,653 170,167 155,875 153,117 158,334 158,515
Kentucky 497,251 494,293 429,102 372,254 427,514 475,365
Louisiana 593,415 563,864 552,481 549,296 581,356 594,364
Maine 138,360 139,524 137,816 142,043 148,049
Maryland 268,440 256,423 176,403 345,740 409,511 413,755
Massachusetts 527,114 559,215 613,186 664,528 666,627 664,891
Michigan 763,232 688,882 589,818 436,652 435,654 551,593
Minnesota 294,589 227,027 203,220 184,947 180,104 188,566
Mississippi 404,263 391,328 368,609 375,585 415,925 478,404
Missouri 469,821 395,478 353,902 411,959 447,062 472,624
Montana 66,465 62,092 58,641 59,204 58,899 63,338
Nebraska 138,322 151,973 145,408 155,169 165,891 178,365
Nevada 60,274 55,876 50,903 48,535 51,169 55,580
New Hampshire 75,701 71,692 70,339 71,037 73,313 73,489
New Jersey 518,833 347,105 309,849 302,687 298,450 307,798
New Mexico 197,565 184,502 96,637 55,020 67,238 75,669
New York 1,737,372 1,667,927 1,803,428 2,193,515 2,173,791 2,283,293
North Carolina 764,482 779,229 764,886 797,903 827,039 907,413
North Dakota 40,062 39,654 37,675 38,191 38,957
Ohio 902,211 786,322 702,143 796,720 777,632 904,380
Oklahoma**** 245,075 207,441 - 224,742 221,984 249,678
Oregon 154,801 149,461 148,258 171,997 191,101
Pennsylvania 857,818 763,255 580,749 520,251 416,498
Rhode Island 52,239 46,817 44,852 49,285 49,809
South Carolina 365,409 359,910 401,611 446,938 474,465 542,764
South Dakota 49,056 47,845 46,588 50,783 53,666 58,203
Tennessee^ 18 3 1 0 0 0
Texas 2,058,903 1,986,178 1,894,447 1,853,536 1,852,801 1,917,351
Utah 114,321 105,676 126,953 128,297 133,164 136,682
Vermont 78,376 83,057 58,037 88,322 103,228 109,328
Virginia 417,580 396,719 383,880 373,491 347,251 333,880
Washington 305,791 292,733 274,463 301,753 339,440
West Virginia 299,967 280,550 267,398 274,842 261,544 269,174
Wisconsin 309,582 265,987 221,508 224,213 267,417 262,238
Wyoming 35,415 33,426 32,510 33,285 33,342 36,704

Recipients are defined as individuals who received drugs, not as everyone eligible to receive drugs.
* FY 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington.
**Puerto Rico and the U.S. Territories are not included in the national totals.
***Hawaii did not report on time for FY 1997. They are excluded from the national total for that year. Hawaii also did not report for FY 2000. Their
FY 1999 data is included in the FY 2000 Total.
****Oklahoma did not report for FY 1998. They are excluded from the national total for that year.
^Tennessee does not report drug recipients because beneficiaries are enrolled in managed care & receive pharmaceutical benefits through these
plans.

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Source: CMS, HCFA-2082 Report, FY 1996-FY1998 and MSIS Report, FY 1999-2001.

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Total Medicaid Eligibles by Basis of Eligibility, 2001*


Age 65 Blind/ Foster Care/ BOE
State Total Eligibles And Older Disabled Children Adults Children Unknown
National Total
Alabama
Alaska 115,996 6,403 11,443 70,446 25,920 1,772 12
Arizona 808,386 37,102 102,909 430,749 229,944 7,682 0
Arkansas 550,668 52,240 104,421 267,241 120,840 5,913 13
California 8,495,030 626,550 959,584 3,169,960 3,598,569 140,366 1
Colorado 410,611 46,708 65,407 202,166 79,337 16,878 115
Connecticut 446,326 59,510 58,579 234,953 84,401 8,862 21
Delaware 133,079 9,613 16,500 59,452 45,580 1,934 0
District of Columbia 152,597 9,957 31,334 71,667 35,007 4,632 0
Florida 2,462,171 248,466 478,847 1,190,510 503,789 40,545 14
Georgia 1,328,379 109,245 229,725 717,007 253,525 18,877 0
Hawaii
Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0
Illinois 1,796,814 112,122 282,418 952,300 367,676 82,235 63
Indiana 825,556 78,267 113,799 484,090 137,344 12,056 0
Iowa 331,025 41,128 57,426 157,333 65,498 9,640 0
Kansas 291,837 31,659 52,513 150,022 44,424 13,219 0
Kentucky 762,871 70,730 207,524 374,318 101,494 8,805 0
Louisiana 886,518 101,002 173,725 499,771 102,480 9,540 0
Maine
Maryland 704,628 54,654 114,951 386,346 132,309 16,367 1
Massachusetts 1,125,607 112,994 235,157 453,373 323,473 610 0
Michigan 1,430,246 100,156 288,790 744,902 255,755 40,564 79
Minnesota 609,856 64,108 83,579 309,972 142,313 9,884 0
Mississippi 681,161 74,018 159,306 369,654 74,943 3,224 16
Missouri 1,032,047 95,603 140,938 538,423 233,282 23,801 0
Montana 101,966 9,952 17,757 50,954 19,335 3,947 21
Nebraska 249,079 23,026 28,877 138,980 47,826 10,121 249
Nevada 167,247 17,920 29,993 79,283 35,217 4,834 0
New Hampshire 108,562 12,833 13,507 63,942 15,675 2,605 0
New Jersey 923,697 106,976 164,564 436,335 195,988 19,834 0
New Mexico 423,543 22,605 50,326 268,391 78,634 3,587 0
New York 3,548,630 385,586 684,658 1,573,767 825,201 79,418 0
North Carolina 1,397,486 180,515 234,304 685,285 281,193 16,189 0
North Dakota
Ohio 1,660,463 145,324 263,878 861,621 348,936 40,533 171
Oklahoma 631,996 62,350 76,638 397,586 88,507 6,915 0
Oregon
Pennsylvania
Rhode Island
South Carolina 871,675 78,673 120,088 444,607 220,606 7,692 9
South Dakota 106,154 9,894 16,042 61,743 16,704 1,771 0
Tennessee 1,601,406 88,350 324,191 682,755 493,266 12,822 22
Texas 2,729,660 362,522 351,509 1,526,365 458,079 31,185 0
Utah 214,597 11,855 26,386 119,196 50,579 6,581 0
Vermont 154,991 19,534 18,529 67,666 46,876 2,382 4
Virginia 700,715 97,093 137,282 359,463 92,543 14,334 0
Washington
West Virginia 351,489 31,183 86,566 168,367 58,889 6,484 0
Wisconsin 673,538 61,165 133,983 299,529 160,354 18,505 2
Wyoming 58,013 4,984 8,476 32,076 10,638 1,839 0
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: CMS, MSIS Report, FY 2001.

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Total Medicaid Eligibles


Per 1000 Population, 2001*
Total State Total Eligibles per
State Population Eligibles 1000 Populations
National Total 285,317,559
Alabama 4,468,912
Alaska 633,630 115,996 183.1
Arizona 5,306,966 808,386 152.3
Arkansas 2,694,698 550,668 204.4
California 34,600,463 8,495,030 245.5
Colorado 4,430,989 410,611 92.7
Connecticut 3,434,602 446,326 129.9
Delaware 796,599 133,079 167.1
District of Columbia 573,822 152,597 265.9
Florida 16,373,330 2,462,171 150.4
Georgia 8,405,677 1,328,379 158.0
Hawaii 1,227,024
Idaho 1,320,585 172,348 130.5
Illinois 12,520,227 1,796,814 143.5
Indiana 6,126,743 825,556 134.7
Iowa 2,931,967 331,025 112.9
Kansas 2,702,125 291,837 108.0
Kentucky 4,068,816 762,871 187.5
Louisiana 4,470,368 886,518 198.3
Maine 1,284,470
Maryland 5,386,079 704,628 130.8
Massachusetts 6,401,164 1,125,607 175.8
Michigan 10,006,266 1,430,246 142.9
Minnesota 4,984,535 609,856 122.3
Mississippi 2,859,733 681,161 238.2
Missouri 5,637,309 1,032,047 183.1
Montana 905,382 101,966 112.6
Nebraska 1,720,039 249,079 144.8
Nevada 2,097,722 167,247 79.7
New Hampshire 1,259,359 108,562 86.2
New Jersey 8,511,116 923,697 108.5
New Mexico 1,830,935 423,543 231.3
New York 19,084,350 3,548,630 185.9
North Carolina 8,206,105 1,397,486 170.3
North Dakota 636,550
Ohio 11,389,785 1,660,463 145.8
Oklahoma 3,469,577 631,996 182.2
Oregon 3,473,441
Pennsylvania 12,303,104
Rhode Island 1,059,659
South Carolina 4,062,125 871,675 214.6
South Dakota 758,324 106,154 140.0
Tennessee 5,749,398 1,601,406 278.5
Texas 21,370,983 2,729,660 127.7
Utah 2,278,712 214,597 94.2
Vermont 612,978 154,991 252.8
Virginia 7,196,750 700,715 97.4
Washington 5,993,390
West Virginia 1,800,975 351,489 195.2
Wisconsin 5,405,947 673,538 124.6
Wyoming 493,754 58,013 117.5
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon,
Pennsylvania, Rhode Island, and Washington. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: U.S. Department of Commerce, Bureau of the Census, State Population Estimates; CMS, MSIS, FY 2001.

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Medicaid Total Net Expenditures and Eligibles, 2001*


Total Net Medical Total Average
State Assistance Expenditures Eligibles Per Eligible
National Total $215,809,899,631
Alabama $2,875,372,953
Alaska $576,586,201 115,996 $4,971
Arizona $2,665,261,328 808,386 $3,297
Arkansas $1,852,176,546 550,668 $3,364
California $23,870,521,004 8,495,030 $2,810
Colorado $2,142,029,851 410,611 $5,217
Connecticut $3,213,848,086 446,326 $7,201
Delaware $591,974,246 133,079 $4,448
District of Columbia $979,941,105 152,597 $6,422
Florida $8,557,796,303 2,462,171 $3,476
Georgia $5,037,084,881 1,328,379 $3,792
Hawaii $634,781,970
Idaho $693,205,598 172,348 $4,022
Illinois $7,764,611,352 1,796,814 $4,321
Indiana $4,008,812,857 825,556 $4,856
Iowa $1,666,923,701 331,025 $5,036
Kansas $1,686,410,544 291,837 $5,779
Kentucky $3,304,053,663 762,871 $4,331
Louisiana $4,201,982,590 886,518 $4,740
Maine $1,315,523,163
Maryland $3,256,576,882 704,628 $4,622
Massachusetts $6,619,524,971 1,125,607 $5,881
Michigan $7,218,697,113 1,430,246 $5,047
Minnesota $3,835,870,579 609,856 $6,290
Mississippi $2,438,979,981 681,161 $3,581
Missouri $4,744,963,426 1,032,047 $4,598
Montana $482,357,404 101,966 $4,731
Nebraska $1,187,237,577 249,079 $4,767
Nevada $674,337,888 167,247 $4,032
New Hampshire $873,248,831 108,562 $8,044
New Jersey $7,123,653,988 923,697 $7,712
New Mexico $1,467,417,736 423,543 $3,465
New York $31,367,464,639 3,548,630 $8,839
North Carolina $6,150,681,587 1,397,486 $4,401
North Dakota $406,418,593
Ohio $8,433,412,161 1,660,463 $5,079
Oklahoma $2,021,033,069 631,996 $3,198
Oregon $2,658,358,391
Pennsylvania $10,908,343,146
Rhode Island $1,187,880,819
South Carolina $3,019,387,228 871,675 $3,464
South Dakota $464,455,469 106,154 $4,375
Tennessee $5,501,312,153 1,601,406 $3,435
Texas $11,583,679,558 2,729,660 $4,244
Utah $833,720,115 214,597 $3,885
Vermont $601,467,093 154,991 $3,881
Virginia $3,036,846,387 700,715 $4,334
Washington $4,305,724,247
West Virginia $1,548,398,817 351,489 $4,405
Wisconsin $3,976,142,914 673,538 $5,903
Wyoming $243,408,927 58,013 $4,196
* 2001 MSIS data are preliminary and subject to change. Data have not yet been released for Alabama, Hawaii, Maine, North Dakota, Oregon, Pennsylvania, Rhode Island, and
Washington. Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

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

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Appendix C:
Medicaid Rebate Law

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TITLE 42 - THE PUBLIC HEALTH AND WELFARE


CHAPTER 7 - SOCIAL SECURITY
SUBCHAPTER XIX - GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS

Sec. 1396r-8. Payment for covered outpatient drugs*

(a) Requirement for rebate agreement

(1) In general
In order for payment to be available under section 1396b(a) of this title for covered outpatient drugs of a
manufacturer, the manufacturer must have entered into and have in effect a rebate agreement described in
subsection (b) of this section with the Secretary, on behalf of States (except that, the Secretary may authorize a
State to enter directly into agreements with a manufacturer), and must meet the requirements of paragraph
(5)(with respect to drugs purchased by a covered entity on or after the first day of the first month that begins after
November 4,1992) and paragraph (6). Any agreement between a State and a manufacturer prior to April 1, 1991,
shall be deemed to have been entered into on January 1, 1991, and payment to such manufacturer shall be
retroactively calculated as if the agreement between the manufacturer and the State had been entered into on
January 1,1991. If a manufacturer has not entered into such an agreement before March 1, 1991, such an
agreement, subsequently entered into, shall become effective as of the date on which the agreement is entered into
or, at State option, on any date thereafter on or before the first day of the calendar quarter that begins more than
60 days after the date of the agreement is entered into.

(2) Effective date


Paragraph (1) shall first apply to drugs dispensed under this subchapter on or after January 1, 1991.

(3) Authorizing payment for drugs not covered under rebate agreements
Paragraph (1), and section 1396b(i)(10)(A) of this title, shall not apply to the dispensing of a single source drug or
innovator multiple source drug if (A)(i) the State has made a determination that the availability of the drug is
essential to the health of beneficiaries under the State plan for medical assistance; (ii) such drug has been given a
rating of 1-A by the Food and Drug Administration; and (iii)(I) the physician has obtained approval for use of the
drug in advance of its dispensing in accordance with a prior authorization program described in subsection (d) of
this section, or (II) the Secretary has reviewed and approved the State’s determination under subparagraph (A); or
(B) the Secretary determines that in the first calendar quarter of 1991, there were extenuating circumstances.

(4) Effect on existing agreements


In the case of a rebate agreement in effect between a State and a manufacturer on November 5, 1990, such
agreement, for the initial agreement period specified therein, shall be considered to be a rebate agreement in
compliance with this section with respect to that State, if the State agrees to report to the Secretary any rebates
paid pursuant to the agreement and such agreement provides for a minimum aggregate rebate of 10 percent of the
State’s total expenditures under the State plan for coverage of the manufacturer’s drugs under this subchapter. If,
after the initial agreement period, the State establishes to the satisfaction of the Secretary that an agreement in
effect on November 5, 1990, provides for rebates that are at least as large as the rebates otherwise required under
this section, and the State agrees to report any rebates under the agreement to the Secretary, the agreement shall
be considered to be a rebate agreement in compliance with the section for the renewal periods of such agreement.

(5) Limitation on prices of drugs purchased by covered entities

(A) Agreement with Secretary


A manufacturer meets the requirements of this paragraph if the manufacturer has entered into an
agreement with the Secretary that meets the requirements of section 256b of this title with respect to
covered outpatient drugs purchased by a covered entity on or after the first day of the first month that
begins after November 4, 1992.

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*This is section 1927 of the Social Security Act. It is codified as Section 1396r-8 of Title 42 of the United States
Code.

(B) “Covered entity” defined


In this subsection, the term “covered entity” means an entity described in section 256b(a)(4) of this title.

(C) Establishment of alternative mechanism to ensure against duplicate discounts or rebates


If the Secretary does not establish a mechanism under section 256b(a)(5)(A) of this title within 12 months
of November 4, 1992, the following requirements shall apply:
(i) Entities
Each covered entity shall inform the single State agency under section 1396a(a)(5) of this title when it is
seeking reimbursement from the State plan for medical assistance described in section 1396d(a)(12) of
this title with respect to a unit of any covered outpatient drug which is subject to an agreement under
section 256b(a) of this title.
(ii) State agency
Each such single State agency shall provide a means by which a covered entity shall indicate on any drug
reimbursement claims form (or format, where electronic claims management is used) that a unit of the
drug that is the subject of the form is subject to an agreement under section 256b of this title, and not
submit to any manufacturer a claim for a rebate payment under subsection (b) of this section with respect
to such a drug.

(D) Effect of subsequent amendments


In determining whether an agreement under subparagraph (A) meets the requirements of section 256b of
this title, the Secretary shall not take into account any amendments to such section that are enacted after
November 4, 1992.

(E) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to
the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the
provisions of section 256b of this title (as in effect immediately after November 4, 1992) and would have
entered into an agreement under such section (as such section was in effect at such time), but for a
legislative change in such section after November 4, 1992.

(6) Requirements relating to master agreements for drugs procured by Department of Veterans Affairs and certain
other Federal agencies

(A) In general
A manufacturer meets the requirements of this paragraph if the manufacturer complies with the provisions
of section 8126 of title 38, including the requirement of entering into a master agreement with the
Secretary of Veterans Affairs under such section.

(B) Effect of subsequent amendments


In determining whether a master agreement described in subparagraph (A) meets the requirements of
section 8126 of title 38, the Secretary shall not take into account any amendments to such section that are
enacted after November 4, 1992.

(C) Determination of compliance


A manufacturer is deemed to meet the requirements of this paragraph if the manufacturer establishes to
the satisfaction of the Secretary that the manufacturer would comply (and has offered to comply) with the
provisions of section 8126 of title 38, (as in effect immediately after November 4, 1992) and would have
entered into an agreement under such section (as such section was in effect at such time), but for a
legislative change in such section after November 4, 1992.

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(b) Terms of rebate agreement

(1) Periodic rebates

(A) In general
A rebate agreement under this subsection shall require the manufacturer to provide, to each State plan
approved under this subchapter, a rebate for a rebate period in an amount specified in subsection (c) of
this section for covered outpatient drugs of the manufacturer dispensed after December 31, 1990, for
which payment was made under the State plan for such period. Such rebate shall be paid by the
manufacturer not later than 30 days after the date of receipt of the information described in paragraph (2)
for the period involved.

(B) Offset against medical assistance


Amounts received by a State under this section (or under an agreement authorized by the Secretary under
subsection (a)(1) of this section or an agreement described in subsection (a)(4) of this section) in any
quarter shall be considered to be a reduction in the amount expended under the State plan in the quarter
for medical assistance for purposes of section 1396b(a)(1) of this title.

(2) State provision of information

(A) State responsibility


Each State agency under this subchapter shall report to each manufacturer not later than 60 days after the
end of each rebate period and in a form consistent with a standard reporting format established by the
Secretary, information on the total number of units of each dosage form and strength and package size of
each covered outpatient drug dispensed after December 31, 1990, for which payment was made under the
plan during the period, and shall promptly transmit a copy of such report to the Secretary.

(B) Audits
A manufacturer may audit the information provided (or required to be provided) under subparagraph (A).
Adjustments to rebates shall be made to the extent that information indicates that utilization was greater
or less than the amount previously specified.

(3) Manufacturer provision of price information

(A) In general
Each manufacturer with an agreement in effect under this section shall report to the Secretary - (i) not
later than 30 days after the last day of each rebate period under the agreement (beginning on or after
January 1, 1991), on the average manufacturer price (as defined in subsection (k)(1) of this section) and,
(for single source drugs and innovator multiple source drugs), the manufacturer’s best price (as defined in
subsection (c)(2)(B) of this section) for covered outpatient drugs for the rebate period under the
agreement, and (ii) not later than 30 days after the date of entering into an agreement under this section on
the average manufacturer price (as defined in subsection (k)(1) of this section) as of October 1, 1990 for
each of the manufacturer’s covered outpatient drugs.

(B) Verification surveys of average manufacturer price


The Secretary may survey wholesalers and manufacturers that directly distribute their covered outpatient
drugs, when necessary, to verify manufacturer prices reported under subparagraph (A). The Secretary
may impose a civil monetary penalty in an amount not to exceed $100,000 on a wholesaler, manufacturer,
or direct seller, if the wholesaler, manufacturer, or direct seller of a covered outpatient drug refuses a
request for information about charges or prices by the Secretary in connection with a survey under this
subparagraph or knowingly provides false information. The provisions of section 1320a-7a of this title
(other than subsections (a) (with respect to amounts of penalties or additional assessments) and (b)) shall

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apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a
penalty or proceeding under section 1320a-7a(a) of this title.

(C) Penalties
(i) Failure to provide timely information
In the case of a manufacturer with an agreement under this section that fails to provide information
required under subparagraph (A) on a timely basis, the amount of the penalty shall be increased by
$10,000 for each day in which such information has not been provided and such amount shall be paid to
the Treasury, and, if such information is not reported within 90 days of the deadline imposed, the
agreement shall be suspended for services furnished after the end of such 90-day period and until the date
such information is reported (but in no case shall such suspension be for a period of less than 30 days).

(ii) False information


Any manufacturer with an agreement under this section that knowingly provides false information is
subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information.
Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions
of section 1320a-7a of this title (other than subsections (a) and (b)) shall apply to a civil money penalty
under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under
section 1320a-7a(a) of this title.

(D) Confidentiality of information


Notwithstanding any other provision of law, information disclosed by manufacturers or wholesalers under
this paragraph or under an agreement with the Secretary of Veterans Affairs described in subsection
(a)(6)(A)(ii) of this section is confidential and shall not be disclosed by the Secretary or the Secretary of
Veterans Affairs or a State agency (or contractor therewith) in a form which discloses the identity of a
specific manufacturer or wholesaler, prices charged for drugs by such manufacturer or wholesaler,
except-
(i) as the Secretary determines to be necessary to carry out this section,
(ii) to permit the Comptroller General to review the information provided, and
(iii) to permit the Director of the Congressional Budget Office to review the information provided.

(4) Length of agreement

(A) In general
A rebate agreement shall be effective for an initial period of not less than 1 year and shall be
automatically renewed for a period of not less than one year unless terminated under subparagraph (B).

(B) Termination
(i) By the Secretary
The Secretary may provide for termination of a rebate agreement for violation of the requirements of the
agreement or other good cause shown. Such termination shall not be effective earlier than 60 days after
the date of notice of such termination. The Secretary shall provide, upon request, a manufacturer with a
hearing concerning such a termination, but such hearing shall not delay the effective date of the
termination.
(ii) By a manufacturer
A manufacturer may terminate a rebate agreement under this section for any reason. Any such
termination shall not be effective until the calendar quarter beginning at least 60 days after the date the
manufacturer provides notice to the Secretary.
(iii) Effectiveness of termination
Any termination under this subparagraph shall not affect rebates due under the agreement before the
effective date of its termination.
(iv) Notice to States

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In the case of a termination under this subparagraph, the Secretary shall provide notice of such
termination to the States within not less than 30 days before the effective date of such termination.
(v) Application to terminations of other agreements
The provisions of this subparagraph shall apply to the terminations of agreements described in section
256b(a)(1) of this title and master agreements described in section 8126(a) of title 38.

(C) Delay before reentry


(c) In the case of any rebate agreement with a manufacturer under this section which is terminated, another such
agreement with the manufacturer (or a successor manufacturer) may not be entered into until a period of 1
calendar quarter has elapsed since the date of the termination, unless the Secretary finds good cause for an
earlier reinstatement of such an agreement.

Determination of amount of rebate

(1) Basic rebate for single source drugs and innovator multiple
source drugs

(A) In general
Except as provided in paragraph (2), the amount of the rebate specified in this subsection for a rebate
period (as defined in subsection (k)(8) of this section) with respect to each dosage form and strength of a
single source drug or an innovator multiple source drug shall be equal to the product of -
(i) the total number of units of each dosage form and strength paid for under the State plan in the rebate
period (as reported by the State); and
(ii) subject to subparagraph (B)(ii), the greater of -
(I) the difference between the average manufacturer price and the best price (as defined in
subparagraph (C)) for the dosage form and strength of the drug, or
(II) the minimum rebate percentage (specified in subparagraph (B)(i)) of such average manufacturer
price, for the rebate period.

(B) Range of rebates required


(i) Minimum rebate percentage
For purposes of subparagraph (A)(ii)(II), the “minimum rebate percentage” for rebate periods beginning -
(I) after December 31, 1990, and before October 1, 1992, is 12.5 percent;
(II) after September 30, 1992, and before January 1, 1994, is 15.7 percent;
(III) after December 31, 1993, and before January 1, 1995, is 15.4 percent;
(IV) after December 31, 1994, and before January 1, 1996, is 15.2 percent; and
(V) after December 31, 1995, is 15.1 percent.
(ii) Temporary limitation on maximum rebate amount
In no case shall the amount applied under subparagraph (A)(ii) for a rebate period beginning -
(I) before January 1, 1992, exceed 25 percent of the average manufacturer price; or
(II) after December 31, 1991, and before January 1, 1993, exceed 50 percent of the average
manufacturer price.

(C) “Best price” defined


For purposes of this section -
(i) In general
The term “best price” means, with respect to a single source drug or innovator multiple source drug of a
manufacturer, the lowest price available from the manufacturer during the rebate period to any
wholesaler, retailer, provider, health maintenance organization, nonprofit entity, or governmental entity
within the United States, excluding -
(I) any prices charged on or after October 1, 1992, to the Indian Health Service, the Department of
Veterans Affairs, a State home receiving funds under section 1741 of title 38, the Department of
Defense, the Public Health Service, or a covered entity described in subsection (a)(5)(B) of this
section;

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(II) any prices charged under the Federal Supply Schedule of the General Services Administration;
(III) any prices used under a State pharmaceutical assistance program; and
(IV) any depot prices and single award contract prices, as defined by the Secretary, of any agency of
the Federal Government.
(ii) Special rules
The term “best price” -
(I) shall be inclusive of cash discounts, free goods that are contingent on any purchase requirement,
volume discounts, and rebates (other than rebates under this section);
(II) shall be determined without regard to special packaging, labeling, or identifiers on the dosage form
or product or package; and
(III) shall not take into account prices that are merely nominal in amount.

(2) Additional rebate for single source and innovator multiple source drugs

(A) In general
The amount of the rebate specified in this subsection for a rebate period, with respect to each dosage form
and strength of a single source drug or an innovator multiple source drug, shall be increased by an amount
equal to the product of -
(i) the total number of units of such dosage form and strength dispensed after December 31, 1990, for
which payment was made under the State plan for the rebate period; and
(ii) the amount (if any) by which -
(I) the average manufacturer price for the dosage form and strength of the drug for the period, exceeds
(II) the average manufacturer price for such dosage form and strength for the calendar quarter
beginning July 1, 1990 (without regard to whether or not the drug has been sold or transferred to an
entity, including a division or subsidiary of the manufacturer, after the first day of such quarter),
increased by the percentage by which the consumer price index for all urban consumers (United States
city average) for the month before the month in which the rebate period begins exceeds such index for
September 1990
.
(B) Treatment of subsequently approved drugs
In the case of a covered outpatient drug approved by the Food and Drug Administration after October 1,
1990, clause (ii)(II) of subparagraph (A) shall be applied by substituting “the first full calendar quarter
after the day on which the drug was first marketed” for “the calendar quarter beginning July 1, 1990” and
“the month prior to the first month of the first full calendar quarter after the day on which the drug was
first marketed” for “September 1990”.

(3) Rebate for other drugs

(A) In general
The amount of the rebate paid to a State for a rebate period with respect to each dosage form and strength
of covered outpatient drugs (other than single source drugs and innovator multiple source drugs) shall be
equal to the product of -
(i) the applicable percentage (as described in subparagraph (B)) of the average manufacturer price for the
dosage form and strength for the rebate period, and
(ii) the total number of units of such dosage form and strength dispensed after December 31, 1990, for
which payment was made under the State plan for the rebate period.

(B) “Applicable percentage” defined


For purposes of subparagraph (A)(i), the “applicable percentage” for rebate periods beginning -
(i) before January 1, 1994, is 10 percent, and
(ii) after December 31, 1993, is 11 percent.

(d) Limitations on coverage of drugs

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(1) Permissible restrictions

(A) A State may subject to prior authorization any covered outpatient drug. Any such prior authorization
program shall comply with the requirements of paragraph (5).

(B) A State may exclude or otherwise restrict coverage of a covered outpatient drug if -
(i) the prescribed use is not for a medically accepted indication (as defined in subsection (k)(6) of this
section);
(ii) the drug is contained in the list referred to in paragraph (2);
(iii) the drug is subject to such restrictions pursuant to an agreement between a manufacturer and a State
authorized by the Secretary under subsection (a)(1) of this section or in effect pursuant to subsection
(a)(4) of this section; or
(iv) the State has excluded coverage of the drug from its formulary established in accordance with
paragraph (4).

(2) List of drugs subject to restriction


The following drugs or classes of drugs, or their medical uses, may be excluded from coverage or otherwise
restricted:

(A) Agents when used for anorexia, weight loss, or weight gain.
(B) Agents when used to promote fertility.
(C) Agents when used for cosmetic purposes or hair growth.
(D) Agents when used for the symptomatic relief of cough and colds.
(E) Agents when used to promote smoking cessation.
(F) Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.
(G) Nonprescription drugs.
(H) Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that
associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.
(I) Barbiturates.
(J) Benzodiazepines.

(3) Update of drug listings


The Secretary shall, by regulation, periodically update the list of drugs or classes of drugs described in paragraph
(2) or their medical uses, which the Secretary has determined, based on data collected by surveillance and
utilization review programs of State medical assistance programs, to be subject to clinical abuse or inappropriate
use.

(4) Requirements for formularies


A State may establish a formulary if the formulary meets the following requirements:

(A) The formulary is developed by a committee consisting of physicians, pharmacists, and other
appropriate individuals appointed by the Governor of the State (or, at the option of the State, the State’s
drug use review board established under subsection (g)(3) of this section).

(B) Except as provided in subparagraph (C), the formulary includes the covered outpatient drugs of any
manufacturer which has entered into and complies with an agreement under subsection (a) of this section
(other than any drug excluded from coverage or otherwise restricted under paragraph (2)).

(C) A covered outpatient drug may be excluded with respect to the treatment of a specific disease or
condition for an identified population (if any) only if, based on the drug’s labeling (or, in the case of a
drug the prescribed use of which is not approved under the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 301 et seq.) but is a medically accepted indication, based on information from the appropriate
compendia described in subsection (k)(6) of this section), the excluded drug does not have a significant,
clinically meaningful therapeutic advantage in terms of safety, effectiveness, or clinical outcome of such

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treatment for such population over other drugs included in the formulary and there is a written
explanation (available to the public) of the basis for the exclusion.

(D) The State plan permits coverage of a drug excluded from the formulary (other than any drug excluded
from coverage or otherwise restricted under paragraph (2)) pursuant to a prior authorization program that
is consistent with paragraph (5).

(E) The formulary meets such other requirements as the Secretary may impose in order to achieve
program savings consistent with protecting the health of program beneficiaries. A prior authorization
program established by a State under paragraph (5) is not a formulary subject to the requirements of this
paragraph.

(5) Requirements of prior authorization programs


A State plan under this subchapter may require, as a condition of coverage or payment for a covered outpatient
drug for which Federal financial participation is available in accordance with this section, with respect to drugs
dispensed on or after July 1, 1991, the approval of the drug before its dispensing for any medically accepted
indication (as defined in subsection (k)(6) of this section) only if the system providing for such approval –

(A) provides response by telephone or other telecommunication device within 24 hours of a request for
prior authorization; and

(B) except with respect to the drugs on the list referred to in paragraph (2), provides for the dispensing of
at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (as defined by
the Secretary).

(6) Other permissible restrictions


A State may impose limitations, with respect to all such drugs in a therapeutic class, on the minimum or
maximum quantities per prescription or on the number of refills, if such limitations are necessary to discourage
waste, and may address instances of fraud or abuse by individuals in any manner authorized under this chapter.

(e) Treatment of pharmacy reimbursement limits

(1) In general
During the period beginning on January 1, 1991, and ending on
December 31, 1994 –

(A) a State may not reduce the payment limits established by regulation under this subchapter or any
limitation described in paragraph (3) with respect to the ingredient cost of a covered outpatient drug or the
dispensing fee for such a drug below the limits in effect as of January 1, 1991, and

(B) except as provided in paragraph (2), the Secretary may not modify by regulation the formula
established under sections 447.331 through 447.334 of title 42, Code of Federal Regulations, in effect on
November 5, 1990, to reduce the limits described in subparagraph (A).

(2) Special rule


If a State is not in compliance with the regulations described in paragraph (1)(B), paragraph (1)(A) shall not apply
to such State until such State is in compliance with such regulations.

(3) Effect on State maximum allowable cost limitations


This section shall not supersede or affect provisions in effect prior to January 1, 1991, or after December 31,
1994, relating to any maximum allowable cost limitation established by a State for payment by the State for
covered outpatient drugs, and rebates shall be made under this section without regard to whether or not payment
by the State for such drugs is subject to such a limitation or the amount of such a limitation.

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(4) Establishment of upper payment limits


HCFA shall establish a Federal upper reimbursement limit for each multiple source drug for which the FDA has
rated three or more products therapeutically and pharmaceutically equivalent, regardless of whether all such
additional formulations are rated as such and shall use only such formulations when determining any such upper
limit.

(f) Repealed and redesignated

(g) Drug use review

(1) In general

(A) In order to meet the requirement of section 1396b(i)(10)(B) of this title, a State shall provide, by not
later than January 1, 1993, for a drug use review program described in paragraph (2) for covered
outpatient drugs in order to assure that prescriptions (i) are appropriate, (ii) are medically necessary, and
(iii) are not likely to result in adverse medical results. The program shall be designed to educate
physicians and pharmacists to identify and reduce the frequency of patterns of fraud, abuse, gross
overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists, and patients, or
associated with specific drugs or groups of drugs, as well as potential and actual severe adverse reactions
to drugs including education on therapeutic appropriateness, overutilization and underutilization,
appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug-drug
interactions, incorrect drug dosage or duration of drug treatment, drug-allergy interactions, and clinical
abuse/misuse.

(B) The program shall assess data on drug use against predetermined standards, consistent with the
following:
(i) compendia which shall consist of the following:
(I) American Hospital Formulary Service Drug Information;
(II) United States Pharmacopeia-Drug Information;
(III) the DRUGDex information System;
(IV) American Medical Association Drug Evaluations; and
(ii) the peer-reviewed medical literature.

(C) The Secretary, under the procedures established in section 1396b of this title, shall pay to each State
an amount equal to 75 per centum of so much of the sums expended by the State plan during calendar
years 1991 through 1993 as the Secretary determines is attributable to the statewide adoption of a drug
use review program which conforms to the requirements of this subsection.

(D) States shall not be required to perform additional drug use reviews with respect to drugs dispensed to
residents of nursing facilities which are in compliance with the drug regimen review procedures
prescribed by the Secretary for such facilities in regulations implementing section 1396r of this title,
currently at section 483.60 of title 42, Code of Federal Regulations.

(2) Description of program


Each drug use review program shall meet the following requirements for covered outpatient drugs:

(A) Prospective drug review


(i) The State plan shall provide for a review of drug therapy before each prescription is filled or delivered
to an individual receiving benefits under this subchapter, typically at the point-of-sale or point of
distribution. The review shall include screening for potential drug therapy problems due to therapeutic
duplication, drug-disease contraindications, drug-drug interactions (including serious interactions with
nonprescription or over-the-counter drugs), incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse/misuse. Each State shall use the compendia and literature referred
to in paragraph (1)(B) as its source of standards for such review.

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(ii) As part of the State’s prospective drug use review program under this subparagraph applicable State
law shall establish standards for counseling of individuals receiving benefits under this subchapter by
pharmacists which includes at least the following:
(I) The pharmacist must offer to discuss with each individual receiving benefits under this subchapter
or caregiver of such individual (in person, whenever practicable, or through access to a telephone
service which is toll-free for long-distance calls) who presents a prescription, matters which in the
exercise of the pharmacist’s professional judgment (consistent with State law respecting the provision
of such information), the pharmacist deems significant including the following:
(aa) The name and description of the medication.
(bb) The route, dosage form, dosage, route of administration, and duration of drug therapy.
(cc) Special directions and precautions for preparation, administration and use by the patient.
(dd) Common severe side or adverse effects or interactions and therapeutic contraindications that
may be encountered, including their avoidance, and the action required if they occur.
(ee) Techniques for self-monitoring drug therapy.
(ff) Proper storage.
(gg) Prescription refill information.
(hh) Action to be taken in the event of a missed dose.
(II) A reasonable effort must be made by the pharmacist to obtain, record, and maintain at least the
following information regarding individuals receiving benefits under this subchapter:
(aa) Name, address, telephone number, date of birth (or age) and gender.
(bb) Individual history where significant, including disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices.
(cc) Pharmacist comments relevant to the individual’s drug therapy.
Nothing in this clause shall be construed as requiring a pharmacist to provide consultation when
an individual receiving benefits under this subchapter or caregiver of such individual refuses such
consultation.

(B) Retrospective drug use review


The program shall provide, through its mechanized drug claims processing and information retrieval
systems (approved by the Secretary under section 1396b(r) of this title) or otherwise, for the ongoing
periodic examination of claims data and other records in order to identify patterns of fraud, abuse, gross
overuse, or inappropriate or medically unnecessary care, among physicians, pharmacists and individuals
receiving benefits under this subchapter, or associated with specific drugs or groups of drugs.

(C) Application of standards


The program shall, on an ongoing basis, assess data on drug use against explicit predetermined standards
(using the compendia and literature referred to in paragraph (1)(B) as the source of standards for such
assessment) including but not limited to monitoring for therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, and clinical
abuse/misuse and, as necessary, introduce remedial strategies, in order to improve the quality of care and
to conserve program funds or personal expenditures.

(D) Educational program


The program shall, through its State drug use review board established under paragraph (3), either directly
or through contracts with accredited health care educational institutions, State medical societies or State
pharmacists associations/societies or other organizations as specified by the State, and using data
provided by the State drug use review board on common drug therapy problems, provide for active and
ongoing educational outreach programs (including the activities described in paragraph (3)(C)(iii) of this
subsection) to educate practitioners on common drug therapy problems with the aim of improving
prescribing or dispensing practices.

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(3) State drug use review board

(A) Establishment
Each State shall provide for the establishment of a drug use review board (hereinafter referred to as the
“DUR Board”) either directly or through a contract with a private organization.

(B) Membership
The membership of the DUR Board shall include health care professionals who have recognized
knowledge and expertise in one or more of the following:
(i) The clinically appropriate prescribing of covered outpatient drugs.
(ii) The clinically appropriate dispensing and monitoring of covered outpatient drugs.
(iii) Drug use review, evaluation, and intervention.
(iv) Medical quality assurance.
The membership of the DUR Board shall be made up at least 1/3 but no more than 51 percent licensed
and actively practicing physicians and at least 1/3 licensed and actively practicing pharmacists.

(C) Activities
The activities of the DUR Board shall include but not be limited to the following:
(i) Retrospective DUR as defined in section.
(ii) Application of standards as defined in paragraph (2)(C).
(iii) Ongoing interventions for physicians and pharmacists, targeted toward therapy problems or
individuals identified in the course of retrospective drug use reviews performed under this subsection.
Intervention programs shall include, in appropriate instances, at least:
(I) information dissemination sufficient to ensure the ready availability to physicians and pharmacists
in the State of information concerning its duties, powers, and basis for its standards;
(II) written, oral, or electronic reminders containing patient-specific or drug-specific (or both)
information and suggested changes in prescribing or dispensing practices, communicated in a manner
designed to ensure the privacy of patient-related information;
(III) use of face-to-face discussions between health care professionals who are experts in rational drug
therapy and selected prescribers and pharmacists who have been targeted for educational intervention,
including discussion of optimal prescribing, dispensing, or pharmacy care practices, and follow-up
face-to-face discussions; and
(IV) intensified review or monitoring of selected prescribers or dispensers. The Board shall re-evaluate
interventions after an appropriate period of time to determine if the intervention improved the quality
of drug therapy, to evaluate the success of the interventions and make modifications as necessary.

(D) Annual report


Each State shall require the DUR Board to prepare a report on an annual basis. The State shall submit a
report on an annual basis to the Secretary which shall include a description of the activities of the Board,
including the nature and scope of the prospective and retrospective drug use review programs, a summary
of the interventions used, an assessment of the impact of these educational interventions on quality of
care, and an estimate of the cost savings generated as a result of such program. The Secretary shall utilize
such report in evaluating the effectiveness of each State’s drug use review program.

(h) Electronic claims management

(1) In general
In accordance with chapter 35 of title 44 (relating to coordination of Federal information policy), the Secretary
shall encourage each State agency to establish, as its principal means of processing claims for covered outpatient
drugs under this subchapter, a point-of-sale electronic claims management system, for the purpose of performing
on-line, real time eligibility verifications, claims data capture, adjudication of claims, and assisting pharmacists
(and other authorized persons) in applying for and receiving payment.

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(2) Encouragement
In order to carry out paragraph (1) -

(A) for calendar quarters during fiscal years 1991 and 1992, expenditures under the State plan attributable
to development of a system described in paragraph (1) shall receive Federal financial participation under
section 1396b(a)(3)(A)(i) of this title (at a matching rate of 90 percent) if the State acquires, through
applicable competitive procurement process in the State, the most cost-effective telecommunications
network and automatic data processing services and equipment; and

(B) the Secretary may permit, in the procurement described in subparagraph (A) in the application of part
433 of title 42, Code of Federal Regulations, and parts 95, 205, and 307 of title 45, Code of Federal
Regulations, the substitution of the State’s request for proposal in competitive procurement for advance
planning and implementation documents otherwise required.

(i) Annual report

(1) In general
Not later than May 1 of each year the Secretary shall transmit to the Committee on Finance of the Senate, the
Committee on Energy and Commerce of the House of Representatives, and the Committees on Aging of the
Senate and the House of Representatives a report on the operation of this section in the preceding fiscal year.

(2) Details
Each report shall include information on –

(A) ingredient costs paid under this subchapter for single source drugs, multiple source drugs, and
nonprescription covered outpatient drugs;

(B) the total value of rebates received and number of manufacturers providing such rebates;

(C) how the size of such rebates compare with the size of rebates offered to other purchasers of covered
outpatient drugs;

(D) the effect of inflation on the value of rebates required under this section;

(E) trends in prices paid under this subchapter for covered outpatient drugs; and

(F) Federal and State administrative costs associated with compliance with the provisions of this
subchapter.

(j) Exemption of organized health care settings

(1) Covered outpatient drugs dispensed by health maintenance organizations, including Medicaid managed care
organizations that contract under section 1396b(m) of this title, are not subject to the requirements of this section.

(2) The State plan shall provide that a hospital (providing medical assistance under such plan) that dispenses
covered outpatient drugs using drug formulary systems, and bills the plan no more than the hospital’s purchasing
costs for covered outpatient drugs (as determined under the State plan) shall not be subject to the requirements of
this section.

(3) Nothing in this subsection shall be construed as providing that amounts for covered outpatient drugs paid by
the institutions described in this subsection should not be taken into account for purposes of determining the best
price as described in subsection (c) of this section.

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(k) Definitions
In this section -

(1) Average manufacturer price


The term “average manufacturer price” means, with respect to a covered outpatient drug of a manufacturer for a
rebate period, the average price paid to the manufacturer for the drug in the United States by wholesalers for drugs
distributed to the retail pharmacy class of trade, after deducting customary prompt pay discounts.

(2) Covered outpatient drug


Subject to the exceptions in paragraph (3), the term “covered outpatient drug” means -

(A) of those drugs which are treated as prescribed drugs for purposes of section 1396d(a)(12) of this title,
a drug which may be dispensed only upon prescription (except as provided in paragraph (5)), and -
(i) which is approved for safety and effectiveness as a prescription drug under section 505 or 507 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355, 357) or which is approved under section 505(j) of
such Act (21 U.S.C. 355(j));
(ii)(I) which was commercially used or sold in the United States before October 10, 1962, or which is
identical, similar, or related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal
Regulations) to such a drug, and (II) which has not been the subject of a final determination by the
Secretary that it is a “new drug” (within the meaning of section 201(p) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 321(p))) or an action brought by the Secretary under section 301, 302(a), or
304(a) of such Act (21 U.S.C. 331, 332(a), 334(a)) to enforce section 502(f) or 505(a) of such Act (21
U.S.C. 352(f), 355(a)); or
(iii)(I) which is described in section 107(c)(3) of the Drug Amendments of 1962 and for which the
Secretary has determined there is a compelling justification for its medical need, or is identical, similar, or
related (within the meaning of section 310.6(b)(1) of title 21 of the Code of Federal Regulations) to such
a drug, and (II) for which the Secretary has not issued a notice of an opportunity for a hearing under
section 505(e) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355(e)) on a proposed order of the
Secretary to withdraw approval of an application for such drug under such section because the Secretary
has determined that the drug is less than effective for some or all conditions of use prescribed,
recommended, or suggested in its labeling; and

(B) a biological product, other than a vaccine which -


(i) may only be dispensed upon prescription,
(ii) is licensed under section 262 of this title, and
(iii) is produced at an establishment licensed under such section to produce such product; and

(C) insulin certified under section 506 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 356).

(3) Limiting definition


The term “covered outpatient drug” does not include any drug, biological product, or insulin provided as part of,
or as incident to and in the same setting as, any of the following (and for which payment may be made under this
subchapter as part of payment for the following and not as direct reimbursement for the drug):

(A) Inpatient hospital services.

(B) Hospice services.

(C) Dental services, except that drugs for which the State plan authorizes direct reimbursement to the
dispensing dentist are covered outpatient drugs.

(D) Physicians’ services.

(E) Outpatient hospital services.

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(F) Nursing facility services and services provided by an intermediate care facility for the mentally
retarded.

(G) Other laboratory and x-ray services.

(H) Renal dialysis.


Such term also does not include any such drug or product for which a National Drug Code number is not
required by the Food and Drug Administration or a drug or biological used for a medical indication which
is not a medically accepted indication. Any drug, biological product, or insulin excluded from the
definition of such term as a result of this paragraph shall be treated as a covered outpatient drug for
purposes of determining the best price (as defined in subsection (C)(1)(C) of this section) for such drug,
biological product, or insulin.

(4) Nonprescription drugs


If a State plan for medical assistance under this subchapter includes coverage of prescribed drugs as described in
section 1396d(a)(12) of this title and permits coverage of drugs which may be sold without a prescription
(commonly referred to as “over-the-counter” drugs), if they are prescribed by a physician (or other person
authorized to prescribe under State law), such a drug shall be regarded as a covered outpatient drug.

(5) Manufacturer
The term “manufacturer” means any entity which is engaged in -

(A) the production, preparation, propagation, compounding, conversion, or processing of prescription


drug products, either directly or indirectly by extraction from substances of natural origin, or
independently by means of chemical synthesis, or by a combination of extraction and chemical synthesis,
or

(B) in the packaging, repackaging, labeling, relabeling, or distribution of prescription drug products. Such
term does not include a wholesale distributor of drugs or a retail pharmacy licensed under State law.

(6) Medically accepted indication


The term “medically accepted indication” means any use for a covered outpatient drug which is approved under
the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.) or the use of which is supported by one or more
citations included or approved for inclusion in any of the compendia described in subsection (g)(1)(B)(i) of this
section.

(7) Multiple source drug; innovator multiple source drug; noninnovator multiple source drug; single source drug

(A) Defined
(i) Multiple source drug
The term “multiple source drug” means, with respect to a rebate period, a covered outpatient drug (not
including any drug described in paragraph (5)) for which there are 2 or more drug products which -
(I) are rated as therapeutically equivalent (under the Food and Drug Administration’s most recent
publication of “Approved Drug Products with Therapeutic Equivalence Evaluations”),
(II) except as provided in subparagraph (B), are pharmaceutically equivalent and bioequivalent, as
defined in subparagraph (C) and as determined by the Food and Drug Administration, and
(III) are sold or marketed in the State during the period.
(ii) Innovator multiple source drug The term “innovator multiple source drug” means a multiple source
drug that was originally marketed under an original new drug application approved by the Food and Drug
Administration.
(iii) Noninnovator multiple source drug

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The term “noninnovator multiple source drug” means a multiple source drug that is not an innovator
multiple source drug.
(iv) Single source drug
The term “single source drug” means a covered outpatient drug which is produced or distributed under an
original new drug application approved by the Food and Drug Administration, including a drug product
marketed by any cross-licensed producers or distributers operating under the new drug application.

(B) Exception
Subparagraph (A)(i)(II) shall not apply if the Food and Drug Administration changes by regulation the
requirement that, for purposes of the publication described in subparagraph (A)(i)(I), in order for drug
products to be rated as therapeutically equivalent, they must be pharmaceutically equivalent and
bioequivalent, as defined in subparagraph (C).

(C) Definitions
For purposes of this paragraph -
(i) drug products are pharmaceutically equivalent if the products contain identical amounts of the same
active drug ingredient in the same dosage form and meet compendial or other applicable standards of
strength, quality, purity, and identity;
So in original. Probably should be “pharmaceutically”.
(ii) drugs are bioequivalent if they do not present a known or potential bioequivalence problem, or, if they
do present such a problem, they are shown to meet an appropriate standard of bioequivalence; and
(iii) a drug product is considered to be sold or marketed in a State if it appears in a published national
listing of average wholesale prices selected by the Secretary, provided that the listed product is generally
available to the public through retail pharmacies in that State.

(8) Rebate period


The term “rebate period” means, with respect to an agreement under subsection (a) of this section, a calendar
quarter or other period specified by the Secretary with respect to the payment of rebates under such agreement.

(9) State agency


The term “State agency” means the agency designated under section 1396a(a)(5) of this title to administer or
supervise the administration of the State plan for medical assistance.

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Appendix D:
Federal Upper Limits for
Multiple Source Products

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The following list of multiple source drugs meets the criteria set forth in 42 CFR 447.332 and §1927(e) of the
Social Security Act, as amended by OBRA 1993. The development of the current Federal Upper Limit (FUL)
listing has been accomplished by computer. Payments for multiple source drugs identified and listed in the
accompanying addendum must not exceed, in the aggregate, payment levels determined by applying to each drug
entity a reasonable dispensing fee (established by the State and specified in the State plan), plus an amount based
on the limit per unit which CMS has determined to be equal to a 150 percent applied to the lowest price listed (in
package sizes of 100 units, unless otherwise noted) in any of the published compendia of cost information of
drugs. Issued by CMS on November 20, 2001 the initial listing was based on data current as of April 2001 from
the First Data Bank (Blue Book), Medi-Span, and the Red Book. The listing was revised to reflect additional
changes (i.e., additions, deletions, pricing changes) through May 11, 2003. The list does not reference the
commonly known brand names. However, the brand names are included in the FUL listing provided to the State
agencies in electronic media format. The FUL price list is in Microsoft Word format at
http://www.cms.hhs.gov/Medicaid/drugs/drug10.asp.

In accordance with current policy, Federal financial participation will not be provided for any drug on the FUL
listing for which the Food and Drug Administration (FDA) has issued a notice of an opportunity for a hearing as
a result of the Drug Efficacy Study and Implementation (DESI) program and which has been found to be less
than effective or is identical, related, or similar (IRS) to the DESI drug. The DESI drug is identified by the FDA
or reported by the drug manufacturer for purposes of the Medicaid drug rebate program.

The November 20, 2001 list has been amended with all changes to be implemented no later than May 11, 2003.

Generic Name Upper Limit per Unit (Source)

Acebutolol Hydrochloride
Eq 200 mg base, Capsule, Oral 100 $0.4612 B
Eq 400 mg base, Capsule, Oral 100 0.6713 B

Acetaminophen; Codeine Phosphate


300 mg; 15 mg, Tablet, Oral 100 0.1500 R
300 mg; 30 mg, Tablet, Oral 100 0.2137 B
300 mg; 60 mg, Tablet, Oral 100 0.2812 B

Acetaminophen; Hydrocodone Bitartrate


500 mg; 5 mg, Capsule, Oral 100 0.1943 B
500 mg /15 ml; 7.5 mg/15 ml Elixir, Oral 473 ml 0.1014 R
500 mg; 5 mg, Tablet, Oral 100 0.1153 B
500 mg; 7.5 mg, Tablet, Oral 100 0.1913 B
500 mg; 10 mg, Tablet, Oral 100 0.4603 B
650 mg; 7.5 mg, Tablet, Oral 100 0.1550 B
650 mg; 10 mg, Tablet, Oral 100 0.1852 R
660 mg; 10 mg, Tablet, Oral 100 0.5284 B
750 mg; 7.5 mg, Tablet, Oral 100 0.1750 R

Acetaminophen; Oxycodone Hydrochloride


500 mg; 5 mg, Capsule, Oral 100 0.2137 B
325 mg; 5 mg, Tablet, Oral 100 0.1192 B

Acetaminophen; Propoxyphene Hydrochloride


650 mg; 65 mg, Tablet, Oral 100 0.1688 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-3


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Acetaminophen; Propoxyphene Napsylate


650 mg; 100 mg, Tablet, Oral 100 0.2250 B

Acetazolamide
250 mg, Tablet, Oral 100 0.2454 R

Acetylcysteine
10%, Solution, Inhalation; Oral 10 ml 0.7634 B
20%, Solution, Inhalation; Oral 10 ml 0.9285 B

Acyclovir
200 mg, Capsule, Oral 100 0.3525 B
400 mg, Tablet, Oral 100 0.7048 R
800 mg, Tablet, Oral 100 1.2160 B

Albuterol
0.09 mg/inh, Aerosol, Metered, Inhalation, 17 gm 0.8823 B

Albuterol Sulfate
Eq 0.083% base, Solution, Inhalation 3ml 0.1450 B
Eq 0.5% base, Solution, Inhalation 20 ml 0.3360 B

Allopurinol
100 mg, Tablet, Oral 100 0.0784 B
300 mg, Tablet, Oral 100 0.1671 B

Alprazolam
0.25 mg, Tablet, Oral 100 0.0614 R
0.5 mg, Tablet, Oral 100 0.0698 B
1 mg, Tablet, Oral 100 0.0885 B
2 mg, Tablet, Oral 100 0.1745 R

Amantadine Hydrochloride
50 mg/5 ml, Syrup, Oral 480 ml 0.0656 M

Amiloride Hydrochloride; Hydrochlorothiazide


Eq 5 mg Anhydrous; 50 mg, Tablet, Oral 100 0.0675 B

Aminophylline
100 mg, Tablet, Oral 100 0.0278 B
200 mg, Tablet, Oral 100 0.0390 R

Amiodarone Hydrochloride
200 mg, Tablet, Oral 60 1.6875 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-4 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Amitriptyline Hydrochloride
10 mg, Tablet, Oral 100 0.0608 B
25 mg, Tablet, Oral 100 0.0653 B
50 mg, Tablet, Oral 100 0.0666 B
75 mg, Tablet, Oral 100 0.1425 B
100 mg, Tablet, Oral 100 0.1500 R
150 mg, Tablet, Oral 100 0.2430 B

Amitriptyline Hydrochloride; Perphenazine


10 mg; 2 mg, Tablet, Oral 100 0.0704 B
25 mg; 2 mg, Tablet, Oral 100 0.0869 B

Amoxapine
50 mg, Tablet, Oral 100 0.5425 R

Amoxicillin
250 mg, Capsule, Oral 100 0.0636 B
500 mg, Capsule, Oral 100 0.1272 B
125 mg/5 ml, Powder for reconstitution, Oral 150 0.0201 B
250 mg, Tablet, Chewable, Oral 100 0.1595 B

Ampicillin/Ampicillin Trihydrate
250 mg, Capsule, Oral, 100 0.1295 R
500 mg, Capsule, Oral, 100 0.2171 B

Aspirin; Carisoprodol
325 mg; 200 mg, Tablet, Oral 100 0.3522 B

Atenolol
25 mg, Tablet, Oral 100 0.1595 B
50 mg, Tablet, Oral 100 0.0885 B
100 mg, Tablet, Oral 100 0.1650 B

Atenolol; Chlorthalidone
50 mg; 25 mg, Tablet, Oral 100 0.1762 B
100 mg; 25 mg, Tablet, Oral 100 0.2549 B

Atropine Sulfate; Diphenoxylate Hydrochloride


0.025 mg; 2.5 mg, Tablet, Oral 100 0.3743 R

Benzonatate
100 mg, Capsule, Oral 100 0.4387 B

Benztropine Mesylate
0.5 mg, Tablet, Oral 100 0.1227 B
1 mg, Tablet, Oral 100 0.1502 B
2 mg, Tablet, Oral 100 0.1930 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-5


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Betamethasone Dipropionate
Eq 0.05% base, Cream, Topical 15 gm 0.2330 B
Eq 0.05% base, Lotion, Topical 60 ml 0.1437 B

Betamethasone Valerate
Eq 0.1% base, Cream, Topical 45 gm 0.1197 B
Eq 0.1% base, Lotion, Topical 60 ml 0.1087 B

Bisoprolol Fumarate; Hydrochlorothiazide


2.5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B
5 mg; 6.25 mg, Tablet, Oral 100 0.8250 B
10 mg; 6.25 mg, Tablet, Oral 100 0.8250 B

Bumetanide
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-6 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Cefaclor
Eq 250 mg base, Capsule, Oral 100 0.6600 B
Eq 500 mg base, Capsule, Oral 100 1.2900 B
Eq 125 mg base/5 ml,
Powder for reconstitution, Oral 150 0.1107 B
Eq 187 mg base/5 ml,
Powder for reconstitution, Oral 100 0.1661 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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-7


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Cimetidine Hydrochloride
Eq 300 mg bases/ 5 ml solution, Oral 240 ml 0.1139 B

Clindamycin Hydrochloride
Eq 150 mg base, Capsule, Oral 100 0.9180 R

Clindamycin Phosphate
Eq 1% base, Solution, Topical 60 ml 0.2060 R

Clobetasol Propionate
0.05%, Cream, Topical 30 gm 0.8315 B

Clomipramine Hydrochloride
25 mg, Capsule, Oral 100 0.3322 R
50 mg, Capsule, Oral 100 0.5138 B
75 mg, Capsule, Oral 100 0.5772 B

Clonazepam
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

Dexamethasone; Neomycin Sulfate; Polymyxin B Sulfate


0.1%; Eq 3.5 mg base/gm; 10,000 units/gm, Ointment, Ophthalmic 3.5 gm 1.0713 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-8 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-9


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Doxycycline Hyclate
Eq 50 mg base, Capsule, Oral 50 0.0915 B
Eq 100 mg base, Capsule, Oral 50 0.1050 B
Eq 100 mg base, Tablet, Oral 50 0.1287 B

Erythromycin
250 mg, Capsule, Delayed Released Pellets, Oral 100 0.1889 B
2%, Solution, Topical 60 ml 0.0687 B

Estazolam
1 mg, Tablet, Oral 100 0.5925 R
2 mg, Tablet, Oral 100 0.6449 R

Estradiol
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-10 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-11


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Gramicidin; Neomycin Sulfate; Polymyxin B Sulfate


0.025 mg/ml; Eq 1.75 mg base/ml; 10,000 units/ml
Solution/Drops, Ophthalmic 10 ml 2.2185 B

Guanfacine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.5250 B
Eq 2 mg base, Tablet, Oral 100 0.7200 B

Haloperidol Lactate
Eq 2 mg base/ml, Concentrate, Oral 120 ml 0.1500 B

Homatropine Methylbromide; Hydrocodone Bitartrate


1.5 mg/5 ml; 5mg/5 ml, Syrup, Oral 480 ml 0.0280 R

Hydralazine Hydrochloride
10 mg, Tablet, Oral 100 0.0354 B
25 mg, Tablet, Oral 100 0.0450 B

Hydrochlorothiazide; Propranolol Hydrochloride


25 mg; 40 mg, Tablet, Oral 100 0.0877 B
25 mg; 80 mg, Tablet, Oral 100 0.1320 B

Hydrochlorothiazide; Spironolactone
25 mg; 25 mg, Tablet, Oral 100 0.3463 B

Hydrochlorothiazide; Triamterene
25 mg; 37.5 mg, Capsule, Oral 100 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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-12 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-13


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Levobunolol Hydrochloride
0.25%, Solution/Drops, Ophthalmic 10 ml 1.2749 B
0.5%, Solution/Drops, Ophthalmic 10 ml 1.4925 B

Lidocaine Hydrochloride
2%, Solution, Oral 100 ml 0.0278 M

Lisinopril
2.5 mg, Tablet, Oral, 100 0.3855 B
5 mg, Tablet, Oral, 100 0.5783 B
10 mg, Tablet, Oral, 100 0.5970 B
20 mg, Tablet, Oral, 100 0.6390 B
30 mg, Tablet, Oral, 100 0.9038 B
40 mg, Tablet, Oral, 100 0.9345 B

Lisinopril ; Hydrochlorothiazide
10 mg ; 12.5 mg, Tablet, Oral, 100 0.6450 B
20 mg ; 12.5 mg, Tablet, Oral, 100 0.6983 B
20 mg ; 25 mg, Tablet, Oral, 100 0.7065 B

Lorazepam
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-14 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Methazolamide
25 mg, Tablet, Oral 100 0.3150 R
50 mg, Tablet, Oral 100 0.4650 R

Methenamine Mandelate
1 gm, Tablet, Oral 100 0.2923 B

Methocarbamol
500 mg, Tablet, Oral 100 0.1943 B

Methotrexate Sodium
Eq 2.5 mg base, Tablet, Oral 100 1.2637 B

Methylphenidate Hydrochloride
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-15


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

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

Nystatin; Triamcinolone Acetonide


100,000 units/gm; 0.1%, Cream, Topical 30 gm 0.0975 B

Orphenadrine Citrate
100 mg, Tablet, Extended Release, Oral 100 1.8225 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

D-16 National Pharmaceutical Council


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

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

Polymyxin B Sulfate; Trimethoprim Sulfate


10,000 units/ml; Eq 1 mg base/ml, Solution/Drops, Ophthalmic 10 ml 1.2360 B

Potassium Chloride
8 mEq, Tablet, Extended Release, Oral 100 0.0772 B

Prednisolone
15 mg/5 ml, Syrup, Oral 480 ml 0.2081 B

Prednisolone Acetate
1%, Suspension/Drops, Ophthalmic 10 ml 1.6950 B

Prednisone
5 mg, Tablet, Oral 100 0.0330 B
10 mg, Tablet, Oral 100 0.0548 B
20 mg, Tablet, Oral 100 0.0758 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

National Pharmaceutical Council D-17


Pharmaceutical Benefits 2002

Generic Name Upper Limit per Unit (Source)

Primidone
250 mg, Tablet, Oral 100 0.6405 B

Probenecid
500 mg, Tablet, Oral 100 0.7059 B

Prochlorperazine Maleate
Eq 5 mg base, Tablet, Oral 100 0.3986 B
Eq 10 mg base, Tablet, Oral 100 0.5766 B

Promethazine Hydrochloride
6.25 mg/5 ml, Syrup, Oral 120 ml 0.0264 B

Propranolol Hydrochloride
10 mg, Tablet, Oral 100 0.0585 B
20 mg, Tablet, Oral 100 0.0705 B
40 mg, Tablet, Oral 100 0.0848 B
80 mg, Tablet, Oral 100 0.1140 B

Pseudoephedrine Hydrochloride; Tripolidine Hydrochloride


60 mg; 2.5 mg, Tablet, Oral 100 0.0336 B

Quinidine Gluconate
324 mg, Tablet, Extended Release, Oral 100 0.4500 B

Ranitidine Hydrochloride
Eq 150 mg base, Tablet, Oral, 100 0.3411 R
Eq 300 mg base, Tablet, Oral 100 0.3180 B

Selegiline Hydrochloride
5 mg, Tablet, Oral 60 0.7658 R

Selenium Sulfide
2.5%, Lotion/Shampoo, Topical 120 ml 0.0750 B

Spironolactone
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Sulfasalazine
500 mg, Tablet, Oral 100 0.1757 B

Sulindac
150 mg, Tablet, Oral 100 0.3317 B
200 mg, Tablet, Oral 100 0.4289 B

Temazepam
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

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Tobramycin
0.3%, Solution/Drops, Ophthalmic 5 ml 1.1850 M

Tolazamide
250 mg, Tablet, Oral 100 0.4005 B

Tramadol Hydrochloride
50 mg, Tablet, Oral, 100 0.3068 B

Trazodone Hydrochloride
50 mg, Tablet, Oral 100 0.0684 R
100 mg, Tablet, Oral 100 0.0952 B
150 mg, Tablet, Oral 100 0.3113 B

Triamcinolone Acetonide
0.025%, Cream, Topical 80 gm 0.0364 B
0.1%, Cream, Topical 80 gm 0.0448 B
0.5%, Cream, Topical 15 gm 0.1889 B
0.1%, Lotion, Topical 60 ml 0.1215 B
0.1%, Ointment, Topical 80 gm 0.0502 B
0.1%, Paste, Dental 5 gm 0.8280 B

Triazolam
0.125 mg, Tablet, Oral 100 0.4041 B

Trifluoperazine Hydrochloride
Eq 1 mg base, Tablet, Oral 100 0.2433 B
Eq 2 mg base, Tablet, Oral 100 0.3552 B
Eq 5 mg base, Tablet, Oral 100 0.4271 B
Eq 10 mg base, Tablet, Oral 100 0.5403 B

Trihexyphenidyl Hydrochloride
2 mg, Tablet, Oral 100 0.1275 B
5 mg, Tablet, Oral 100 0.2580 B

Tropicamide
0.5%, Solution/Drops, Ophthalmic 15 ml 0.6550 B
1%, Solution/Drops, Ophthalmic 15 ml 0.7000 B

Valproic Acid
250 mg, Capsule, Oral 100 0.3488 B
250 mg/5 ml, Syrup, Oral 480 ml 0.0594 M

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Generic Name Upper Limit per Unit (Source)

Verapamil Hydrochloride
120 mg, Capsule, Extended Release, Oral 100 0.8250 B
180 mg, Capsule, Extended Release, Oral 100 0.8700 B
240 mg, Capsule, Extended Release, Oral 100 0.4350 B
40 mg, Tablet, Oral 100 0.1963 R
80 mg, Tablet, Oral 100 0.0735 B
120 mg, Tablet, Oral 100 0.1110 B
180 mg, Tablet, Extended Release, Oral 100 0.4350 B
240 mg, Tablet, Extended Release, Oral 100 0.3683 B

SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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SOURCE: B = Blue Book; M = Medi-Span; R = Red Book

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Appendix E:
Glossary

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GLOSSARY OF MEDICAL, MEDICAID,


AND MANAGED CARE TERMS

Term Definition

Access A patient’s ability to obtain medical care. The ease of access is determined by
components such as the availability of medical services and their acceptability
to the patient, the location of health care facilities, transportation, hours of
operation and affordability of care.

Actual Acquisition Cost (AAC) The pharmacist’s net payment made to purchase a drug product, after taking
into account such items as purchasing allowances, discounts, and rebates.

Actual Charge The amount a physician or other provider actually bills a patient for a
particular medical service, procedure or supply in a specific instance. The
actual charge may differ from the usual, customary, prevailing, and/or
reasonable charge.

Acute Care Medical treatment rendered to individuals whose illnesses or health problems
are of a short-term or episodic nature. Acute care facilities are those hospitals
that mainly serve persons with short-term health problems.

Additional Drug Benefit List A list of pharmaceutical products approved by a health plan and employer for
dispensing in larger quantities than the standards covered under a benefit
package in order to facilitate long-term patient use. The list is subject to
periodic review and modification by the health plan. Also called “drug
maintenance list.”

Adjudication Processing a claim through a series of edits in order to determine proper


payment.

Administrative Costs The costs incurred by a carrier, such as an insurance company or HMO, for
services such as claims processing, billing and enrollment, and overhead
costs. Administrative costs can be expressed as a percentage of premiums or
on a per member per month basis. Additional costs that are often expressed as
administrative include those related to utilization review, insurance marketing,
medical underwriting, agents’ commissions, premium collection, claims
processing, insurer profit, quality assurance activities, medical libraries and
risk management.

Administrative Services Only (ASO) An insurance arrangement requiring the employer to be at risk for the cost of
health care services provided, while a separate company delivers
administrative services. This is a common arrangement when an employer
sponsors a self-funded health care program.

Adverse Selection A term used to describe a situation in which a health plan disproportionally
enrolls a population that is prone to higher than average utilization of benefits,
thereby driving up costs and increasing financial risk.

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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.

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Term Definition

Ancillary Services Hospital services other than room, board, and professional services. They
may include X-rays, lab tests, or anesthesia.

Antitrust A legal term encompassing a variety of efforts on the part of government to


assure that sellers do not conspire to restrain trade or fix prices for their goods
or services in the market.

Any Willing Provider A requirement that a health insurance plan or a health maintenance
organization (HMO) must sign a contract for the delivery of healthcare
services with any provider in the area that would like to provide such services
to the plan’s or HMO’s enrollees, and can meet the terms of a contract.

Assignee The person to whom the rights to a health insurance policy are assigned, either
in part or in whole, by the original policyholder.

Assignment of Benefits A method under which a claimant requests that his/her benefits under a claim
be paid to some designated person or institution, usually a physician or
hospital.

At-Risk Accepting prepayment as full coverage for a predetermined healthcare benefit


and assuming financial liability for any loss that occurs when premiums paid
are less than the cost of services provided.

Authorization As it applies to managed care, authorization is the approval of care, such as


hospitalization.

Average Cost Per Claim The average dollar amount of administrative and/or medical services rendered
for the unit of measure within each expenditure category. The calculation is
$amount / #of units.

Average Manufacturer Price (AMP) The average price paid by wholesalers for products distributed to the retail
class of trade.

Average Wholesale Price (AWP) The published suggested wholesale price of a drug. It is often used by
pharmacies as a cost basis for pricing prescriptions.

Barriers To Access Barriers to access can be financial (insufficient monetary resources),


geographic (distance to providers), organizational (lack of available
providers) and sociological (e.g., discrimination, language barriers). Efforts to
improve access often focus on providing/improving health coverage.

Behavioral Health Care Assessment and treatment of mental and/or psychoactive substance abuse
disorders.

Beneficiary An individual who receives benefits from or is covered by an insurance policy


or other health care financing program. Also known as a "member,"
"enrollee," "subscriber," or "insured."

Benefit A service provided under an insurance policy or prepayment plan.

Benefit Maximum Specifies a dollar limit for the total reimbursement of health care costs during
a benefit period.

Benefit Package Services an insurer, government agency, or health plan offers to a group or
individual under the terms of a contract.

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Term Definition

Best Price For purposes of Medicaid rebate calculations, lowest price paid for a product
by any purchaser other than Federal agencies and State pharmaceutical
assistance programs.

Biological Equivalents Those chemical equivalents which, when administered in the same amounts,
will provide the same biological or physiological availability, as measured by
blood levels, urine levels, etc.

Blue Book (MDBT) The generic name for a widely used pricing guide entitled the American
Druggist First Databank Annual Directory of Pharmaceuticals. Brand name
and generic drugs are listed by product, manufacturer, National Drug or
Universal Price Codes, direct price and average wholesale price (AWP).
Other pricing guides are the Red Book and Medispan’s Pricing Guide.

Brand Name Name identifying a drug as the product of a specific pharmaceutical company.
Also known as proprietary trademark name.

Cafeteria Plan An employee benefit plan under which all participants are permitted to choose
among two or more benefit options according to their needs and/or ability to
pay. Also called a flexible benefit plan of “flex plan.”

Capitation A method of payment in which a health plan, such as an HMO or a specific


health care provider, receives a fixed amount for each person eligible to
receive services ($ per member per month), which is made whether or not the
covered person becomes an active patient and without regard to the number
and mix of services used by that patient.

Capitation Fund A fund based on the number of members multiplied by the budgeted or
capitated amount each member pays. Some HMOs, in lieu of reimbursing
physicians on a direct capitation basis, may establish such a fund. Physicians
are then reimbursed on a fee-for-service basis from the capitation fund. The
HMO monitors patient visits for over-utilization; patients exceeding the norm
are notified.

Card Programs The use of a drug benefit identification card which, when presented to a
participating pharmacy by employees or their dependents, usually entitles
them to receive the medication for a copay.

Care Coordinator A primary health care practitioner: (1) who provides primary care services to
an enrollee, (2) who is generally responsible for coordinating the enrollee’s
healthcare, and (3) with whom, other than in an emergency, a patient must
consult to obtain a referral to a specialist provider in order to obtain the
highest level of benefits available under a health plan. Care coordinators are
sometimes called “gatekeepers.”

Carve Out A decision to purchase separately a service that is typically a part of an


indemnity or HMO plan. Example: an HMO may “carve out” the behavioral
health benefits and select a specialized vendor to supply these services on a
stand-alone basis.

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Term Definition

Case Management (1) A process whereby covered persons with specific health care needs are
identified and a plan designed to efficiently utilize healthcare resources is
formulated and implemented to achieve the optimum patient outcome in the
most cost-effective manner. (2) A utilization management program that assists
the patient in determining the most appropriate and cost-effective treatment
plan. It is used for patients who have prolonged expensive or chronic
conditions, helps determine the treatment location (hospital, or other
institution, or home), and authorizes payment for such care if it is not covered
under the patient’s benefit agreement.

Case Manager An experienced professional (e.g., nurse, doctor or social worker) who works
with patients, providers and insurers to coordinate all services deemed
necessary to provide the patient with a plan of medically necessary and
appropriate health care.

Categorically Needy Under Medicaid, categorically needy causes are aged, blind, or disabled
individuals or families and children who meet financial eligibility
requirements for 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.

Claim Information on medical services provided that is submitted by a provider or a


covered person from which processing for payment to the provider or covered
person is made. The term generally refers to the liability for health care
services received by covered persons.

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Term Definition

Claims Administration A carrier function involving the review of health insurance claims submitted
for payment, by individual claim or in the aggregate. Claims administration,
as it relates to professional review programs, is an identification procedure,
screening treatment or charge pattern, for subsequent peer review and
adjudication.

Claims Clearinghouse System A system which allows electronic claims submission through a single source.

Claims Review The method by which an enrollee’s health care service claims are reviewed
before reimbursement is made. The purpose of this monitoring system is to
validate the medical appropriateness of the provided services and to be sure
the cost of the service is not excessive.

Clearinghouse Capability A company capable of submitting electronic and/or paper claims to several
third-party payers.

Clinical Indicator A tool or marker used to monitor and evaluate care to assure desirable
outcomes and to explain or prevent undesirable outcomes.

Clinical Outcome The status of the patient’s health, especially after receipt of medical care
services. Assessment of outcomes may be dependent upon targeted goals,
clinical markers, and the ability to provide objective measurements.

Clinical Practice Guidelines Guidelines that specify the appropriate course(s) of treatment for specified
health conditions.

Closed-Panel HMO Generally offers the services of a relatively limited number of healthcare
providers, e.g., physicians employed by the HMO. Staff- and group-model
HMOs are usually referred to as being in this category.

CMS MSIS Report The CMS MSIS Report, formerly the HCFA-2082 Report, is the basic source
of state-reported eligibility and claims data on the Medicaid population, their
characteristics, utilization, and payments. Through FY 1998, the HCFA-2082
was an annual State submitted report designed to collect aggregate statistical
data on Medicaid eligibles, recipients, services, and expenditures during each
federal fiscal year. States summarized and reported the data processed through
their own Medicaid claims processing and payment systems unless they opted
to participate in The Medicaid Statistical Information System (MSIS) where
the 2082 Report was produced by CMS. State-by-State national summary
tables were developed based on the 2082 Reports. As a result of legislation
enacted by The Balanced Budget Act of 1997, States, beginning in FY 1999,
are required to submit all of their eligibility and claims data on a quarterly
basis through MSIS. The State requirement for completing the HCFA-2082
Report has been eliminated.

CMS-64 Report The CMS-64 Report is a product of the financial budget and grant system. It
is a statement of expenditures for The Medicaid program that states submit to
CMS 30 days after each quarter. The Report is an accounting statement of
actual expenditures made by the States for which they are entitled to receive
federal reimbursement under Title XIX for that quarter. Along with The CMS
MSIS Report, it is one of the primary sources for Medicaid statistical data.

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.

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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.

Compliance The degree to which patients follow treatment recommendations.

Comprehensive Benefits Plan A variation of the major medical plan which carries copayment requirements,
usually 10-20 percent of all health expenses and deductibles ranging from
$100 to $1,000.

Concurrent Drug Evaluation An electronic assessment of claims at the point of service to detect potential
problems that should be addressed prior to dispensing drugs to patients.

Consolidated Omnibus Reconciliation 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.

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Term Definition

Copay/Copayment A cost-sharing arrangement in which a covered person pays a specified charge


for a specified service, such as $10 for an office visit. The covered person is
usually responsible for payment at the time the healthcare is rendered.
Typical copayments are fixed or variable flat amounts for physician office
visits, prescriptions or hospital services. Some copayments are referred to as
coinsurance, with the distinguishing characteristics that copayments are flat or
variable dollar amounts and coinsurance is a defined percentage of the
charges for services rendered.

Cosmetic Procedures Those procedures which involve physical appearance, but which do not
correct or materially improve a physiological function and are not deemed
medically necessary.

Cost Sharing Any provision of a health insurance policy that requires the insured to pay
some portion of medical expenses. The general term includes deductibles,
copayments, and coinsurance.

Cost Shifting The redistribution of payment sources. Typically, cost shifting occurs when
one payer obtains a discount on provider services, and the providers increase
costs to another payer to make up the difference.

Cost-Based Reimbursement Payment by third party insurers in which the amount is based on the cost to
the provider of delivering services.

Cost-Effectiveness Usually considered as a ratio, the cost-effectiveness of a drug or procedure,


for example, relates the cost of that drug or procedure to the health benefits
resulting from it. In health terms, it is often expressed as the cost per year per
life saved.

Counter Detailing A process of re-educating or influencing prescribers in a closed or controlled


HMO plan. Usually done in order to gain more compliance with a formulary.
In a counter-detailing program, techniques used by pharmaceutical sales
representatives are adapted to a “counter” objective, i.e., to provide doctors
with basic pharmacological information designed to influence their
prescribing habits.

Coverage Entire range of protection provided under an insurance contract.

Covered Expenses Medical and related costs, experienced by those covered under the policy, that
qualify for reimbursement under terms of the insurance contract.

Covered Services The specific services and supplies for which Medicaid will provide
reimbursement. Covered services under Medicaid consist of a combination of
mandatory and optional services within each State.

Credentialing A process of review to approve a provider who applies to participate in a


health plan. Specific criteria and prerequisites are applied in determining
initial and ongoing participation in the health plan.

Customary Charge The charge a physician or supplier usually bills his patients for furnishing a
particular service or supply is called the customary charge.

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Term Definition

Customary, Prevailing, and Reasonable 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.

Dependent An individual who relies on an employee for support or obtains health


coverage through a spouse, parent, or grandparent who is the covered person.

Depot Price The price(s) available to any depot of the Federal government, for purchase of
drugs from the Manufacturer through the depot system of procurement.

Diagnosis Center Freestanding or hospital-based facility that specializes in diagnosing illnesses


and injuries.

Diagnosis Related Group (DRG) A system of classification for inpatient hospital services based on principal
diagnosis, secondary diagnosis, surgical procedures, age, sex and presence of
complications. This system of classification is used as a financing mechanism
to reimburse hospital and selected other providers for services rendered.

Disability (1) Any condition that results in functional limitations that interfere with an
individual’s ability to perform his/her customary work and which results in
substantial limitation in one of more major life activities. (2) Condition(s) that
prevent or limit an individual’s ability to engage in normal activities. These
may be temporary.

Disability Income Insurance Type of health insurance that periodically pays a disabled subscriber to
replace income lost during the period of disability.

Disease Management An effort to improve patient outcomes and lower costs by organizing managed
care initiatives around patients with a particular disease or condition.

Dismemberment Loss of body parts stemming from accidental physical injury.

Dispense As Written (DAW) A prescribing directive issued by physicians to indicate that the pharmacy
should not in any way alter a prescription. Such alterations are usually done
in order to substitute a generic drug for the brand-name drug ordered.

Dispensing, Fill or Professional Fee The amount paid to a pharmacy for each prescription, in addition to the
negotiated formula for reimbursing ingredient cost.

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Term Definition

Disproportionate Share Hospital (DSH) A disproportionate share hospital (DSH) is a hospital that serves a
disproportionate number of low-income patients with special needs and
receives a payment adjustment for providing such services. In addition to
certain requirements for the provision of obstetrical services to individuals
entitled to medical assistance, a hospital is deemed to be a disproportionate
share hospital if 1) the hospital’s Medicaid inpatient utilization rate is at least
one standard deviation above the mean Medicaid inpatient utilization rate for
hospitals receiving Medicaid payments in the state, or 2) the hospital’s low-
income utilization rate exceeds 25 percent.

Drug Detailing Presenting information about a brand name drug product to prescribers to
educate them about its activity, uses, side effects, proper dosage and
administration, etc.

Drug Formulary A listing of prescription medications which are preferred for use by a health
plan and which may be dispensed through participating pharmacies to covered
persons. This list is subject to periodic review and modification by the health
plan. A plan that has adopted an “open or voluntary” formulary allows
coverage for both formulary and non-formulary medications. A plan that has
adopted a “closed, select or mandatory” formulary limits coverage to those
drugs in the formulary.

Drug Use Evaluation (DUE) Evaluations of prescribing patterns of prescribers to specifically determine the
appropriateness of drug therapy. There are three forms of DUE: prospective
(before or at the time of prescription dispensing), concurrent (during the
course of drug therapy), and retrospective (after the therapy has been
completed). Same as “Drug Utilization Review.”

Drug Utilization The prescribing, dispensing, administering and ingestion or use of


pharmaceutical products.

Drug Utilization Review (DUR) A quantitative evaluation of prescription drug use, physician prescribing
patterns or patient drug utilization to determine the appropriateness of drug
therapy. Most often focuses on over-utilization.

Early and Periodic Screening, 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.

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Pharmaceutical Benefits 2002

Term Definition

Estimated Acquisition Cost (EAC) An estimate of the price generally, and currently, paid by providers for a drug
marketed or sold by a particular manufacturer or labeler in the package size
most frequently purchased by providers.

Exclusions Specific conditions or circumstances listed in the contract or employee benefit


plan for which the policy or plan will not provide benefit payments.

Exclusivity Clause A part of a contract which prohibits physicians from contracting with more
than one health maintenance organization or preferred provider organization.

Expenditures Under Medicaid, “expenditures” refers to an amount paid out by a State


agency for the covered medical expenses of eligible participants.

Experience Rating The process of setting rates based partially or in whole on previous claims
experience and projected required revenues for a future policy year for a
specific group or pool of groups.

Experimental, Investigational or 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.

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Pharmaceutical Benefits 2002

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.

Formulary See “Drug Formulary.”

Free-Standing Hospital Any hospital that is not affiliated with a multihospital system.

Freedom-of-Choice (FOC) Legislation requiring managed care organizations to allow members to choose
providers whether or not they connect with the plans (often coupled with any
willing provider (AWP) legislation).

Gatekeeper See “Care Coordinator.”

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Pharmaceutical Benefits 2002

Term Definition

Generic Drug A chemically equivalent copy of a brand name drug whose patent has expired.
Drug formulations must be of identical composition with respect to the active
ingredient (i.e., meet official standards of identity, purity, and quality of active
ingredient). Also called generic equivalent or non-innovator multiple source
drug.

Generic Equivalent See “Generic Drug.”

Generic Substitution Dispensing a generic drug in place of a brand-name medication.

Global Target A financing method identical to a global budget except that no enforcement
mechanism is used to keep providers and hospitals within budget (i.e.,
providers and hospitals will receive additional funding if their costs exceed
their budgeted payments).

HCFA 1500 A universal form developed by the government agency previously known as
the Health Care Financing Administration (HCFA, now CMS), for providers
of services to bill professional fees to health carriers.

HCFA Common Procedural Coding 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.

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Pharmaceutical Benefits 2002

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.

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Pharmaceutical Benefits 2002

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.

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Pharmaceutical Benefits 2002

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.

Medicaid A Federally aided State-operated and administered program that provides


medical benefits for certain indigent or low-income persons in need of health
and medical care. The program, authorized by Title XIX of the Social
Security Act, is basically for the poor. It does not cover all of the poor,
however, but only persons who meet specified eligibility criteria. Subject to
broad Federal guidelines, States determine the benefits covered, program
eligibility, rates of payment for providers, and methods of administering the
program. Also referred to as State Medical Assistance Programs.

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Pharmaceutical Benefits 2002

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 Beneficiary A person designated by the Social Security Administration as entitled to


receive Medicare benefits.

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.”

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Pharmaceutical Benefits 2002

Term Definition

Medigap (Medicare Supplemental See “Medicare Supplemental Insurance.”


Insurance)

Members A participant in a health plan (member or eligible dependent). Also used to


describe an individual specified within a subscriber contract that may receive
health care services according to the terms of the subscriber policy. Also
known as "beneficiary," "enrollee," "subscriber," or "insured."

Modified Fee-for-Service A system in which providers are paid on a fee-for-service basis, with certain
fee maximums for each procedure.

Most Favored Nations Discount or 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.

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Pharmaceutical Benefits 2002

Term Definition

Out-of-Pocket Limit The total payments toward eligible expenses that a covered person funds for
him/herself and/or dependents: i.e., deductibles, copays and coinsurance - as
defined per the contract. Once this limit is reached, benefits will increase to
100% for health services received during the rest of that calendar year. Some
out-of-pocket costs (e.g., mental health, penalties for non-precertification,
etc.) are not eligible for out-of-pocket limits.

Outcome Measures Assessments which gauge the effect or results of treatment for a particular
disease or condition. Outcome measures include such parameters as: the
patient’s perception of restoration of function, quality of life and functional
status, as well as objective measures of mortality, morbidity and health status.

Outcomes Management Systematically improving healthcare results, typically by modifying practices


in response to data gleaned through outcomes measurement, then remeasuring
and remodifying - often in a formal program of continuous quality
improvement.

Outcomes Research Studies aimed at measuring the effect of a given product, procedure, or
medical technology on health or costs.

Outlier An observation in a distribution that is outside a certain range, often defined


as two or three standard deviations from the mean or exceeding a specific
percentile. Frequently refers to a case or hospital stay that is unusually long or
expensive for its type, or to a physician practice that uses an abnormally high
or low volume of resources.

Outpatient Services Outpatient services are medical and other services provided on a non-resident
basis (patients are not admitted to the facility) by a hospital or other qualified
facility, such as a mental health clinic, rural health clinic, mobile X-ray unit,
or freestanding dialysis unit. Such services include outpatient physical therapy
services, diagnostic X-ray and laboratory tests, and X-ray and other radiation
therapy.

Over-the-Counter (OTC) A drug product that does not require a prescription under Federal or State law.

Participating Provider A provider who has contracted with the health plan to provide medical
services to covered persons. The provider may be a hospital, pharmacy, other
facility or a physician who has contractually accepted the terms and
conditions as set forth by the health plan.

Patient Health Status Survey Questionnaire used to solicit patient perceptions regarding the state of their
health. Questions may be general and address overall health status with regard
to a specific condition (e.g., an arthritic patient’s ability to make a fist or an
asthmatic patient’s ability to climb a flight of stairs).

Patient Satisfaction Survey Questionnaire used to solicit the perceptions the plan enrollees or patients
have regarding how a health plan meets their medical needs and how the
delivery of care is handled, (e.g., waiting time, access to treatments).

Payer A general term indicating the responsible party for the payment of medical
care service expenses. Payers may be patients, insurance companies,
government agencies, or a combination of these.

Peer Review The evaluation of quality of total healthcare provided, by medical staff with
equivalent training.

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Pharmaceutical Benefits 2002

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.

Practice Guideline Systematically developed statements on medical practice that assist a


practitioner and a patient in making decisions about appropriate healthcare for
specific medical conditions. Managed care organizations frequently use these
guidelines to evaluate appropriateness and medical necessity of care. Terms
used synonymously include practice parameters, standard treatment protocols
and clinical practice guidelines.

Practice Parameters See “Practice Guidelines.”

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Pharmaceutical Benefits 2002

Term Definition

Practice Variation An assessment of the patterns of a practitioner’s practice to determine if the


provider’s care is significantly different from others with similar practices. If
there is a significant difference, the practitioner’s practice is analyzed to
determine the reasons for the variation and whether that practitioner’s practice
patterns should be modified.

Pre-Certification Review See “Utilization Review.”

Pre-Existing Condition (PEC) Any medical condition that has been diagnosed or treated within a specified
period immediately preceding the covered person’s effective date of coverage
under the master group contract.

Preferred Provider Organization 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 Basic or general healthcare traditionally provided by family practice,


pediatrics and internal medicine. See also “Secondary 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.

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Pharmaceutical Benefits 2002

Term Definition

Primary Care Physician (PCP) The primary care practitioner (e.g., internist, family/general practitioner,
pediatrician, and in some cases, OB/Gyn) in managed care organizations who
determines whether the presenting patient needs to see a specialist or requires
other non-routine services. See Care Coordinator.

Prior Authorization The process of obtaining prior approval as to the appropriateness of a service
or medication. Prior authorization does not guarantee coverage.

Prospective Financing Financing for health care services based on prices or budgets determined prior
to the delivery of service. Payments can be per unit of service, per member, or
per time period. In all its forms prospective financing differs from cost-based
reimbursement, under which a provider is paid for costs incurred.

Protocol See “Practice Guidelines.”

Provider Network See “Network Plan.”

Providers A physician, hospital, group practice, nurse, nursing home, pharmacy or any
individual or group of individuals that provides a healthcare service.

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

Quality Assurance (QA) or Quality 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.

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Term Definition

Rebate A monetary amount that is returned to a payer from a prescription drug


manufacturer based upon utilization by a covered person or purchases by a
provider.

Recipient A recipient of Medicaid is an individual who has been determined to be


eligible for Medicaid and who has used medical services covered under
Medicaid.

Referral The process of sending a patient from one practitioner to another for health
care services. Health plans may require that designated primary care providers
authorize a referral for coverage of specialty services.

Restrictive Formulary A term often used synonymously with closed formulary. See “Drug
Formulary.”

Retrospective Review Determination of medical necessity and/or appropriate billing practice for
services already rendered.

Risk Responsibility for paying for or otherwise providing a level of health care
services based on an unpredictable need for these services.

Risk Contract (1) An agreement between a State Medicaid program and an HMO or
competitive medical plan requiring the HMO to furnish at a minimum all
Medicaid covered services to Medicaid eligible enrollees for an annually
determined, fixed monthly payment rate from the state government. The
HMO is then liable for services regardless of their extent, expense or degree.
(2) An agreement between a provider and payer, or intermediary, on behalf of
a payer, that requires the provider to furnish all specified services for a
specified enrollee for a set fee, usually prepaid, and for a set period of time
(usually one year). The provider is then liable for services regardless of their
extent, expense or degree. Such stated limitations for such liability are stated
in advance and may be subject to reinsurance.

Rural Health Clinic A rural health clinic is an outpatient facility which is primarily engaged in
furnishing physician and other medical and health services, which meets
certain other requirements designed to ensure the health and safety of the
individuals served by the clinic. The clinic must be located in an area that is
not urbanized as defined by the Census Bureau and that is designated by the
Secretary of DHHS either as an area with a shortage of personal health
services, or as a health manpower shortage area, and has filed an agreement
with the Secretary not to charge any individual or other person for items or
services for which such individual is entitled to have payment made by
Medicare, except for the amount of any deductible or coinsurance amount
applicable.

Secondary Care Services provided by medical specialists, such as cardiologists, urologists and
dermatologists, who generally do not have first contact with patients. See also
“Primary Care.”

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Term Definition

Section 1115 Waivers Section 1115 of the Social Security Act grants the Secretary of Health and
Human Services broad authority to waive certain laws relating to Medicaid for
the purpose of conducting pilot, experimental or demonstration projects.
Section 1115 demonstration waivers allow States to change provisions of their
Medicaid programs, including: eligibility requirements, the scope of services
available, the freedom to choose a provider, a provider’s choice to participate
in a plan, the method of reimbursing providers, and the statewide application
of the program. Projects typically run three to five years.

Section 1915(b) Waivers Prior to the passage of the Balanced Budget Act (BBA) of 1997, Section
1915(b) freedom-of-choice waivers allowed States to require Medicaid
recipients to enroll in HMOs or other managed care plans in an effort to
control costs. The waivers allowed States to: implement a primary care case-
management system; require Medicaid recipients to choose from a number of
competing health plans; provide additional benefits in exchange for savings
resulting from recipients’ use of cost-effective providers; and limit the
providers from which beneficiaries can receive non-emergency treatment.
Under the BBA, States can enroll recipients into managed care without
applying for 1915(b) waivers.

Self-Referral Restrictions Restrictions on or prohibitions against providers referring patients to a


designated health service (e.g., pharmacies, clinical laboratories, and
outpatient surgery) in which the provider or the provider’s immediate family
member has a financial interest.

Sin Taxes Taxes imposed on items considered harmful to public health interests, such as
tobacco and alcohol.

Single-Source Drug A single-source drug is a covered outpatient drug which is produced or


distributed under an original new drug application approved by the FDA,
including a drug product marketed by any cross-licensed producers or
distributors operating under the new drug application.

Skilled Nursing Facility (SNF) A facility, either freestanding or part of a hospital, that accepts patients in
need of rehabilitation and medical care that is of a lesser intensity than that
received in a hospital.

Skilled Nursing Facility Services All services furnished to inpatients of, and billed for by, a formally certified
skilled nursing facility that meets standards set by Secretary of DHHS.

Spend-Down Under Medicaid, “spend-down” refers to a method by which an individual


establishes Medicaid eligibility by reducing gross income through incurring
medical expenses until net income (after medical expenses) meets Medicaid
financial requirements.

State Buy-In The term given to the process by which a State may provide Supplementary
Medical Insurance coverage for its needy eligible persons through an
agreement with the Federal government under which the State pays the
premiums for them.

State Mandated Benefits Laws State laws requiring insurance contracts to provide coverage for certain health
services (e.g., in vitro fertilization) or services provided by certain health care
providers (e.g., audiologists). Self-insureds are exempt from these
requirements. There are over 800 mandates nationwide.

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Term Definition

State Medical Assistance Programs See “ Medicaid.”

State Pharmacy Assistant Programs State authorized programs to provide pharmaceutical coverage or assistance
to low-income and/or persons with disabilities who do not qualify for
Medicaid. Also known as Expanded Drug Benefit Programs.

State Plan The Medicaid State Plan is a comprehensive written commitment by a


Medicaid agency to administer or supervise the administration of a Medicaid
program in accordance with Federal requirements.

Stop Loss That point at which a third party has reinsurance to protect against the overly
large single claim or the excessively high aggregate claim during a given
period of time. Large employers, who are self-insured, may also purchase
“reinsurance” for stop-loss purposes.

Supplemental Security Income (SSI) A Federal cash assistance program for low-income aged, blind and disabled
individuals established by Title XVI of the Social Security Act. States may
use SSI income limits to establish Medicaid eligibility.

Tax Equity and Fiscal Responsibility 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.

Total Quality Management (TQM) See “Continuous Quality Improvement.”

Title XIX See “ Medicaid.”

Universal Access The availability of affordable public or private insurance coverage for every
United States citizen or legal resident. There is no guarantee, however, that all
individuals will actually choose to purchase or have the funds to purchase
coverage. See “Universal Coverage.”

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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.

Utilization Review A formal assessment of the medical necessity, efficiency, and/or


appropriateness of healthcare services and treatment plans on a prospective,
concurrent or retrospective basis.

Vendor A medical vendor is an institution, agency, organization, or individual


practitioner that provides health or medical products and/or services either to
a medical provider, who in turn interfaces with patients, or directly to the
public.

Vendor Payments In welfare programs, direct payments are made by the State to providers such
as physicians, pharmacists and health care institutions rather than to the
welfare recipient himself.

Waiver A rider or clause in a health insurance contract excluding an insurer’s liability


for some sort of pre-existing illness or injury. Also refers to a plan
amendment, such as a CMS waiver or plan modification.

Withhold “At-risk” portion of a claim deducted and withheld by the health plan before
payment is made to a participating physician as an incentive for appropriate
utilization and quality of care. This amount – for example, 20% of the claim
– remains within the plan and is credited to the doctor’s account. Can be used
where the plan needs additional funds to pay for claims. The withhold may be
returned to the physician in varying levels which are determined based on
analysis of his/her performance or productivity compared against his/her
peers. Also called “physician contingency reserve (PCR).”

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ACRONYMS

AABD Aid to Aged, Blind, and Disabled


AAC Actual Acquisition Cost
AB Aid to the Blind
AFDC Aid to Families with Dependent Children
AHRQ Agency for Health Research and Quality
AIDS Acquired Immune Deficiency Syndrome
AMP Average Manufacturer Price
ANSI American National Standards Institute
APTD Aid to the Permanently and Totally Disabled
ARF Area Resource File
ASO Administrative Services Only
AWP Any Willing Provider OR Average Wholesale Price
BBA Balanced Budget Act of 1997
BIPA Benefits Improvement and Protection Act
BLS Bureau of Labor Statistics
CFR Code of Federal Regulations
CMP Competitive Medical Plan
CMS Centers for Medicare and Medicaid Services (formerly HCFA)
CMSO CMS’ Center for Medicaid and State Operations
CNAB Categorically Needy Aid to the Blind
CNAFDC Categorically Needy Aid to Families with Dependent Children
CNAPTD Categorically Needy Aid to the Permanently and Totally Disabled
CNOAA Categorically Needy Old Age Assistance
COBRA Consolidated Omnibus Reconciliation Act of 1985
COM-MCO Commercial Managed Care Organization
CON Certificate of Need
CPI Consumer Price Index
CPR Customary Prevailing, and Reasonable (charges)
CPT Current Procedural Terminology
CQI Continuous Quality Improvement
DAW Dispense As Written
dba Doing Business As
DEFRA Deficit Reduction Act of 1984
DESI Drug Efficacy Study and Implementation
DHHS Department of Health and Human Services
DRGs Diagnostic Related Groupings
DSH Disproportionate Share Hospital
DUE Drug Use Evaluation
DUR Drug Utilization Review

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EAC Estimated Acquisition Cost


EDI Electronic Data Interchange
EPSDT Early and Periodic Screening, Diagnostic and Treatment
ERISA Employee Retirement Income Security Act
ESRD End Stage Renal Disease
FDA Food and Drug Administration
FFP Federal Financial Participation
FFS Fee-for-Service
FMAP Federal Medical Assistance Percentage
FOC Freedom of Choice
FPL Federal Poverty Level
FQHC Federally Qualified Health Center
FUL Federal Upper Limits
FY Fiscal Year
HCFA Health Care Financing Administration (see CMS)
HCPCS HCFA Common Procedural Coding System
HCPP Health Care Prepayment Plan
HEDIS Health Plan Employer Data and Information Set
HH Home Health
HIO Health Insuring Organizations
HIPAA Health Insurance Portability and Accountability Act
HMO Health Maintenance Organization
HRSA Health Resources and Services Administration
ICF Intermediate Care Facility
ICF-MR Intermediate Care Facility for the Mentally Retarded
IPA Individual Practice Association
MAC Maximum Allowable Cost
MAIC Maximum Allowable Ingredient Cost
MCAID-MCO Medicaid-only Managed Care Organization
MCO Managed Care Organization
MMIS Medicaid Management Information System
MNAB Medically Needy Aid to the Blind
MNAFDC Medically Needy Aid to Families with Dependent Children
MNAPTD Medically Needy Aid to the Permanently and Totally Disabled
MNOAA Medically Needy Old Age Assistance
MQC Medicaid Quality Control
MSA Medical Savings Account
MSIS Medicaid Statistical Information System
NDC National Drug Code
NP Nurse Practitioner
OAA Old Age Assistance
OACT Office of the Actuary

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OASDI Old Age, Survivors, and Disability Insurance


OBRA Omnibus Budget Reconciliation Act
OHS Outpatient Hospital Services
OMB Office of Management and Budget
ORD Office of Research and Demonstrations
OT Occupational Therapy
OTC Over-the-Counter (drugs)
P&T Pharmacy and Therapeutics Committee
PA Physician’s Assistant OR Prior Authorization
PCCM Primary Care Case Management
PCF Program Characteristics File
PCP Primary Care Physician
PHP Prepaid Health Plan
PMPM Per Member Per Month
PHO Physician-Hospital Organization
POS Point-of-Service
PPO Preferred Provider Organization
PRO Peer Review Organization
ProPAC Prospective Payment Assessment Commission
PT Physical Therapy
QA/QI Quality Assurance/Quality Improvement
QMB Qualified Medicare Beneficiary
RHC Rural Health Clinic
RPH Registered Pharmacist
Rx Pharmaceutical
SCHIP State Children’s Health Insurance Program
SFO State Funds Only
SNF Skilled Nursing Facility
SSA Social Security Administration
SSI Supplemental Security Income
SSP State Supplemental Payments
TANF Temporary Assistance for Needy Families
TDOC Total Days of Care
TEFRA Tax Equity & Fiscal Responsibility Act
Title XIX Title XIX of The Social Security Act (See Medicaid)
TPA Third-Party Administrator
TQM Total Quality Management
UCR Usual, Customary and Reasonable
UM Utilization Management
UR Utilization Review
WAC Weighted Average Cost OR Wholesale Acquisition Cost

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