National Pharmaceutical Council Pharmaceutical Benefits 2003

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TABLE OF CONTENTS
INTRODUCTION......................................................................................................................................v
SECTION 1: THE MEDICARE PRESCRIPTION DRUG, MODERNIZATION,
AND IMPROVEMENT ACT OF 2003, DUAL ELIGIBLES, AND
IMPACT ON STATES.................................................................................................. 1-1
SECTION 2: THE MEDICAID PROGRAM ..................................................................................... 2-1
Medicaid Program Overview.................................................................................................... 2-3
- Total Medicaid Eligibles by Maintenance Assistance Status, 2001........................ 2-11
- Total Medicaid Eligibles by Age Group, 2001........................................................ 2-12
- Total Medicaid Eligibles by Basis of Eligibility, 2001 ........................................... 2-13
- Total Medicaid Eligibles by per 1000 Population, 2001 ........................................ 2-14
- Total Net U.S. Medical Assistance Expenditures by Type of Service ................... 2-15
- Federal Medical Assistance Percentages (FMAP), FY 2004 and FY 2005 ........... 2-16
- Medicaid Total Net Expenditures and Eligibles, 2001 ........................................... 2-17
- Total Medicaid Program Expenditures, 2002 ......................................................... 2-18
- Total SCHIP Expenditures, 2002 ........................................................................... 2-19
Medicaid Managed Care Enrollment ................................................................................... 2-21
- Medicaid Managed Care Enrollment, As of June 30, 2002..................................... 2-23
- Pharmaceutical Benefits Under Managed Care Plans ............................................ 2-24
- Medicaid Managed Care Enrollment Trends, 1998-2002 ....................................... 2-25
- Medicaid Managed Care Plan Type, As of June 30, 2002 ...................................... 2-26
- Medicaid Managed Enrollment by Plan Type, As of June 30, 2002....................... 2-27
- Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2002 ............................................................................................... 2-28
Medicaid Managed Care Waivers.......................................................................................... 2-29
- Section 1915(b) Waivers, As of June 30, 2002 ....................................................... 2-33
- Section 1115 Research and Demonstration Waivers, As of June 30, 2002............. 2-35
- Pharmacy Plus Demonstrations Program Status, Pharmacy Waivers
Under 115 Authority................................................................................................ 2-36
SECTION 3: STATE CHARACTERISTICS ……………………………………………………….3-1
Sociodemographics
- Age Demographics, 2002 .......................................................................................... 3-5
- Race Demographics, 2002......................................................................................... 3-6
- Hispanic Demographics, 2002 .................................................................................. 3-7
- Insurance Status-Populations, 2002 .......................................................................... 3-8
- Insurance Status-Percentages, 2002 ........................................................................ 3-9
- Poverty Status-Populations, 2002 ........................................................................... 3-10
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- Poverty Status-Percentages, 2002............................................................................ 3-11
- Employment Status, 2003........................................................................................ 3-12
Health Care Delivery System
− Medicaid/Medicare Certified Facilities ................................................................... 3-13
− Licensed Pharmacies................................................................................................ 3-14
− Physicians, 2001 ...................................................................................................... 3-16
− Other Providers ........................................................................................................ 3-17
SECTION 4: PHARMACY PROGRAM CHARACTERISTICS..................................................... 4-1
Medicaid Drug Program........................................................................................................... 4-3
− Drug Expenditures Trends ......................................................................................... 4-5
− Ranking Based on Drug Expenditures....................................................................... 4-6
− Drugs as a Percentage of Total Net Expenditures, 2002 ........................................... 4-7
− Drugs as a Percentage of Total Net Expenditures, 2000-2002.................................. 4-8
− Share of Drug Expenditures by Category, 2002........................................................ 4-9
− Share of Prescriptions Processed, 2002 ................................................................... 4-11
− Medicaid Average Cost per Prescription, 2002....................................................... 4-13
Medicaid Drug Rebates ........................................................................................................... 4-15
− Medicaid Drug Rebates, 2002 ................................................................................. 4-17
− Medicaid Drug Rebate Trends, 1998-2002.............................................................. 4-18
− Medicaid Drug Rebate Trends, Annual Percent Change, 1997-2002...................... 4-19
− Rebates As Percent of Drug Expenditures, 2002..................................................... 4-20
Medicaid Drug Coverage ........................................................................................................ 4-21
− Pharmacy Advisory Committees ............................................................................. 4-23
− Pharmacy Benefit Design – Coverage ..................................................................... 4-24
− Coverage of Injectables ........................................................................................... 4-27
− Coverage of Vaccines and Unit Dose ...................................................................... 4-28
− Coverage of Over-the-Counter Medications............................................................ 4-29
− Prior Authorization Process and Procedures ........................................................... 4-31
− Prior Authorization .................................................................................................. 4-34
− Drug Utilization Review.......................................................................................... 4-37
− Prescribing/Dispensing Limits................................................................................. 4-38
Pharmacy Payment and Patient Cost Sharing...................................................................... 4-39
− Pharmacy Payment and Patient Cost Sharing.......................................................... 4-41
− Maximum Allowable Cost (MAC) Programs.......................................................... 4-42
− Mandatory Substitution............................................................................................ 4-43
− Counseling Requirements and Payment for Cognitive Services ............................. 4-44
− Prescription Price Updating..................................................................................... 4-45
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SECTION 5: STATE PROFILES........................................................................................................ 5-1
SECTION 6: STATE PHARMACY ASSISTANCE PROGRAMS.................................................. 6-1
APPENDIXES
Appendix A: State and Federal Medicaid Contacts.................................................................... A-1
Appendix B: Medicaid Program Statistics – CMS MSIS Tables ................................................B-1
Appendix C: Medicaid Rebate Law.............................................................................................C-1
Appendix D: Federal Upper Limits for Multiple Source Products............................................. D-1
Appendix E: Glossary..................................................................................................................E-1

































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National Pharmaceutical Council Pharmaceutical Benefits 2003


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INTRODUCTION
The 2003 edition of Pharmaceutical Benefits under State Medical Assistance Programs marks the 38
th

year that the National Pharmaceutical Council (NPC) has compiled and published one of the largest
sources of information on pharmacy programs within the State Medical Assistance Programs (Title
XIX) and expanded pharmacy programs for the elderly and disabled. Due to the hard work of a skilled
team and countless contributors, the “Medicaid Compilation” has become a standard reference and
invaluable resource in government offices, research libraries, consultancies, the pharmaceutical
industry, numerous businesses, and policy organizations.

The data used to create each edition of the Compilation are assembled from numerous sources. The
Compilation incorporates information on each State pharmacy program from an annual NPC survey of
State Medicaid program administrators and pharmacy consultants, statistics from the Centers for
Medicare and Medicaid Services (CMS), and information from other Federal agencies and
organizations.

In order to give a better understanding of the content of the “Medicaid Compilation,” the information
contained in this version of the book is summarized below by section:
• Section 1: Reports on the Medicare Modernization Act provisions, the dual eligibles it will
affect, and the overall impact on the States.
• Section 2: Contains an overview of the Medicaid program, details about Medicaid managed
care enrollment, including a breakdown by plan type and enrollment by plan type, and a
synopsis of 1915(b) waivers and 1115 demonstrations.
• Section 3: Consists of sociodemographic statistics, by age, race, insurance, income, and
employment, for the fifty States and the District of Columbia for calendar year 2002.
Additionally, a description of the Medicaid certified facilities in each State, including the
number of hospitals, skilled nursing facilities, and intermediate care facilities for the mentally
retarded (ICFs-MR), home health agencies, and rural health clinics are presented.
• Section 4: Provides Medicaid pharmacy program characteristics, drawn largely from the 2003
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2001 and program
expenditure data for fiscal years 2001 and 2002. Medicaid pharmacy programs are
characterized by estimates of total expenditures, drug payments, drug benefit design, and
pharmacy payment and patient cost sharing.
• Section 5: Contains detailed profiles of the States’ Medicaid pharmacy programs. This
section contains a description of medical assistance benefits and eligibles, drug payments and
recipients, benefit design, pharmacy payment and patient cost sharing, use of managed care,
and State contacts.
• Section 6: Profiles the “expanded” drug programs in States that are providing pharmaceutical
coverage or discounts to the elderly and/or disabled persons.
The book also contains a series of appendices. Appendix A features a list of State contacts, CMS
regional offices and Medicaid program personnel. Appendix B provides a national level summary on
total Medicaid program recipients by type of service for FY 2000 and FY 2001 and data on total
number of drug recipients for each State and the nation as a whole for the period 1996-2001.
Appendix C provides the current Medicaid drug rebate law. Appendix D contains the list of CMS
upper limits on multiple source products. Appendix E is a glossary and list of acronyms.

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Each year, finding and compiling current, relevant information for inclusion in the Compilation
presents a challenge. For example, each year CMS makes available on its website the Medical
Statistical Information System (MSIS) Statistical Reports for the most recent enrollment and
expenditure data available. The MSIS tables are used throughout several sections as a secondary data
source. This year, CMS released MSIS reports on federal Fiscal Year 2001. However, at the time of
publication, the FY 2001 information for Washington State was not yet available. FY 2000 data have
been substituted in their place. Additionally, Hawaii did not report for FY 2000 and FY 2001,
therefore, their FY 1999 numbers are used.

In addition, updated information for the Medicaid Waivers and Managed Care statistics have not been
released at this time. We believe that this remains an important aspect of State Medical Assistance
Programs and have included last year’s data in its place.

As we continue to update and discover data, we are able to improve the Compilation with new tables
and sources that we believe enhance its overall significance to the user. These new tables and sources
include:

• Eligibility and maintenance assistance status table;
• Eligibility and age table;
• New poverty tables including raw numbers and percentages;
• Enhanced employment tables;
• Additional information on the Pharmacy Plus Demonstration waivers under Section 1115
Authority;
• New listing for brand name products contacts in the State Profiles and Appendix A; and
• A new source for the registered nurses.

NPC gratefully acknowledges the cooperation and assistance of the many State and Federal program
officials and their staffs. With their cooperation, we were able to achieve a 90 percent response rate to
the 2003 Survey. Unfortunately, not all States were able to submit revised/updated information. In
such instances, we have incorporated the most recently available data from other sources. However,
for these States, much of the information may reflect data that have been presented in previous
versions of the Compilation.

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


Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council
National Pharmaceutical Council Pharmaceutical Benefits 2003
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Section 1:
The Medicare Prescription
Drug, Improvement, and
Modernization Act of 2003:
Dual Eligibles and Impact
on the States








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BACKGROUND AND PURPOSE

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

• Provide a concise summary of the key provisions affecting those dually eligible and the States.

• Provide details of the demographic and Medicaid expenditure characteristics of the dually
eligible, using data from ten states.

THE MEDICARE MODERNIZATION ACT OF 2003

The MMA
1
has been described as the most significant expansion of the Medicare program since the
latter was originally enacted in 1965. It affects all aspects of Medicare and related programs. MMA
enacted:

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

• A new Medicare Prescription Drug Discount Card Program as a transition to the Prescription
Drug Program, available from mid-2004 through December 2005.

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

• Revisions to the Medicare provisions for Health Maintenance Organizations (HMOs), now
called the Medicare Advantage (MA) program [Medicare Part C].

• New payment provisions for drugs furnished by physicians [under Medicare
Part B].

• Dozens of other amendments affecting the existing Medicare program, including:
o Enhancements of services furnished in rural areas.
o Coverage of additional preventive screening tests (cardiovascular screening blood
tests; diabetes screening tests; an initial preventive screening examination; payment
improvements for mammography tests).
o Additional demonstration projects and studies, including a demonstration project for
the coverage of certain prescription drugs and biologicals.
o Authority to replace Medicare fiscal intermediaries and carriers with regular
government contractors.

1
The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. Law No. 108-173
(December 8, 2003).
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o Detailed procedures for appealing Medicare coverage provisions and other
administrative decisions.
o Establishment of a unified center within CMS for the coordinated administration of
the Medicare HMO, drug, and beneficiary marketing and outreach programs.

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

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

• Establishment of Health Savings Accounts and other tax amendments.

PROVISIONS OF MMA AFFECTING DUAL ELIGIBLES AND THE STATES
The Prescription Drug Program

A separate Medicare program. The prescription drug program will be a new, separate part of the
Medicare program (Part D). Enrolling in the program, and paying the required premiums, will be a
voluntary choice for most beneficiaries. However, a Medicare beneficiary must first be entitled to
Medicare Part A or enrolled in Medicare Part B in order to be eligible to enroll in a Part D Prescription
Drug Plan (PDP). A full-benefit dual eligible individual who fails to enroll in a drug plan may be
enrolled by CMS into a drug plan whose monthly premium does not exceed the amount of the
premium subsidy. If there is more than one such plan available, CMS will enroll the individual on a
random basis among all plans in the region. However, the individual will remain free to decline or
change this enrollment.

A covered Part D drug is defined as a drug that may be dispensed only with a prescription and that
meets the same tests for safety and efficacy under the Federal Food, Drug, and Cosmetic Act as apply
under the Medicaid drug rebate program. Also covered are approved biologicals, insulin and medical
supplies associated with insulin injections, and approved vaccines. However, drugs excluded from the
Medicaid drug rebate program are also excluded from Medicare Part D, except for smoking cessation
agents, which can be covered.

Enrolling in a Drug Plan. A beneficiary currently in the traditional Medicare fee-for-service program
will be able to enroll in a PDP. A beneficiary enrolled in a Medicare HMO, called a Medicare
Advantage (MA) Plan, will be able to enroll only in that Plan’s drug benefits program if it qualifies
under the new law (“an MA-PD Plan”); such a beneficiary will not be allowed to enroll in a fee-for-
service drug Plan unless the MA-Plan lacks qualified drug coverage.

CMS must ensure that there are at least two Drug Plans available in each area, offered by different
entities, and at least one of the Plans must be a PDP. The other may be an MA-PD Plan.
Premium and Cost-Sharing Subsidies for Low-Income Beneficiaries

The new law defines a subsidy eligible individual as an individual eligible for Medicare Part D drug
benefits who is enrolled in a PDP or an MA-PD Plan; has income below 150% of the Federal poverty
line; and whose resources for 2006 do not exceed three times the maximum amount of resources under
the SSI program (which is $2,000 in countable resources for an individual or $3,000 for a married
couple). Thus, the Part D resources limit would be $6,000 for an individual or $9,000 for a married
couple. These limits will be increased each year in multiples of $10 by the percentage increase in the
Consumer Price Index (“CPI”). For individuals with income below 135% of the Federal poverty level,
National Pharmaceutical Council Pharmaceutical Benefits 2003
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the resources limit for 2006 is $10,000 for an individual, or $20,000 for a married couple, increased
annually in multiples of $10 by the CPI.

The new law defines a full-benefit dual eligible individual as a beneficiary who has qualified for
prescription drug benefits under a Medicare PDP, and who has been determined by the State Medicaid
program to be eligible for any category of full Medicaid benefits. This includes the “medically
needy,” once they have “spent down” their medical expenses to meet the Medicaid income and
resource levels.

When a dually eligible beneficiary has access to drug coverage under both a PDP under Medicare Part
C or D, and under the State’s Medicaid program, Medicare will be the primary payer and no Medicaid
benefits will be available for the drugs themselves or for any cost sharing for them, such as deductibles
and co-payments. However, a State Medicaid Plan may choose to continue to provide Medicaid
coverage in case of a drug that is not covered under a PDP and is covered by the Medicaid Plan.

CMS will notify a PDP of the exact status of each subsidy eligible individual enrolled in the Plan. The
Plan will reduce the beneficiary’s premiums, deductibles, and co-payments appropriately, and CMS
will periodically reimburse the Plan for such reductions.

Individuals with income below 135% of the Federal poverty line will be eligible for a subsidy of
100% of the premium for basic drug coverage. They will be subject to a drug deductible of zero.
Benefits will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”),
subject to reduced cost sharing, but no co-insurance will be due for full benefit dual eligibles who are
institutionalized. The reduced cost sharing for individuals who are not institutionalized will be $2 for
a generic drug or a multiple source drug and $5 for any other drug. However, individuals with income
not exceeding 100% of the Federal poverty line who are not institutionalized will be subject to a
reduced co-payment of $1 for a generic drug or a preferred multiple source drug, and $3 for any other
drug, increased annually in multiples of 5 cents and 10 cents, respectively, by the percentage increase
in annual aggregate Part D expenditures. There will be no cost sharing for the cost of drugs that
exceeds the out-of-pocket limit ($3600).

Other individuals with income below 150% of the federal poverty line will be entitled to a reduced
deductible of $50 for 2006, increased annually in multiples of $1 by the percentage increase in
aggregate Part D expenditures. They will also be entitled to a premium subsidy based on a sliding
scale ranging from 100% premium subsidy for individuals with income at or below 135% of the
Federal poverty line, to a premium subsidy of 0 for individuals at or above 150% of the Federal
poverty level. These individuals will also be entitled to a reduced annual deductible of $50. Benefits
will be payable for drug costs incurred above the initial coverage limit (the “doughnut hole”), subject
to reduced co-payment of 15% (instead of 25%).
Phased Down State Contribution

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

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

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

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

This product is increased each year (beginning with 2004 up to and including the year involved) by the
“growth factor.”

The “base year State Medicaid per capita expenditures” for covered Part D drugs for full-benefit
dual eligible individuals for a State is the weighted average of:

• the gross per capita Medicaid expenditures for prescription drugs for 2003; and
• the estimated actuarial value of prescription drug benefits under a capitated managed care plan
per full-benefit dual eligible individual for 2003.

The “growth factor” for 2004, 2005, and 2006 is the average annual percent change from the previous
year of the per capita amount of prescription drug expenditures as determined based on the most recent
National Health Expenditures for the years involved. For subsequent years, the growth factor is the
percentage change in aggregate annual expenditures for Part D drugs.

The “phase in factor” for a month is 90% in 2006; 88 1/3% in 2007; 86 2/3% in 2008; 85% in 2009;
83 1/3% in 2010; 81 2/3% in 2011; 80% for 2012; 78 1/3% for 2013; 76 2/3% for 2014; and 75%
thereafter.
MMA Medicaid Amendments Requiring State Medicaid Program Actions

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

CHARACTERISTICS OF DUALLY ELIGIBLE BENEFICARIES

The following analysis is based on detailed Medicaid Management Information System (MMIS) data
from ten States, for Federal Fiscal Year 2000. Medicaid Statistical Information System (MSIS) data
consists of four claims files and an eligibility file. The claims files are inpatient, long-term care,
prescription drug, and the “other” file. These files contain all claims paid during each fiscal quarter.
A copy of the data dictionary and a detailed overview of the MSIS files can be found at
http://cms.hhs.gov/medicaid/datasources.asp.

The data used in this analysis were obtained under strict confidentiality agreements with the States,
which prohibits their identification. The ten States are both programmatically and geographically
diverse, but comparisons of the ten States to all States using currently available data confirmed that the
ten States are reasonably representative of all States for FFY 2000.
Analytic File Development

Developing the analytical files involved several steps. To begin, we created a research file from the
MSIS data files that would permit us to differentiate dual and non-dual Medicaid eligibles. Next, all
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claims for these beneficiaries were extracted and placed in a temporary file. A list of recipient
identification numbers, which are unique to each individual, was compiled and unduplicated, creating
a single file of all recipients. The final step was to extract all claims for this unduplicated list of
recipients from the four claims files and the eligibility file and created a single record for each
individual. This resulted in a record that contained all Medicaid expenditures for those beneficiaries.
The analysis examines the demographic characteristics and expenditures patterns for dual eligibles and
then contrasts the dual eligibles with those not dually eligible.

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

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

Table 1. Population by Gender and Eligibility Status*


All
Recipients
% of All
Recipients
Dual
Eligible
Population
% Dual
Eligibles
Not Dual
Eligibles
% Not
Dual
Eligibles
Total Medicaid
Population 6,647,300 100% 1,002,400 15% 5,644,900 85%

Female 3,890,401 59% 657,562 66% 3,232,839 57%
Male 2,756,899 41% 344,838 34% 2,412,061 43%

*A small number of claims were missing information on gender and have been excluded from Table 1. Therefore, the
column totals for number of beneficiaries may differ slightly with those in other tables.
As shown in Table 1, the dual eligible population is 66 percent female and 34 percent male. By
comparison, the non-dual eligible population is 57 percent female and 43 percent male. In terms of
gender. the total Medicaid population is 59 percent female and 41 percent male, very similar to the
non-dual eligible population. However, even though dual eligibles constitute only 15 percent of the
total Medicaid population, they account for a disproportionate share (42 percent) of Medicaid program
expenditures (Table 2).


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Table 2. Medicaid Expenditures by Gender and Eligibility Status
Total Paid
% of
Total Paid
Dual Eligible
Paid
% Dual
Eligibles
Paid
Not Dual
Eligibles Paid
% Not
Dual
Eligibles
Paid
Total Medicaid Paid
$21,942,055,818
100% $9,215,082,242 42% $12,726,973,576 58%

Female $13,338,032,842 59% $6,186,874,474 67% $7,151,158,368 56%
Male $8,604,022,976 41% $3,028,207,768 33% $5,575,815,208 44%

Further analysis of the data in Table 2 indicates that the male/female breakouts for expenditures are
virtually identical to the demographic splits (Table 1). Within each of the eligibility categories,
females account for the greatest proportions of Medicaid payments.
Table 3. Payments Per Capita by Gender
Average Per Capita by Gender
Gender
Dual Eligible Medicaid
Paid
Dual Eligible Per Capita
Not Dual Eligible
Medicaid Paid
Not Dual
Eligible Per
Capita
Female $6,186,874,474
$9,409
$7,151,158,368
$2,212
Male $3,028,207,768
$8,782
$5,575,815,208
$2,312
Total $9,215,082,242
$9,193
$12,726,973,576
$2,255

Average Medicaid payments per capita by gender are presented in Table 3. For the dual eligible
population, average expenditures per capita expenditure are 400 percent higher than for non-dual
eligibles. Within each group, average per capita spending is fairly similar for males and females.
Table 4. Population Percentages by Age and Eligibility Status

All
Recipients
% of All
Recipients
Dual Eligible
Population
% Dual
Eligibles
Not Dual
Eligibles
% Not Dual
Eligibles
Total Medicaid Population 6,558,236 100% 1,002,432 15% 5,555,804 85%

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

Table 4 shows the population distribution by age and eligibility status. For dual eligibles, 59 percent
of the population is 65 years of age or older. More importantly, 41 percent of the dual eligibles are
under 65 years of age. These are overwhelmingly disabled individuals. More interestingly, 17 percent
(120,881 of 708,494 beneficiaries) of the Medicaid population over 65 is not dually eligible. Many
individuals interested in the MMA provisions have incorrectly assumed that all Medicaid recipients
over 65 are dually eligible. Therefore, even if some of these individuals are incorrectly classified by
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Medicaid programs and/or may become eligible for Part D prescription drug coverage, States will
have aged beneficiaries remaining on their rolls. This occurs because many states have expanded their
Medicaid eligibility criteria and/or have elected to cover optional groups whose incomes and assets
exceed the criteria for dual eligibles.
Table 5. Medicaid Expenditures Percentages by Age and Eligibility Status

Total
Medicaid Paid
% of
Total Paid
Dual Eligible
Medicaid Paid
% Dual
Eligibles Paid
Not Dual
Eligibles
Medicaid Paid
% Not Dual
Eligibles
Paid
Total Medicaid Paid 21,353,868,898 100% 9,215,343,151 43% 12,138,525,747 57%

Age
Group 0 to 4 2,116,168,842 10% 6,096,559 0% 2,110,072,283 17%
5 to 12 1,669,434,562 8% 20,577,970 0% 1,648,856,592 14%
13 to 24 2,809,026,255 13% 121,273,602 1% 2,687,752,653 22%
25 to 44 4,149,276,161 19% 1,317,227,181 14% 2,832,048,980 23%
45 to 64 4,087,134,021 19% 1,885,855,392 20% 2,201,278,629 18%
Subtotal 64 14,831,039,841 69% 3,351,030,704 36% 11,480,009,137 95%
65 plus 6,522,829,057 31% 5,864,312,447 64% 658,516,610 5%
Dual eligibles account for 43 percent of all Medicaid expenditures (Table 5). For dual eligibles, nearly
two-thirds, 64 percent, of Medicaid expenditures are for the elderly and 36 percent are for the
population under 65 years of age. By contrast, among non-dual eligibles, only 5 percent of
expenditures are for beneficiaries 65 years of age and older and 95 percent are for non-elderly
recipients. Of the approximately $6.5 billion in Medicaid program spending for the elderly, $659
million (10.1 percent) was spent on the population 65 and older who are not dually eligible.
Dual Eligible Expenditures by Type of Service
Tables 6 and 7 summarize total patient counts and Medicaid program payments by type of service for
dual and non-dual eligibles. Please note that, because an eligible beneficiary can receive more than
one service, patient counts may be duplicated. However in calculating the percentages, we used the
unduplicated totals (see Table 1).











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Table 6. Summary of Medicaid Data by Service Type and Eligible Status
Patient Count
Service Type Dual Eligible
% Dual
Eligible
Not Dual
Eligible
% Not Dual
Eligible
Long Term
(NF/ICF/MR) 206,678 21% 54,567 1%
Prescription Drug 822,235 82% 3,213,848 57%
Inpatient 223,978 22% 690,048 12%
Other 652,018 65% 2,318,574 41%
Capitated Payments
HMO/HIO 74,397 7% 1,808,451 32%
Physicians 781,145 78% 3,212,998 57%
Outpatient Hospital 551,116 55% 2,062,036 37%
Clinic 267,253 27% 1,211,036 21%
Personal Care Svcs 68,607 7% 21,769 0%
Dental 125,120 12% 1,278,122 23%
Home Health 42,798 4% 49,310 1%
Targeted Case
Mgmt 27,651 3% 184,342 3%
Emergency Room 175,069 17% 1,194,406 21%
Lab and X-Ray 260,823 26% 1,325,548 23%
Capitated Payments
for PCCM 117,297 12% 1,971,936 35%
Private Duty
Nursing 1072 0% 2,472 0%
Members w/o
Claims 28,566 3% 491,756 9%
Total 1,002,400 100% 5,644,900 100%

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


2
Please note that persons in capitation arrangements may have used other services, which are reported separately
from their membership in capitation plans. The MMIS reporting system we are using requires that States collect
and report managed care “encounters.” These records appear in the database but do not have the expenditure
fields completed since, by definition, managed care organizations do not charge separately for each service.
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Table 7. Summary of Medicaid Expenditures by Service Type and Eligibility Status
Medicaid Paid
Service Type Dual Eligible
% Dual
Eligible
Not Dual
Eligible
% Not Dual
Eligible
Long Term
(NF/ICF/MR) $4,375,191,574 47% $1,170,665,993 10%
Prescription Drug $1,914,514,871 21% $1,518,678,388 13%
Inpatient $335,566,759 4% $2,449,561,265 20%
Other $1,035,967,616 11% $1,554,693,387 13%
Capitated Payments
HMO/HIO $193,803,464 2% $2,014,430,322 17%
Physicians $255,046,010 3% $1,013,919,106 8%
Outpatient Hospital $330,030,811 4% $908,154,113 7%
Clinic $174,616,069 2% $517,907,551 4%
Personal Care Svcs $334,877,197 4% $142,456,278 1%
Dental $29,430,515 0% $279,049,989 2%
Home Health $153,738,248 2% $100,913,904 1%
Targeted Case
Mgmt $33,920,739 0% $150,925,649 1%
Emergency Room $19,775,428 0% $127,124,720 1%
Lab and X-Ray $20,006,385 0% $89,964,175 1%
Capitated Payments
for PCCM $7,045,120 0% $68,025,641 1%
Private Duty
Nursing $1,812,345 0% $32,055,266 0%
Members w/o
Claims $0 0% $0 0%
Total $9,215,343,151 100% $12,138,525,747 100%

Table 7 illustrates the distribution of expenditures for both dual and non-dual eligibles. For the dual
eligible population, long-term care (nursing homes and ICFs/MR) and prescription drugs are the two
largest expenditures categories. Long-term care, for example, accounts for 47 percent of the monies
spent on dual eligibles. Prescription drugs comprise an additional 21 percent of the expenditures. By
comparison long-term care is only 10 percent and prescription drugs 13 percent of total expenditures
for the non-dual eligible population. These variations reflect the demographic characteristics of the
dual eligible population and the fact that Medicare is paying for certain sources (i.e., inpatient care) for
dual eligible beneficiaries.
Inpatient care ($2.4 billion) is the most expensive service type for non-dual eligibles. However, while
it accounts for 20 percent of expenditures, only 12 percent of the non-dual eligible population had
claims for inpatient care (Table 6). Conversely, for dual eligibles, 22 percent of the population had
claims for inpatient care but, in terms of expenditures, inpatient care comprised only 4 percent of their
total Medicaid program payments.

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Table 8. Summary of Medicaid Data by Drug Type and Dual Eligible Status
Patient Count Medicaid Paid
AHFS 2 digit
Dual
Eligible
%
Dual
Eligible
Not Dual
Eligible
% Not
Dual
Eligible Dual Eligible
%
Dual
Eligible
Not Dual
Eligible
% Not
Dual
Eligible
28 - Central
Nervous System
Drugs 694,111 69% 1,501,358 27% $698,194,103 36% $587,625,205 39%
24 -
Cardiovascular
Drugs 500,805 50% 295,794 5% $289,693,604 15% $109,044,722 7%
56 -
Gastrointestinal
Drugs 415,094 41% 388,738 7% $231,734,451 12% $119,202,951 8%
08 - Anti-
Infective Agents 544,750 54% 2,094,058 37% $122,658,237 6% $207,645,271 14%
68 - Hormones
And Synthetic
Substitutes 407,361 41% 717,795 13% $152,717,579 8% $121,689,014 8%
12 - Autonomic
Drugs 297,568 30% 701,771 12% $81,162,590 4% $59,301,825 4%
92 -
Unclassified
Therapeutic
Agents 120,405 12% 154,685 3% $78,521,356 4% $46,003,044 3%
20 - Blood
Formation And
Coagulation 139,717 14% 172,901 3% $40,782,856 2% $64,052,725 4%
40 - Electrolytic,
Caloric Balance 381,513 38% 229,361 4% $58,678,234 3% $21,098,611 1%
04 -
Antihistamine
Drugs 235,506 23% 908,566 16% $27,477,911 1% $48,917,940 3%
Other 524,159 52% 1,991,217 35% $132,893,950 7% $134,097,080 9%
No Rx Claims 180,197 18% 2,341,956 41% $0 0% $0 0%
Total 1,002,400 100% 5,644,900 100% $1,914,514,871 100% $1,518,678,388 100%

Table 8 summarizes drug utilization and cost data for the dual eligible and non-dual eligible
populations. Analysis of these data yields some interesting results. First, across all of the categories, a
significantly higher proportion of dual eligible beneficiaries compared to non-dual eligibles had drug
claims and a smaller proportion of dual eligible beneficiaries had no drug claims. Furthermore,
although dual eligibles comprise only 15 percent of the beneficiaries in the study, they account for
more than half (56 percent) of total drug expenditures.
For almost every drug category, expenditures for dual eligibles exceed those for non-dual eligible
beneficiaries, even where the actual number of dual eligible recipients is significantly smaller than the
number of non-dual eligible recipients. For example, expenditures for central nervous system (CNS)
drug are the highest expenditure category for both the dual and non-dual eligible population groups.
However, a much higher proportion of dual eligible beneficiaries had claims for CNS drugs than did
non-dual eligibles. Furthermore, despite the fact that more than twice as many non-dual eligible
beneficiaries had claims for CNS drugs, total expenditures for CNS drugs were more than $110
million higher for the dual eligible group.



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Conclusion

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



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Section 2:
The Medicaid Program
















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MEDICAID PROGRAM OVERVIEW
Medicaid (Title XIX of the Federal Social Security Act) is a Federal-State funded program of national
health assistance that provides health care coverage to certain individuals and families with low-
incomes and resources. The 50 States, the District of Columbia, and Puerto Rico, Guam, Virgin
Islands, American Samoa, and Northern Mariana Islands each operate medical assistance programs
according to State or territorial rules and criteria that vary within a broad framework of Federal
guidelines.
MEDICAID ELIGIBILITY
Medicaid Eligibility: Medicaid is a “means tested program for low-income individuals.” To qualify,
a Medicaid recipient must not have “income” or “resources” that exceed the applicable limits
prescribed in the law and regulations.
Every State, in order to receive Federal funding under Title XIX, must provide Medicaid benefits to
certain “categorically needy” persons. These are the “mandatory” categorically needy. In addition,
the State has the option of providing Medicaid benefits to certain additional categories of persons.
These are the “optional” categorically needy. An additional category of Medicaid recipients that a
State may choose to include in its program is the “medically needy.”
Mandatory Categorically Needy: There are numerous and detailed categories under which the
“categorically needy” may qualify for Medicaid benefits. The principal categories of the mandatory
categorically needy are:
• Low-income families with children;
• Recipients of Supplemental Security Income (SSI) for the Aged, Blind, and Disabled
(this includes disabled children);
• Individuals qualified for adoption assistance agreements or foster care maintenance
payments under Title IV-E of the Social Security Act;
• Qualified pregnant women;
• Newborn children of Medicaid-eligible women;
• Various categories of low-income children; and
• Certain low-income Medicare beneficiaries.
Optional Categorically Needy: These are groups of individuals who meet the characteristics of the
mandatory groups, but the eligibility criteria are somewhat more liberally defined. For example, in
determining their incomes and resources, they are allowed to exclude certain kinds of income. The
“optional categorically needy” include individuals who are aged, blind, disabled, caretaker relatives,
and pregnant women who meet the SSI income and resources requirements but are not receiving SSI
cash payments.
Medically Needy: The “medically needy” are those individuals who meet the definitional
requirements described above, except that their income or resources exceed the limitations applicable
to the categorically needy. These individuals can “spend down” to qualify. That is, they can deduct
their medical bills from their income and resources until they meet the applicable income and
resources requirements. Their Medicaid benefits can then begin.
Special Categories: The Medicaid statute also authorizes limited Medicaid benefits to special
categories of individuals. In general, these are individuals whose income and resources would
otherwise be too high to qualify for full Medicaid benefits under the regular provisions.
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For example, a “Qualified Medicare Beneficiary” (QMB) is an individual who qualifies for Medicare
Part A, whose income does not exceed 100 percent of the Federal poverty level, and whose resources
do not exceed twice the SSI resource-eligibility standard. Medicaid coverage of QMBs is limited to
payment of their Medicare cost-sharing charges, such as the Medicare premiums, coinsurance, and
co-payment amounts.
Non-Eligibles: A State can include in its Medicaid program individuals who do not meet the statutory
eligibility criteria. However, the State must pay the full costs for these individuals. There are no
Federal matching payments.
MEDICAID SERVICES
Title XIX lists the many types of medical care that a State may select for inclusion into its Medicaid
State Plan, thus qualifying for Federal matching payments. However, the law requires that certain
basic benefits must be available to all “categorically needy” recipients. These services include:
• Inpatient and outpatient hospital services;
• Physician services;
• Medical and surgical dental services;
• Laboratory and X-ray services;
• Nursing facility services (for persons 21 years of age or older);
• Early and periodic screening, diagnostic, and treatment (EPSDT) services for children
under age 21;
• Family planning services and supplies;
• Home health services for persons eligible for nursing facility services;
• Rural health clinic services and any other ambulatory services offered by a rural health
clinic that are otherwise covered under the State Plan;
• Nurse-midwife services (to the extent authorized under State law);
• Pediatric and family nurse practitioners services; and
• Federally-qualified health center services and any other ambulatory services offered by a
Federally-qualified health center that are otherwise covered under the State Plan.
If a State chooses to include the “medically needy” population, the State Plan must provide, as a
minimum, the following services:
• Prenatal care and delivery services for pregnant women;
• Ambulatory services to individuals under age 18 and individuals entitled to institutional
services;
• Home health services to individuals entitled to nursing facility services; and
• If the State Plan includes services either in institutions for mental diseases or in
intermediate care facilities for the mentally retarded (ICFs/MR), it must offer medically
needy groups certain specified services provided to the categorically needy.
States may also receive Federal funding if they elect to provide other optional services. The most
commonly covered optional services under the Medicaid program include:
• Clinic services;
• Services of ICFs/MR;
• Nursing facility services (children under 21 years old);
• Prescribed drugs;
• Optometrist services and eyeglasses;
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• TB-related services for TB infected persons;
• Prosthetic devices; and
• Dental services.
States may provide home and community-based care waiver services to certain individuals who are
eligible for Medicaid. The services to be provided to these persons may include case management,
personal care services, respite care services, adult day health services, homemaker/home health aide,
habilitation, and other services requested by the State and approved by CMS.
CHARACTERISTICS OF BENEFITS PROVIDED
Inpatient Hospital Services
Inpatient hospital services are those ordinarily furnished in a hospital for the care and treatment of
inpatients. The facility is one maintained primarily for the care and treatment of patients with
disorders other than mental diseases. There are several general Federal limitations on inpatient
hospital services that apply to all States with Medicaid programs (42 CFR 440.10):
• The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting;
• The facility must meet the requirements for participation in Medicare as a hospital;
• The care and treatment of inpatients must be under the direction of a physician or dentist;
and
• The facility must have in effect an approved utilization review plan, applicable to all
Medicaid patients, unless a waiver has been granted by the Secretary of Health and
Human Services, because the State’s own utilization review procedures are adequate.
• A peer review organization (PRO) may satisfy these requirements.
In addition to the Federal limitations, each State may impose further limitations on inpatient hospital
services.
Outpatient Hospital Services
Outpatient hospital services refer to preventive, diagnostic, therapeutic, rehabilitative, or palliative
services provided to an outpatient. Three Federal limitations are imposed on these services, though
States are free to specify other limits on outpatient hospital services and many have chosen to do so.
• The services must be provided under the direction of a physician or dentist;
• The facility must be licensed or formally approved as a hospital by an officially
designated authority for State standard setting; and
• The facility must meet the requirements for participation in Medicare as a hospital.
Rural Health Clinic Services
Rural health clinic (RHC) services are a mandatory service for the categorically needy. Each RHC is
required to have a nurse practitioner (NP) or physician’s assistant (PA) on its staff. Therefore, a
clinic can be certified to participate in the Medicaid program only if State law permits the delivery of
primary care by an NP or PA.
Services in RHCs must be provided by a physician or by a PA, NP, nurse-midwife, or other
specialized nurse practitioner. Services and supplies are furnished as “incident to” the professional
services of such a practitioner are also covered. Part-time or intermittent visiting nurse services and
related medical supplies are provided if the RHC is located in an area which DHHS has determined
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has a shortage of home health agencies, the services are furnished by nurses employed by the RHC,
and the services are furnished to a homebound recipient under a written plan of treatment.
Other Laboratory and X-Ray Services
Other laboratory and X-ray services are professional and technical laboratory and radiological
services. These services must be:
• Ordered and provided by or under the direction of a physician or other licensed
practitioner of the healing arts within the scope of his or her practice, as defined by State
law, or ordered and billed by a physician but provided by an independent laboratory;
• Provided in an office or similar facility other than a hospital inpatient or outpatient
department or clinic; and
• Provided by a laboratory that meets the requirements for participation in Medicare.
• In addition, the States can place limitations on “other laboratory and X-ray services.”
Nursing Facility Services
Nursing facility (NF) services are provided to individuals age 21 or older. They do not include
services provided in institutions for mental diseases. These services must be needed on a daily basis
and must be provided in an inpatient facility. Federal regulations require that the services be:
• Provided by a facility or a distinct part of a facility that is certified to meet the
requirements for participation in the Medicaid program as a NF; and
• Ordered by and furnished under the direction of a physician.
Early and Periodic Screening, Diagnostic and Treatment Services
Early and periodic screening, diagnostic and treatment (EPSDT) refers to screening and diagnostic
services to determine physical or mental defects in recipients under age 21, as well as health care,
treatment and other measures to correct or ameliorate any defects and chronic conditions discovered
(42 CFR 440.40(b)). Certain basic screening and treatment services must be provided by each State
as a minimum (42 CFR 441.56). These services include:
Screening:
• Comprehensive health and developmental history screening;
• Comprehensive unclothed physical examination;
• Appropriate vision testing;
• Appropriate hearing testing;
• Appropriate laboratory tests;
• Dental screening services furnished by direct referral to a dentist for children beginning
at 3 years of age.
Diagnosis and Treatment:
In addition to any diagnostic and treatment services included in the State Medicaid Plan, the State
must provide to eligible EPSDT recipients the following services, the need for which is indicated by
screening, even if the services are not included in the Plan:
• Diagnosis of and treatment for defects in vision and hearing, including eyeglasses and
hearing aids;
• Dental care, at as early an age as necessary, needed for relief of pain and infections,
restoration of teeth and maintenance of dental health; and
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• Appropriate immunizations. (If it is determined at the time of screening that
immunization is needed and appropriate to administer at the time of screening, then
immunization treatment must be provided at that time.)
The State Medicaid agency may provide for any other medical or remedial care specified as a
Medicaid service even if the agency does not otherwise provide for these services to other recipients
or provides for them in a lesser amount, duration, or scope. This is an exception to the general rule
that the amount, duration, and scope of benefits must be the same for all categorically eligible
recipients, and reflects the importance attached to EPSDT services.
Family Planning Services
Federal Requirements: States are required to provide family planning services and supplies to
individuals of childbearing age (including minors who can be considered to be sexually active) who
are eligible under the State Medicaid Plan and who desire such services and supplies. Specifically,
family planning services must be made available to categorically needy Medicaid recipients, and the
State has the option of furnishing these services to the medically needy.
Defined: The term “family planning services” is not defined in the law or in regulations. However,
the Senate Report accompanying the law stresses Congress’ intent of placing emphasis on the
provision of services to “aid those who voluntarily choose not to risk an initial pregnancy,” as well as
those families with children who desire to control family size. In keeping with Congressional intent,
the State may choose to include in its definition of Medicaid family planning services only those
services which either prevent or delay pregnancy, or the State may more broadly define the term to
include services for the treatment of infertility. However, the Medicaid definition must be consistent
with overall State policy and regulation regarding the provision of family planning services.
The State is free to determine the specific services and supplies that will be covered as Medicaid
family planning services as long as those services are sufficient in amount, duration, and scope to
reasonably achieve their purpose. It must also establish procedures for identifying individuals who
are sexually active and eligible for family planning services.
Federal Matching Payments: Federal Financial Participation (FFP) is available at the “enhanced”
rate of 90 percent for the cost of family planning services. These include counseling services and
patient education, examination and treatment by medical professionals in accordance with applicable
State requirements, laboratory examinations and tests, medically approved methods, procedures,
pharmaceutical supplies and devices to prevent conception, and infertility services, including
sterilization reversals.
FFP at the enhanced rate of 90 percent is also available for the cost of a sterilization if a properly
completed sterilization informed consent form, in accordance with the requirements of 42 CFR Part
441, Subpart F, is submitted to the State prior to payment of the claim.
FFP at the 90 percent rate is not available for the cost of a hysterectomy or for the costs related to
other procedures performed for medical reasons, such as removal of an intrauterine device due to
infection. Only items and procedures clearly provided or performed for family planning purposes
may be matched at the 90 percent rate. Transportation to a family planning service is not eligible for
the 90 percent match. Transportation must be claimed as either an administrative cost or a State Plan
service, in accordance with the State’s approved Medicaid State Plan.
Abortions: Abortions may not be claimed as a family planning service. For more than 20 years,
Congressional restrictions have been placed on appropriated funds for DHHS programs that fund
abortions. FFP is available only in expenditures for an abortion when a physician has found, and so
certified in writing to the Medicaid agency, that on the basis of his/her professional judgment, the life
of the mother would be endangered if the fetus were carried to term. The certification must contain
the name and address of the patient. Congress has prohibited the use of Federal funds for victims of
rape or incest.
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Voluntary Sterilizations: FFP is available in expenditures for the sterilization of an individual only if
she is at least age 21, has voluntarily given informed consent in accordance with Medicaid
regulations, and is not a mentally incompetent individual.
Physicians’ Services
Physicians’ services are covered, whether provided in the office, the patient’s home, a hospital, a
nursing facility, or elsewhere. Such services must be within the physicians’ scope of practice of
medicine or osteopathy as defined by State law, and by or under the personal supervision of an
individual licensed under State law to practice medicine or osteopathy.
Prescribed Drugs
Prescribed drugs are simple or compound substances or mixtures of substances prescribed for the
cure, mitigation, or prevention of disease, or for health maintenance, which are prescribed by a
physician or other licensed practitioner of the healing arts within the scope of their professional
practice, as defined and limited by Federal and State law (42 CFR 440.120). The drugs must be
dispensed by licensed authorized practitioners on a written prescription that is recorded and
maintained in the pharmacist’s or the practitioner’s records.
Home Health Services
Home health services are provided to a recipient at his or her place of residence. This does not
include a hospital, nursing facility, or (ordinarily) an ICF/MR. Services provided must be on
physicians’ orders as part of a written plan of care that is reviewed by the physician every 60 days.
Home health services include three mandatory services (part-time nursing, home health aide, medical
supplies and equipment) and four optional services (physical therapy, occupational therapy, speech
pathology, and audiology services) (42 CFR 440.70). These services are defined as follows:
• Part-Time Nursing: Nursing that is provided on a part-time or intermittent basis by a
home health agency. If there is no home health agency in the area, services may be
provided by a registered nurse who is currently licensed to practice in the State, receives
written orders from the patient’s physician, documents the care and services provided,
and has had orientation to acceptable clinical and administrative record keeping from a
health department nurse.
• Home Health Aide: Home health aide services provided by a home health agency.
• Medical Supplies and Equipment: Medical supplies, equipment, and appliances that are
suitable for use in the home.
• Physical Therapy (PT), Occupational Therapy (OT), Speech Pathology and Audiology
Services: PT, OT, speech and hearing services provided by a home health agency or a
facility licensed by the State to provide medical rehabilitation.
• Home health services are provided to categorically needy recipients age 21 and over and
to those under 21 only if the State Plan provides SNF services for them.
Personal Support Services
Personal support services consist of a variety of services including personal care, targeted case
management, home and community-based care for functionally disabled elderly, rehabilitative
services, hospice services, and nurse-midwife, nurse practitioner, and private duty nursing. Details of
some of these services are provided below:
1. Personal Care Services: Services provided to an individual who is not an inpatient or
resident of a hospital, nursing facility, intermediate care facility for the mentally
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retarded, or institution for mental disease. Services are authorized by a physician in
accordance with a treatment plan, are provided by a qualified individual who is not a
member of the recipient’s family, and are furnished in a home or (at the State’s
option) in another location.
2. Rehabilitative Services: These services include any medical or remedial service
recommended by a physician or other licensed practitioner of the healing arts within
the scope of State law. Services are for the maximum reduction of physical or mental
disability and restoration of a recipient to their best possible functional level.
3. Hospice Services: Hospice services can be received in a hospice facility or elsewhere.
Services are provided to terminally ill individuals by an authorized hospice program
under a written plan established and reviewed by the attending physician, medical
director or physician designee of the program, and an interdisciplinary group.
Nurse-Midwife Services
Nurse-midwife services are those concerned with management of the care of mothers and newborns
throughout the maternity cycle. The Omnibus Budget Reconciliation Act of 1980 required that
payment be made providing for nurse-midwife services to categorically needy recipients (42 CFR
440.165). These provisions require States to provide coverage for nurse-midwife services to the
extent that the nurse-midwife is authorized to practice under State law or regulation. The statute also
requires that States offer direct reimbursement to nurse-midwives as one of the payment options.
Nurse-midwives must be registered nurses who are either certified by an organization recognized by
the Secretary of DHHS or who have completed a program of study and clinical experience that has
been approved by the Secretary.
Pediatric Nurse Practitioner and Family Nurse Practitioner Services
The Omnibus Budget Reconciliation Act of 1989 provides for the availability and accessibility of
services furnished by a certified pediatric nurse practitioner (CPNP) or a certified family nurse
practitioner (CFNP) to Medicaid recipients. These provisions require that services be covered to the
extent that the CPNPs or CFNPs are authorized to practice under State law or regulation, regardless of
whether they are supervised by or associated with a physician or other health care provider. States
are required to offer direct payment to CPNPs and CFNPs as one of their payment options.
CPNP and CFNP certification requirements include a current license to practice as a registered nurse
in the State, meet the applicable state requirements for qualification of pediatric nurse practitioners or
family nurse practitioners, and be currently certified by the American Nurses’ Association as a
pediatric nurse practitioner or a family nurse practitioner.
Federally Qualified Health Center and other Ambulatory Services
Medicaid programs must offer Federally Qualified Health Center (FQHC) services and other
ambulatory services offered by an FQHC under the provisions of the Omnibus Budget Reconciliation
Act of 1989. The definition of FQHC services is the same as that of the services provided by rural
health clinics (RHC). FQHC services include physician services, services provided by physician
assistants, nurse practitioners, clinical psychologists, clinical social workers, and services and
supplies incident to services normally covered if furnished by a physician or if incident to a
physician’s services.
FQHCs are facilities or programs more commonly known as Community Health Centers, Migrant
Health Centers, and Health Care for the Homeless. These centers may qualify as providers of service
under Medicaid, under the following conditions:
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• The facility receives a grant under sections 329, 330, or 340 of the Public Health Service
Act;
• The Health Resources and Services Administration (HRSA) recommends, and the DHHS
Secretary determines, that the facility meets the requirements of the grant; or
• The Secretary determines that a facility may qualify through waivers of the requirements.
Such a waiver cannot exceed two years.
AMOUNT AND DURATION OF SERVICES
Within broad Federal guidelines and certain limitations, States may determine the amount and
duration of services offered under their Medicaid programs. Federal regulations require that the
amount and/or duration of each type of medical and remedial care and services furnished under a
State’s program must be specified in the State Plan, and that these types of care and services must be
sufficient in amount, duration, and scope to “reasonably achieve” their purpose. States are required to
provide Medicaid coverage for comparable amounts, duration, and scope of service to all
“categorically needy” and categorically-related eligible persons.
Each State Plan must include a description of the methods that will be used to assure that the medical
and remedial care and services delivered are of high quality, as well as a description of the standards
established by the State to assure high quality care. The regulations also require that the fee
structures developed must result in participation of a sufficient number of providers so that eligible
persons can receive the medical care and services included in the Plan, at least to the extent that these
are available to the general population. The law further requires that services provided under the Plan
be available throughout the State. Recipients are to have freedom of choice with regard to where they
receive their care, including an option to obtain their care through organizations that provide services
or arrange for their availability on a prepayment basis, such as health maintenance organizations.
MEDICAID PAYMENT FOR SERVICES
The Medicaid program operates on the basis of a division of responsibilities between the Federal
government and the States with the Federal government paying States for a portion of State medical
expenditures and administrative costs. Funding for the program is shared between the two bodies,
with the Federal government matching State health care provider reimbursements at an authorized
rate of between 50% and 72.96%, depending on the State’s per capita income (see the Federal
Medical Assistance Percentage (FMAP) table, page 2-18).
The FMAP is based upon the State’s per capita income; if a State’s per capita income is equal to or
greater than the national average, the Federal share is 50%. If a State’s per capita income is below the
national average, the Federal share is increased, up to a maximum of 76.62%.
The percentages apply to State expenditures for assistance payments and medical services. Federal
statute provides separate Federal matching amounts for administrative costs. Cost sharing for
administrative expenditures vary with the services, i.e., 75% for training, 90% for designing,
developing or installing mechanized claims processing and information retrieval, etc. (Federal
Medicaid Law (Section 1903(a)(2) et seq.)).
In 2000, the Medicaid program enrolled 44.3 million eligible individuals with vendor payments for
medical care services totaling $168.3 billion. The vendor payments reported in the 2000 MSIS
Report do not include Disproportionate Share Hospital (DSH), Medicare premium payments made by
State Medicaid programs, and other Medicaid program expenditures. The CMS-64 Report, which
does include such expenditures, shows total net expenditures for 2000 of $195.2 billion. When
administrative costs are added to total net expenditures, total Medicaid program expenditures in 2000
were $205.7 billion.

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-11
Total Medicaid Eligibles by Maintenance Assistance Status, 2001
1


State
Total
Eligibles
Receiving
Cash
Assistance
Medically
Needy
Poverty
Related Other
1115
Demonstration
MAS
Unknown
National Total 46,910,257 17,555,319 3,661,252 13,529,154 7,779,041 4,384,730 761
Alabama 780,434 282,756 0 373,733 36,442 87,503 0
Alaska 115,996 52,568 0 54,753 8,663 0 12
Arizona 808,386 380,272 0 241,905 156,460 29,749 0
Arkansas 550,668 147,990 21,122 186,090 53,291 142,162 13
California 8,495,030 3,974,456 863,850 413,616 1,299,265 1,943,842 1
Colorado 410,611 211,229 0 152,356 46,911 0 115
Connecticut 446,326 102,886 35,997 76,751 230,671 0 21
Delaware 133,079 89,121 0 11,384 15,909 16,665 0
District of Columbia 152,597 91,862 27,463 25,617 7,655 0 0
Florida 2,462,171 1,085,854 67,479 815,482 355,620 137,722 14
Georgia 1,328,379 536,171 10,277 541,038 240,893 0 0
Hawaii* 202,912 118,221 2,549 50,790 7,605 23,747 0
Idaho 172,348 26,466 0 96,160 49,722 0 0
Illinois 1,798,723 385,404 427,590 866,708 119,021 0 0
Indiana 825,556 319,863 0 313,072 192,621 0 0
Iowa 331,025 148,544 10,091 95,866 76,524 0 0
Kansas 291,837 94,061 20,127 123,446 54,203 0 0
Kentucky 762,871 334,192 39,893 316,906 71,880 0 0
Louisiana 886,518 345,766 9,498 430,313 100,941 0 0
Maine 277,843 81,088 1,360 75,760 55,759 63,876 0
Maryland 704,628 206,159 83,168 365,212 50,088 0 1
Massachusetts 1,125,607 324,129 22,332 422,318 119,755 237,073 0
Michigan 1,430,246 447,720 125,675 476,446 380,326 0 79
Minnesota 609,856 236,283 10,398 9,261 237,221 116,693 0
Mississippi 681,161 293,225 0 359,329 28,591 0 16
Missouri 1,032,047 390,531 0 299,010 148,868 193,638 0
Montana 101,966 42,887 8,790 22,934 27,334 0 21
Nebraska 249,079 59,977 40,691 117,093 31,069 0 249
Nevada 167,247 62,278 0 60,921 44,048 0 0
New Hampshire 108,562 24,877 10,979 48,437 24,269 0 0
New Jersey 923,697 419,211 5,078 330,854 168,554 0 0
New Mexico 423,543 140,380 0 206,321 67,217 9,625 0
New York 3,548,630 1,395,014 1,368,735 328,866 108,099 347,916 0
North Carolina 1,397,486 632,171 44,066 659,687 61,562 0 0
North Dakota 65,425 28,941 16,008 9,203 11,273 0 0
Ohio 1,660,463 479,253 0 329,421 851,618 0 171
Oklahoma 631,996 108,432 7,887 422,073 93,604 0 0
Oregon 594,679 128,859 8,302 168,341 123,016 166,152 9
Pennsylvania 1,647,440 678,978 116,515 526,543 325,404 0 0
Rhode Island 194,113 84,762 4,453 24,881 41,939 38,077 1
South Carolina 871,675 293,556 0 362,039 216,071 0 9
South Dakota 106,154 39,418 0 43,996 22,740 0 0
Tennessee 1,601,406 441,875 108,363 227,155 172,886 651,105 22
Texas 2,729,660 909,653 57,510 1,263,395 493,704 5,398 0
Utah 214,597 47,043 5,830 122,268 39,456 0 0
Vermont 154,991 32,425 12,064 47,404 14,649 48,445 4
Virginia 700,715 149,660 10,067 383,725 157,263 0 0
Washington** 916,838 257,453 13,421 298,026 347,937 0 1
West Virginia 351,489 141,306 4,916 180,978 24,289 0 0
Wisconsin 673,538 231,211 38,708 123,725 154,550 125,342 2
Wyoming 58,013 18,882 0 27,546 11,585 0 0
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.


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

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-12

Total Medicaid Eligibles by Age Group, 2001
1


State Total Eligibles <21 Years 21-64 Years
65 Years and
Older Age Unknown
National Total 46,910,257 25,798,743 15,947,857 5,060,539 103,118
Alabama 780,434 419,575 249,386 111,473 0
Alaska 115,996 78,373 30,761 6,862 0
Arizona 808,386 487,369 271,499 49,518 0
Arkansas 550,668 324,082 162,083 64,502 1
California 8,495,030 4,094,864 3,647,963 752,203 0
Colorado 410,611 243,120 119,729 47,761 1
Connecticut 446,326 240,064 145,949 60,313 0
Delaware 133,079 69,591 53,394 10,094 0
District of Columbia 152,597 83,343 55,159 14,095 0
Florida 2,462,171 1,375,744 765,418 321,008 1
Georgia 1,328,379 815,970 377,044 135,362 3
Hawaii* 202,912 97,259 85,142 20,511 0
Idaho 172,348 118,848 41,602 11,898 0
Illinois 1,798,723 1,111,280 535,863 151,580 0
Indiana 825,556 524,690 222,095 78,771 0
Iowa 331,025 182,275 107,195 41,555 0
Kansas 291,837 180,124 77,305 34,408 0
Kentucky 762,871 436,215 238,295 88,361 0
Louisiana 886,518 566,259 219,039 101,220 0
Maine 277,843 104,883 110,563 62,379 18
Maryland 704,628 429,301 209,135 66,192 0
Massachusetts 1,125,607 500,383 485,350 139,874 0
Michigan 1,430,246 858,526 441,977 129,743 0
Minnesota 609,856 330,451 212,508 66,888 9
Mississippi 681,161 413,084 174,377 93,700 0
Missouri 1,032,047 605,928 330,815 95,302 2
Montana 101,966 57,001 34,020 10,945 0
Nebraska 249,079 161,809 63,820 23,450 0
Nevada 167,247 96,160 52,107 18,980 0
New Hampshire 108,562 66,824 28,834 12,902 2
New Jersey 923,697 497,761 285,365 140,570 1
New Mexico 423,543 286,567 107,030 29,946 0
New York 3,548,630 1,660,024 1,315,242 470,330 103,034
North Carolina 1,397,486 766,160 449,720 181,606 0
North Dakota 65,425 33,884 21,255 10,286 0
Ohio 1,660,463 951,645 561,249 147,569 0
Oklahoma 631,996 426,288 141,887 63,821 0
Oregon 594,679 275,652 273,893 45,134 0
Pennsylvania 1,647,440 882,484 557,684 207,272 0
Rhode Island 194,113 99,308 71,779 23,023 3
South Carolina 871,675 510,230 281,829 79,582 34
South Dakota 106,154 68,539 25,816 11,799 0
Tennessee 1,601,406 740,012 707,585 153,809 0
Texas 2,729,660 1,743,786 632,870 353,003 1
Utah 214,597 140,676 61,889 12,031 1
Vermont 154,991 74,068 59,926 20,997 0
Virginia 700,715 410,269 189,426 101,020 0
Washington** 916,838 568,245 278,676 69,917 0
West Virginia 351,489 193,628 124,482 33,379 0
Wisconsin 673,538 359,417 235,553 78,568 0
Wyoming 58,013 36,705 16,274 5,027 7
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.


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

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-13

Total Medicaid Eligibles by Basis of Eligibility, 2001
1


State Total Eligibles Aged
Blind/
Disabled Children Adults
Foster Care
Children
BOE
Unknown
National Total 46,910,257 4,400,601 7,657,411 22,438,138 11,546,609 866,692 806
Alabama 780,434 89,484 182,696 377,130 125,448 5,676 0
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* 202,912 18,824 21,616 85,074 73,338 4,060 -
Idaho 172,348 11,839 24,701 108,036 25,799 1,973 0
Illinois 1,798,723 112,455 282,956 952,915 368,149 82,248 0
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 277,843 56,942 74,955 91,418 51,163 3,365 0
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 65,425 10,242 9,672 29,750 14,026 1,735 0
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 594,679 43,195 64,579 234,692 237,679 14,525 9
Pennsylvania 1,647,440 206,976 364,161 754,343 275,074 46,886 0
Rhode Island 194,113 19,137 36,402 84,191 48,834 5,548 1
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 92,498 14,334 45
Washington** 916,838 69,054 121,662 520,323 191,871 13,927 1
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
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, MSIS Report, FY 2000 and FY 2001.
National Pharmaceutical Council Pharmaceutical Benefits 2003
2-14

Total Medicaid Eligibles Per 1000 Population, 2001



State
Total State
Population
Total
Eligibles*
Eligibles per
1000 Populations
National Total 285,093,813 46,910,257 164.5
Alabama 4,466,440 780,434 174.7
Alaska 632,674 115,996 183.3
Arizona 5,297,684 808,386 152.6
Arkansas 2,692,041 550,668 204.6
California 34,533,054 8,495,030 246.0
Colorado 4,428,786 410,611 92.7
Connecticut 3,432,550 446,326 130.0
Delaware 795,576 133,079 167.3
District of Columbia 572,716 152,597 266.4
Florida 16,355,193 2,462,171 150.5
Georgia 8,394,795 1,328,379 158.2
Hawaii* 1,225,038 202,912 165.6
Idaho 1,321,309 172,348 130.4
Illinois 12,517,168 1,798,723 143.7
Indiana 6,126,470 825,556 134.8
Iowa 2,932,225 331,025 112.9
Kansas 2,700,453 291,837 108.1
Kentucky 4,067,336 762,871 187.6
Louisiana 4,466,001 886,518 198.5
Maine 1,284,691 277,843 216.3
Maryland 5,383,377 704,628 130.9
Massachusetts 6,399,869 1,125,607 175.9
Michigan 10,005,218 1,430,246 143.0
Minnesota 4,985,202 609,856 122.3
Mississippi 2,857,716 681,161 238.4
Missouri 5,636,220 1,032,047 183.1
Montana 905,954 101,966 112.6
Nebraska 1,719,000 249,079 144.9
Nevada 2,094,633 167,247 79.8
New Hampshire 1,258,974 108,562 86.2
New Jersey 8,504,114 923,697 108.6
New Mexico 1,829,110 423,543 231.6
New York 19,074,843 3,548,630 186.0
North Carolina 8,195,249 1,397,486 170.5
North Dakota 636,285 65,425 102.8
Ohio 11,385,833 1,660,463 145.8
Oklahoma 3,467,181 631,996 182.3
Oregon 3,472,629 594,679 171.2
Pennsylvania 12,298,363 1,647,440 134.0
Rhode Island 1,058,992 194,113 183.3
South Carolina 4,059,818 871,675 214.7
South Dakota 758,156 106,154 140.0
Tennessee 5,745,808 1,601,406 278.7
Texas 21,340,598 2,729,660 127.9
Utah 2,279,590 214,597 94.1
Vermont 612,923 154,991 252.9
Virginia 7,192,697 700,715 97.4
Washington** 5,992,760 916,838 153.0
West Virginia 1,801,641 351,489 195.1
Wisconsin 5,405,140 673,538 124.6
Wyoming 493,720 58,013 117.5
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2001 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: U.S. Department of Commerce, Bureau of the Census, 2003; CMS, MSIS Report, FY 2000 & FY 2001.
National Pharmaceutical Council Pharmaceutical Benefits 2003
2-15

Total Net U.S. Medical Assistance Expenditures
by Type of Service, FY 2001 & FY 2002

Service FY 2002
Percent
of Total
FY 2001
Percent
of Total
Percent
Change
Nursing Facility $47,466,264,432 19.3% $43,317,811,704 20.1% +9.6%
Inpatient Acute Care Hospital $43,690,502,629 17.8% $39,586,413,122 18.3% +10.4%
Pharmaceuticals $29,339,050,970 11.9% $24,656,812,921 11.4% +19.0%
HCBS Waivers $17,169,137,673 7.0% $14,864,788,473 6.9% +15.5%
ICF-Mentally Retarded $11,205,483,449 4.6% $10,686,809,919 5.0% +4.9%
Hospital Outpatient $9,245,799,624 3.8% $7,709,540,429 3.6% +19.9%
Physicians $7,559,242,098 3.1% $6,670,379,109 3.1% +13.3%
Clinic* $7,499,886,627 3.1% $6,689,968,278 3.1% +12.1%
Inpatient Mental Health Hospital $7,446,842,170 3.0% $6,862,423,184 3.2% +8.5%
Personal Care Services $6,037,450,986 2.5% $5,251,140,806 2.4% +15.0%
Home Health Care $2,766,480,497 1.1% $2,613,356,673 1.2% +5.9%
Dental $2,630,870,620 1.1% $2,193,475,415 1.0% +19.9%
Other Practitioners $1,413,870,565 0.6% $1,141,272,064 0.5% +23.9%
EPSDT $1,007,637,056 0.4% $935,836,328 0.4% +7.7%
Lab/X-ray $781,820,930 0.3% $660,398,684 0.3% +18.3%
Other** $50,437,280,350 20.5% $41,969,472,522 19.4% +20.2%
Total Expenditures $245,697,620,676 100%‡ $215,809,899,631 100.0%‡ +13.8%
‡ Values may not add to 100% due to rounding. American Samoa, Guam, N. Mariana Islands, Puerto Rico, and Virgin Islands
excluded.
* Clinic includes clinics, FQHCs, and rural health clinics.
** Other includes hospice, other care services, payments to managed care organizations, etc.

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-16

Federal Medical Assistance Percentage (FMAP),
FY 2004 and FY 2005

State 2004 FMAP
2004 FMAP
(Q1-Q3)*
2004 Enhanced
FMAP** 2005 FMAP
2005 Enhanced
FMAP**
Alabama 70.75% 73.70% 79.53% 70.83% 79.58%
Alaska*** 58.39% 61.34% 70.87% 57.58% 70.31%
Arizona 67.26% 70.21% 77.08% 67.45% 77.22%
Arkansas 74.67% 77.62% 82.27% 74.75% 82.33%
California 50.00% 52.95% 65.00% 50.00% 65.00%
Colorado 50.00% 52.95% 65.00% 50.00% 65.00%
Connecticut 50.00% 52.95% 65.00% 50.00% 65.00%
Delaware 50.00% 52.95% 65.00% 50.38% 65.27%
District of Columbia*** 70.00% 72.95% 79.00% 70.00% 79.00%
Florida 58.93% 61.88% 71.25% 58.90% 71.23%
Georgia 59.58% 62.55% 71.71% 60.44% 72.31%
Hawaii 58.90% 61.85% 71.23% 58.47% 70.93%
Idaho 70.46% 73.91% 79.32% 70.62% 79.43%
Illinois 50.00% 52.95% 65.00% 50.00% 65.00%
Indiana 62.32% 65.27% 73.62% 62.78% 73.95%
Iowa 63.93% 66.88% 74.75% 63.55% 74.49%
Kansas 60.82% 63.77% 72.57% 61.01% 72.71%
Kentucky 70.09% 73.04% 79.06% 69.60% 78.72%
Louisiana 71.63% 74.58% 80.14% 71.04% 79.73%
Maine 66.01% 69.17% 76.21% 64.89% 75.42%
Maryland 50.00% 52.95% 65.00% 50.00% 65.00%
Massachusetts 50.00% 52.95% 65.00% 50.00% 65.00%
Michigan 55.89% 58.84% 69.12% 56.71% 69.70%
Minnesota 50.00% 52.95% 65.00% 50.00% 65.00%
Mississippi 77.08% 80.03% 83.96% 77.08% 83.96%
Missouri 61.47% 64.42% 73.03% 61.15% 72.81%
Montana 72.85% 75.91% 81.00% 71.90% 80.33%
Nebraska 59.89% 62.84% 71.92% 59.64% 71.75%
Nevada 54.93% 57.88% 68.45% 55.90% 69.13%
New Hampshire 50.00% 52.95% 65.00% 50.00% 65.00%
New Jersey 50.00% 52.95% 65.00% 50.00% 65.00%
New Mexico 74.85% 77.80% 82.40% 74.30% 82.01%
New York 50.00% 52.95% 65.00% 50.00% 65.00%
North Carolina 62.85% 65.80% 74.00% 63.63% 74.54%
North Dakota 68.31% 71.31% 77.82% 67.49% 77.24%
Ohio 59.23% 62.18% 71.46% 59.68% 71.78%
Oklahoma 70.24% 73.51% 79.17% 70.18% 79.13%
Oregon 60.81% 63.76% 72.57% 61.12% 72.78%
Pennsylvania 54.76% 57.71% 68.33% 53.84% 67.69%
Rhode Island 56.03% 58.98% 69.22% 55.38% 68.77%
South Carolina 69.86% 72.81% 78.90% 69.89% 78.92%
South Dakota 65.67% 68.62% 75.97% 66.03% 76.22%
Tennessee 64.40% 67.54% 75.08% 64.81% 75.37%
Texas 60.22% 63.17% 72.15% 60.87% 72.61%
Utah 71.72% 74.67% 80.20% 72.14% 80.50%
Vermont 61.34% 65.36% 72.94% 60.11% 72.08%
Virginia 50.00% 53.48% 65.00% 50.00% 65.00%
Washington 50.00% 52.95% 65.00% 50.00% 65.00%
West Virginia 75.19% 78.14% 82.63% 74.65% 82.26%
Wisconsin 58.41% 61.38% 70.89% 58.32% 70.82%
Wyoming 59.77% 64.27% 71.84% 57.90% 70.53%
* The Jobs and Growth Tax Relief and Reconciliation Act of 2003 (May 28, 2003) provides for a temporary increase in the FMAP. This increase is only
available for the last two quarters of FY 2003 and the first three quarters of FY 2004. More information is available at:
http://aspe.os.DHHS.gov/health/FMAP03-04temporaryincrease.html.
** The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all
of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
*** The values for Alaska and the District of Columbia were set for the State Plan under Titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act, the percentage for Alaska is 52.23% and for the
District of Columbia is 50.00%.
Source: Federal Register, November 15, 2002, Vol. 67, No. 221, pages 69223-69225; June 17, 2003, Vol. 68, No. 116, pages 35889-35890; and December
3, 2003, Vol. 68, No. 232, pages 67676-67678.
National Pharmaceutical Council Pharmaceutical Benefits 2003
2-17

Medicaid Total Net Expenditures and Eligibles, 2001



State
Total Net Medical
Assistance Expenditures
Total
Eligibles
Average
Per Eligible
National Total $215,809,899,631 46,910,257 $4,000
Alabama $2,875,372,953 780,434 $3,684
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* $634,781,970 202,912 $3,128
Idaho $693,205,598 172,348 $4,022
Illinois $7,764,611,352 1,798,723 $4,317
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 $1,315,523,163 277,843 $4,735
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 65,425 $6,212
Ohio $8,433,412,161 1,660,463 $5,079
Oklahoma $2,021,033,069 631,996 $3,198
Oregon $2,658,358,391 594,679 $4,470
Pennsylvania $10,908,343,146 1,647,440 $6,621
Rhode Island $1,187,880,819 194,113 $6,120
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** $4,305,724,247 916,838 $4,696
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
*Hawaii did not report MSIS data for FY 2000 or FY 2001. Their FY 1999 MSIS data are used in this table.
**MSIS data for FY 2002 have not yet been released for Washington. FY 2000 MSIS data are used in this table.

Source: CMS, CMS-64 Report, FY 2001 and CMS-MSIS Report, FY 2000 & FY 2001.
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Total Medicaid Program Expenditures, 2002


State
Total Net Medical
Assistance Expenditures
Administrative
Expenditures
Total Program
Expenditures
National Total $245,697,620,676 $11,865,503,019 $257,563,123,695
Alabama $3,093,270,640 $101,262,707 $3,194,533,347
Alaska $685,772,985 $53,525,999 $739,298,984
Arizona $3,541,598,721 $214,483,151 $3,756,081,872
Arkansas $2,237,817,554 $103,472,005 $2,341,289,559
California $26,890,540,967 $2,165,421,909 $29,055,962,876
Colorado $2,323,068,699 $89,593,331 $2,412,662,030
Connecticut $3,456,338,545 $145,108,698 $3,601,447,243
Delaware $634,046,351 $54,177,131 $688,223,482
District of Columbia $1,021,772,693 $60,012,057 $1,081,784,750
Florida $9,871,508,234 $528,381,789 $10,399,890,023
Georgia $6,241,211,454 $302,658,380 $6,543,869,834
Hawaii $740,007,314 $64,472,204 $804,479,518
Idaho $773,534,776 $62,662,990 $836,197,766
Illinois $8,809,060,004 $700,700,368 $9,509,760,372
Indiana $4,448,318,143 $181,277,188 $4,629,595,331
Iowa $2,575,146,342 $79,808,909 $2,654,955,251
Kansas $1,836,717,196 $119,768,351 $1,956,485,547
Kentucky $3,763,204,047 $100,440,133 $3,863,644,180
Louisiana $4,885,971,853 $136,430,738 $5,022,402,591
Maine $1,430,109,134 $59,837,086 $1,489,946,220
Maryland $3,613,476,100 $274,488,455 $3,887,964,555
Massachusetts $8,063,005,258 $317,224,866 $8,380,230,124
Michigan $7,562,053,407 -$163,622,489 $7,398,430,918
Minnesota $4,414,511,470 $247,714,024 $4,662,225,494
Mississippi $2,877,013,521 $87,664,878 $2,964,678,399
Missouri $5,360,607,640 $215,632,683 $5,576,240,323
Montana $571,456,455 $26,886,645 $598,343,100
Nebraska $1,339,132,070 $81,988,159 $1,421,120,229
Nevada $808,198,344 $56,128,326 $864,326,670
New Hampshire $1,016,094,814 $58,564,265 $1,074,659,079
New Jersey $7,745,877,997 $240,847,423 $7,986,725,420
New Mexico $1,776,811,688 $63,569,631 $1,840,381,319
New York $36,295,107,368 $1,181,722,131 $37,476,829,499
North Carolina $6,723,598,560 $302,125,603 $7,025,724,163
North Dakota $461,401,546 $22,525,872 $483,927,418
Ohio $9,658,040,587 $319,681,549 $9,977,722,136
Oklahoma $2,260,403,490 $167,112,579 $2,427,516,069
Oregon $2,571,560,664 $226,191,921 $2,797,752,585
Pennsylvania $12,130,925,035 $556,891,243 $12,687,816,278
Rhode Island $1,358,500,649 $62,877,169 $1,421,377,818
South Carolina $3,292,901,444 $133,484,748 $3,426,386,192
South Dakota $549,884,391 $15,675,093 $565,559,484
Tennessee $5,787,079,096 $245,058,264 $6,032,137,360
Texas $13,523,486,149 $706,759,839 $14,230,245,988
Utah $984,160,785 $78,087,725 $1,062,248,510
Vermont $660,731,979 $55,179,707 $715,911,686
Virginia $3,812,166,436 $187,346,225 $3,999,512,661
Washington $5,168,511,470 $490,873,523 $5,659,384,993
West Virginia $1,584,166,286 $73,009,703 $1,657,175,989
Wisconsin $4,193,175,197 $186,413,731 $4,379,588,928
Wyoming $274,565,128 $23,904,404 $298,469,532
Source: CMS, CMS-64 Report, FY 2002.

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Total SCHIP Expenditures, 2002

State
Medicaid SCHIP
Expenditures
Non-Medicaid SCHIP
Expenditures Total Expenditure
National Total $1,330,657,305 $4,089,702,326 $5,420,359,631
Alabama $4,628,780 $64,702,498 $69,331,278
Alaska $27,348,249 $2,595,488 $29,943,737
Arizona $0 $167,950,645 $167,950,645
Arkansas $1,828,430 $81,548 $1,909,978
California $41,021,160 $647,354,640 $688,375,800
Colorado $0 $47,971,251 $47,971,251
Connecticut $3,447,029 $21,426,909 $24,873,938
Delaware $0 $4,015,741 $4,015,741
District of Columbia $6,269,076 $654,591 $6,923,667
Florida $65,139,446 $323,338,927 $388,478,373
Georgia $0 $148,512,336 $148,512,336
Hawaii $5,596,585 $20,389 $5,616,974
Idaho $16,772,010 $1,230,699 $18,002,709
Illinois $37,305,573 $18,558,488 $55,864,061
Indiana $66,035,063 $16,226,253 $82,261,316
Iowa $16,277,396 $22,540,225 $38,817,621
Kansas $0 $49,811,709 $49,811,709
Kentucky $60,261,647 $30,841,566 $91,103,213
Louisiana $78,484,723 $3,679,622 $82,164,345
Maine $15,623,419 $7,610,776 $23,234,195
Maryland $166,152,918 $17,228,837 $183,381,755
Massachusetts $72,181,353 $20,491,319 $92,672,672
Michigan $25,640,047 $31,334,653 $56,974,700
Minnesota $50,263 $99,462,784 $99,513,047
Mississippi $5,296,814 $78,458,940 $83,755,754
Missouri $83,252,095 $2,240,727 $85,492,822
Montana $0 $14,935,804 $14,935,804
Nebraska $16,028,217 $594,989 $16,623,206
Nevada $0 $31,433,945 $31,433,945
New Hampshire $276,736 $5,748,840 $6,025,576
New Jersey $44,305,712 $344,167,314 $388,473,026
New Mexico $16,902,487 $223,065 $17,125,552
New York $11,633,119 $560,001,709 $571,634,828
North Carolina $0 $117,820,812 $117,820,812
North Dakota $966,615 $3,880,893 $4,847,508
Ohio $175,369,794 $5,979,799 $181,349,593
Oklahoma $37,014,987 $1,008,907 $38,023,894
Oregon $0 $22,796,830 $22,796,830
Pennsylvania $0 $152,372,663 $152,372,663
Rhode Island $18,831,033 $32,810,550 $51,641,583
South Carolina $47,604,923 $5,289,436 $52,894,359
South Dakota $8,746,215 $2,624,039 $11,370,254
Tennessee $4,877,111 $481,001 $5,358,112
Texas $7,340,202 $735,462,302 $742,802,504
Utah $0 $32,706,432 $32,706,432
Vermont $0 $3,443,510 $3,443,510
Virginia $807,958 $59,375,598 $60,183,556
Washington $0 $12,319,513 $12,319,513
West Virginia $2,773 $32,518,236 $32,521,009
Wisconsin $34,000,865 $79,059,901 $113,060,766
Wyoming $0 $4,304,677 $4,304,677
Source: CMS, CMS-21 (SCHIP) Report, 2002.

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14.4%
23.2%
29.4%
40.1%
47.8%
53.6%
55.6% 55.8% 56.8% 57.6% 59.1%
85.6%
76.8%
70.6%
59.9%
52.2%
46.4%
44.4% 44.2% 43.2% 42.4% 40.9%
0%
20%
40%
60%
80%
100%
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Managed Care Fee for Service

MEDICAID MANAGED CARE ENROLLMENT
Since 1981, when Congress authorized States to implement Section 1915(b) and Section 1115
Medicaid waivers to increase access to managed care and test innovative health care financing and
delivery options, enrollment in Medicaid managed care has grown considerably, although the trend
appears to be leveling off. Over the past ten years, managed care enrollment as a percentage of total
Medicaid enrollment has increased by 310 percent (i.e., from 14.4% to 59.1%). In 2003, 59.1% of all
Medicaid beneficiaries were enrolled in some type of managed care program. As of June 30, 2003, all
but three States (Alaska, Mississippi, and Wyoming) were enrolling Medicaid beneficiaries in some
type of managed care plan.
Figure 2-1: Managed Care Enrollment as a Percentage of Total Medicaid Enrollment
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid
& State Operations. *Approximated numbers for 1995. Total Medicaid population was provided by the Office of the Actuary,
which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The managed care population differs from the
11,619,929 reported in the 1995 report as the number represented enrollment of some beneficiaries in more than one plan.

TYPES OF MEDICAID MANAGED CARE PLANS

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

• Health Insuring Organization (HIO): an entity that provides for or arranges for the
provision of care and contracts on a prepaid capitated risk basis to provide a
comprehensive set of services.
• Commercial Managed Care Organization (Com-MCO): a Com-MCO is a health
maintenance organization with a contract under §1876 or a Medicare+Choice
organization, a provider sponsored organization or any other private or public
organization, which meets the requirements of §1902(w). They provide
comprehensive services to commercial and/or Medicare enrollees, as well as
Medicaid enrollees.


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• Medicaid-only Managed Care Organization (Mcaid-MCO): a MCO that provides
comprehensive services to Medicaid beneficiaries, but not commercial or Medicare
enrollees.
• Prepaid Health Plan (PHP): an entity that provides less than comprehensive
services on an at-risk basis or one that provides any benefit package on a non-risk
basis.
• Primary Care Case Management (PCCM): a provider (usually a physician,
physician group practice, or an entity employing or having other arrangements with
such physicians, but sometimes also including nurse practitioners, nurse-midwives,
or physician assistants) who contracts to locate, coordinate, and monitor covered
primary care (and sometimes additional services). This category includes those PHPs
that act as PCCMs.
• “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PHP, Comprehensive MCO, Medicaid-only MCO, or HIO.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.


Table 2-1: Medicaid Managed Care Plans



*This table provides duplicated figures by plan type. The total number of enrollees includes 8,844,848 individuals who were
enrolled in more than one managed care plan. It also includes individuals enrolled in State health care reform programs that
expand eligibility beyond traditional Medicaid eligibility standards.
Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid
& State Operations.


The following tables provide an overview of Medicaid managed care enrollment at the State level.
Number of Plans Number of Enrollees
Health Insuring Organization (HIO) 5 531,349
Commercial Managed Care Organization (COM-MCO) 164 9,920,954
Medicaid-only Managed Care Organization (Mcaid-MCO) 120 6,848,585
Primary Care Case Management (PCCM) 42 6,142,646
Prepaid Health Plan (PHP) 136 10,498,301
Other 44 195886
Total 511 34,107,721*
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Medicaid Managed Care Enrollment, As of June 30, 2003

State Medicaid enrollment includes individuals enrolled in State health care reform programs that expand eligibility beyond traditional Medicaid eligibility
standards. This table provides unduplicated figures for Medicaid Enrollment and Managed Care Enrollment by State for a single point in time. These
values differ significantly (i.e., are lower than) unduplicated annual counts of enrollees over the entire year.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State Operations.
State
Medicaid
Enrollment
Medicaid Managed
Care Enrollment
Percent in
Managed Care
Rank Based on
Percent in
Managed Care
National Total 42,740,719 25,262,873 59.11%
Alabama 760,527 404,797 53.23% 37
Alaska 95,335 0 0.00% 50
Arizona 901,655 808,506 89.67% 6
Arkansas 557,074 374,067 67.15% 24
California 6,272,109 3,258,787 51.96% 39
Colorado 330,499 262,263 79.35% 12
Connecticut 405,064 294,331 72.66% 15
Delaware 121,676 86,709 71.26% 17
District of
Columbia 128,185 85,370 66.60% 26
Florida 2,214,058 1,354,025 61.16% 33
Georgia 1,448,645 1,212,639 83.71% 9
Hawaii 179,522 141,399 78.76% 13
Idaho 156,935 101,257 64.52% 31
Illinois 1,580,944 137,682 8.71% 48
Indiana 707,168 502,401 71.04% 18
Iowa 266,737 243,954 91.46% 5
Kansas 246,186 141,119 57.32% 36
Kentucky 663,002 611,878 92.29% 4
Louisiana 861,846 505,434 58.65% 35
Maine 249,738 148,151 59.32% 34
Maryland 681,096 466,688 68.52% 21
Massachusetts 915,114 572,835 62.60% 32
Michigan 1,322,261 1,314,810 99.44% 2
Minnesota 552,779 362,349 65.55% 28
Mississippi 720,304 0 0.00% 50
Missouri 950,694 425,161 44.72% 44
Montana 80,378 55,372 68.89% 20
Nebraska 197,378 142,377 72.13% 16
Nevada 164,033 74,923 45.68% 42
New Hampshire 91,261 13,407 14.69% 47
New Jersey 782,309 525,864 67.22% 23
New Mexico 404,497 261,015 64.53% 30
New York 3,645,834 1,914,794 52.52% 38
North Carolina 1,074,616 749,152 69.71% 19
North Dakota 53,806 35,515 66.01% 27
Ohio 1,515,712 436,146 28.77% 46
Oklahoma 498,031 338,859 68.04% 22
Oregon 425,627 330,874 77.74% 14
Pennsylvania 1,492,095 1,192,031 79.89% 11
Puerto Rico 957,298 857,310 89.56% 7
Rhode Island 178,543 119,257 66.79% 25
South Carolina 862,175 71,195 8.26% 49
South Dakota 93,208 90,733 97.34% 3
Tennessee 1,304,794 1,304,794 100.00% 1
Texas 2,559,248 1,065,945 41.65% 45
Utah 187,823 162,364 86.45% 8
Vermont 131,051 85,751 65.43% 29
Virgin Islands 16,125 0 0.00% 50
Virginia 583,999 262,961 45.03% 43
Washington 1,059,865 854,861 80.66% 10
West Virginia 296,220 151,515 51.15% 40
Wisconsin 739,431 349,246 47.23% 41
Wyoming 56,209 0 0.00% 50
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Pharmaceutical Benefits Under Managed Care Plans
State
Where do managed care recipients receive
pharmacy benefits?
(State, Managed Care Plan, Both)
Special requirements
for pharmacy benefits
in managed care?
Alabama N/A N/A
Alaska - -
Arizona* - -
Arkansas State None
California Both Statutes, regulations, guidelines, contractual
Colorado Managed Care Plan Contractual
Connecticut Managed Care Plan Contractual
Delaware State N/A
District of Columbia District of Columbia Government 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 Statutes
Iowa State None
Kansas Both Statutes, regulations, contractual
Kentucky Both Contractual
Louisiana N/A N/A
Maine State N/A
Maryland Both Regulations
Massachusetts Managed Care Plan Contractual
Michigan Managed Care Plan Contractual
Minnesota Managed Care Plan Contractual
Mississippi State -
Missouri Managed Care Plan Guidelines, 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 N/A
North Carolina State None
North Dakota State None
Ohio Managed Care Plan Statutes
Oklahoma Both Contractual
Oregon Managed Care Plan 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 Statutes
Texas State N/A
Utah State Regulations
Vermont State None
Virginia Managed Care Plan Contractual
Washington Both Contractual
West Virginia State N/A
Wisconsin Managed Care Plan Statutes, regulations, guidelines, 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 2003 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 1999-2003
State 1999 2000 2001 2002 2003
National Total 17,756,603 18,786,137 20,773,813 23,117,668 25,262,873
Alabama 377,952 325,059 350,485 405,090 404,797
Alaska 0 0 0 0 0
Arizona 363,662 442,254 527,674 697,171 808,506
Arkansas 232,123 222,261 257,662 336,111 374,067
California 2,540,902 2,525,406 2,870,514 3,191,168 3,258,787
Colorado 216,357 254,232 247,181 278,095 262,263
Connecticut 230,217 229,995 239,829 280,106 294,331
Delaware 68,869 75,535 83,422 87,465 86,709
District of Columbia 75,499 78,864 79,673 80,300 85,370
Florida 912,045 1,016,641 1,184,506 1,267,998 1,354,025
Georgia 638,082 806,009 878,140 1,043,154 1,212,639
Hawaii 120,246 121,581 127,779 132,787 141,399
Idaho 31,184 32,338 37,913 58,284 101,257
Illinois 158,888 137,622 136,497 130,988 137,682
Indiana 331,363 376,066 433,014 484,116 502,401
Iowa 176,487 182,251 206,751 227,495 243,954
Kansas 95,868 108,093 118,209 130,162 141,119
Kentucky 324,447 464,191 489,711 500,987 611,878
Louisiana 44,741 48,802 56,542 206,992 505,434
Maine 23,720 57,151 96,051 110,922 148,151
Maryland 347,937 385,687 421,355 451,307 466,688
Massachusetts 575,186 583,324 616,241 628,832 572,835
Michigan 1,130,608 1,063,557 1,023,264 1,208,803 1,314,810
Minnesota 268,360 291,365 322,640 368,186 362,349
Mississippi* 200,347 218,431 297,916 0 0
Missouri 276,628 304,499 378,771 413,361 425,161
Montana 69,738 42,312 46,995 52,209 55,372
Nebraska 122,006 140,199 150,840 163,772 142,377
Nevada 36,945 37,945 47,518 60,823 74,923
New Hampshire 5,812 4,432 6,200 9,206 13,407
New Jersey 356,956 371,641 459,087 523,904 525,864
New Mexico 208,528 199,297 212,456 243,069 261,015
New York 659,569 691,422 728,709 1,099,900 1,914,794
North Carolina 689,104 598,852 674,133 722,089 749,152
North Dakota 23,886 23,962 25,540 30,808 35,515
Ohio 244,888 239,460 277,617 378,476 436,146
Oklahoma 193,902 279,205 299,272 338,819 338,859
Oregon 308,798 312,064 360,926 378,739 330,874
Pennsylvania 1,004,601 975,211 1,037,374 1,140,211 1,192,031
Puerto Rico 764,068 828,021 898,171 865,285 857,310
Rhode Island 85,900 104,041 111,624 117,024 119,257
South Carolina 23,149 32,149 41,716 64,272 71,195
South Dakota 50,220 67,835 79,641 85,868 90,733
Tennessee 1,312,969 1,323,319 1,426,622 1,430,966 1,304,794
Texas 352,062 606,238 753,613 839,798 1,065,945
Utah 118,601 119,200 128,898 154,784 162,364
Vermont 65,692 55,605 78,181 82,261 85,751
Virgin Islands 0 0 0 0 0
Virginia 292,214 280,978 291,767 323,863 262,961
Washington 706,202 800,481 766,366 829,625 854,861
West Virginia 111,532 90,631 122,230 144,911 151,515
Wisconsin 187,543 210,423 266,577 317,106 349,246
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, 1999; 2000; 2001; 2002 and 2003. DHHS, CMS, Center
for Medicaid & State Operations.
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Medicaid Managed Care Plan Type, As of June 30, 2003
State HIO
Commercial
MCO
Medicaid-only
MCO PCCM PHP Other
National Total 5 164 120 42 136 44
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 11 5
Colorado 0 0 1 1 9 1
Connecticut 0 2 2 0 0 0
Delaware 0 1 0 0 0 0
District of Columbia 0 0 4 0 1 0
Florida 0 9 2 1 2 2
Georgia 0 0 0 1 2 0
Hawaii 0 2 1 0 2 1
Idaho 0 0 0 1 0 0
Illinois 0 4 1 0 0 0
Indiana 0 0 3 2 0 0
Iowa 0 3 0 1 1 0
Kansas 0 0 1 1 0 1
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 1
Massachusetts 0 2 2 1 1 6
Michigan 0 9 9 0 20 0
Minnesota 0 6 3 0 0 1
Mississippi - - - - - -
Missouri 0 3 4 0 0 1
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 14 15 6 1 17
North Carolina 0 1 0 2 0 0
North Dakota 0 1 0 1 0 0
Ohio 0 4 2 0 0 2
Oklahoma 0 3 2 0 0
Oregon 0 4 9 1 18 0
Pennsylvania 0 2 9 1 28 1
Puerto Rico 0 3 0 0 2 0
Rhode Island 0 3 0 0 0 0
South Carolina 0 0 1 0 1 0
South Dakota 0 0 0 1 1 0
Tennessee 0 5 3 0 2 1
Texas 0 10 2 2 1 0
Utah 0 0 0 3 13 0
Vermont 0 0 0 1 0 0
Virgin Islands - - - - - -
Virginia 0 6 1 1 0 0
Washington 0 6 2 1 14 1
West Virginia 0 2 0 1 0 0
Wisconsin 0 28 3 0 2 2
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, 2003. DHHS, CMS, Center for Medicaid & State
Operations.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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Medicaid Managed Care Enrollment by Plan Type,
As of June 30, 2003

State HIO
Commercial
MCO
Medicaid-only
MCO PCCM PHP Other
National Total 531,349 9,920,954 6,848,585 6,142,646 10,468,301 195,886
Alabama - - - 401,393 391,912 -
Alaska - - - - - -
Arizona - 68,404 740,102 - 64,021 -
Arkansas - - - 325,886 374,067 -
California 531,349 2,676,278 0 28,002 255,281 3,610
Colorado - - 70,150 82,488 274,174 758
Connecticut - 225,057 69,274 - - -
Delaware - 86,709 - - - -
District of Columbia - - 85,370 - 2,898 -
Florida - 463,173 203,728 667,114 90,281 18,268
Georgia - - - 840,630 1,215,029 -
Hawaii - 94,051 45,756 - 550 1,497
Idaho - - - 101,257 - -
Illinois - 119,225 18,457 - - -
Indiana - - 246,488 255,913 - -
Iowa - 64,365 - 73,332 243,954 -
Kansas - - 60,891 80,186 - 61
Kentucky - - 128,679 375,890 611,878 -
Louisiana - - - 505,434 - -
Maine - - - 148,151 - -
Maryland - - 466,542 - - 146
Massachusetts - 103,554 165,162 304,119 324,207 1,195
Michigan - 450,816 374,781 - 1,319,096 -
Minnesota - 345,968 16,381 - - 825
Mississippi - - - - - -
Missouri - 113,616 311,545 - - 168
Montana - - - 55,372 - -
Nebraska - 30,712 - 35,109 - 142,377
Nevada - 74,923 - - - -
New Hampshire - 13,407 - - - -
New Jersey - 43,672 482,192 - - -
New Mexico - 261,015 - - - -
New York - 968,577 875,494 20,961 6,979 18,313
North Carolina - 11,314 - 749,152 - -
North Dakota - 821 - 34,694 - -
Ohio - 151,026 284,662 - - 458
Oklahoma - - 181,451 160,591 - -
Oregon - 45,333 175,469 9,110 550,413 -
Pennsylvania - 230,556 820,601 135,000 970,455 153
Puerto Rico - 857,310 - - 857,310 -
Rhode Island - 119,257 - - - -
South Carolina - - 53,793 - 17,402 -
South Dakota - - - 71,424 90,733 -
Tennessee - 979,682 450,012 - 1,304,794 227
Texas - 450,054 270,931 332,820 277,613 -
Utah - - - 74,422 371,482 -
Vermont - - - 85,751 - -
Virgin Islands - - - - - -
Virginia - 198,288 64,673 80,796 - -
Washington - 392,203 78,752 3,917 853,226 184
West Virginia - 47,783 - 103,732 - -
Wisconsin - 233,805 107,249 - 546 7,646
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, 2003. DHHS, CMS, Center for Medicaid & State
Operations.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2003
State FEE-FOR-SERVICE (FFS) Fully Capitated (FUL) Partially Capitated (PAR)
National Total 6,188,187 27,704,547 214,987
Alabama 401,393 391,912
Alaska
Arizona 872,527
Arkansas 325,886 374,067
California 28,002 3,466,518
Colorado 82,488 333,171 11,911
Connecticut 294,331
Delaware 86,709
District of Columbia 85,370 2,898
Florida 685,372 757,192
Georgia
840,630 1,215,029
Hawaii 141,854
Idaho 101,257
Illinois 137,682
Indiana 255,913 246,488
Iowa 73,332 308,319
Kansas 80,186 60,952
Kentucky 375,890 740,557
Louisiana 505,434
Maine 148,151
Maryland 466,688
Massachusetts 304,119 594,118
Michigan 2,144,693
Minnesota 825 362,349
Mississippi
Missouri 425,329
Montana 55,372
Nebraska 177,486 30,712
Nevada 74,923
New Hampshire 13,407
New Jersey 525,864
New Mexico 261,015
New York 6,105 1,862,384 21,835
North Carolina 749,152 11,314
North Dakota 34,694 821
Ohio 436,146
Oklahoma 181,451 160,591
Oregon 9,110 771,215
Pennsylvania 135,000 2,021,415 350
Puerto Rico 1,714,620
Rhode Island 119,257
South Carolina 53,793 17,402
South Dakota 71,424 90,733
Tennessee 2,734,715
Texas 332,820 998,598
Utah 133,950 311,954
Vermont 85,751
Virgin Islands
Virginia 80,796 262,961
Washington 3,917 1,324,365
West Virginia 103,732 47,783
Wisconsin 349,246
Wyoming

Individual State totals will not sum to total managed care enrollment (page 2-5) because State totals include individuals enrolled in more than one
plan type including dental, mental, and long-term care.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2003. DHHS, CMS, Center for Medicaid & State
Operations.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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MEDICAID MANAGED CARE WAIVERS
In 1981, Congress authorized States to implement Section 1915(b) and Section 1115 Medicaid
waivers to increase access to managed care and test innovative health care financing and delivery
options. The U.S. Department of Health and Human Services (DHHS) granted these waivers to allow
States to “waive” certain Medicaid requirements in Sections 1902 and 1903 of the Social Security Act
and “mandate” enrollment of Medicaid eligibles in managed care programs.
SECTION 1915(b) “FREEDOM OF CHOICE” WAIVERS
Section 1915(b) waivers are granted to give States the authority to conduct Medicaid programs
outside of the scope of the Medicaid statute, allowing them to waive freedom of choice, statewide
access to care, and comparability requirements under Section 1902 of the Social Security Act. With a
1915(b) waiver, a State can require mandatory enrollment of Medicaid recipients in managed care
plans. Section 1915(b) waivers can also allow a State to create a “carveout” delivery system for
specialty care, e.g., a Managed Behavioral Health Care Plan. Section 1915(b) waivers cannot
negatively impact beneficiary access or quality of care of services, and must be cost-effective (i.e.,
cost must be less than the Medicaid program would cost without the waiver). Section 1915(b)
waivers are typically limited to a targeted geographical area or population, are approved for an initial
period of two years, and can be renewed on an ongoing basis if the State reapplies.
Four options for 1915(b) waivers exist; each is governed by a different subsection(s) of Section
1915(b);
• Paragraph (b)(1) - Case Management: States are allowed to implement case management
systems which can be as simple as requiring each beneficiary to choose a primary care
provider or as comprehensive as mandating enrollment in a prepaid health plan. The
Balanced Budget Act of 1997 also gave States the option to enroll certain beneficiaries
into managed care via a State Plan Amendment.
• Paragraph (b)(2) - Central Broker: Localities are allowed to act as a central broker in
assisting Medicaid eligibles in selecting among competing health care plans, if such a
restriction does not substantially impair access to medically necessary services of
adequate quality.
• Paragraph (b)(3) - Shared Cost Saving: States are allowed to share (through provision of
additional services) cost savings (resulting from use by the recipient of more cost-
effective medical care) with recipients of medical assistance under the State Plan.
• Paragraph (b)(4) - Restrict Providers: States can limit the number of providers of certain
services. These waivers are sometimes referred to as selective contracting waivers and
are gaining in popularity. For example, some approved 1915(b)(4) waivers include
programs to restrict the number of providers of transportation services, organ transplants,
and inpatient obstetrical care.

Refer to the table on page 2-33 for a listing of 1915(b) waivers.

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


National Pharmaceutical Council Pharmaceutical Benefits 2003
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SECTION 1115 RESEARCH AND DEMONSTRATION WAIVERS
Section 1115 research and demonstration waivers release States from standard Medicaid
requirements, allowing them the flexibility to test substantially new ideas of policy merit. Along with
Section 1915(b) waivers, Section 1115 waivers allow States to waive freedom of choice, statewide
access to care, and comparability requirements. However, a Section 1115 waiver also allows States
to provide new and additional services, test new payment methods, offer benefits to new and
expanded populations, and contract with managed care organizations that do not meet the necessary
criteria of Section 1903 of the Social Security Act.
To receive approval of a Section 1115 waiver, States submit a proposal to CMS for discussion and
review. Once operational, States allow formal evaluations of the research and public policy value of
the programs and to demonstrate that their programs do not exceed costs, which would have
otherwise occurred under traditional Medicaid programs (i.e., States must demonstrate budget
neutrality). Section 1115 waivers are usually granted for a five-year period and each State must
submit a request for continuation. For example, Arizona has operated its program under a Section
1115 waiver for over 20 years. The Benefits Improvement and Protection Act (BIPA) of 2000
streamlined the process for States to submit requests for and receive extensions of Section 1115
demonstration waivers.
Currently, there are 17 Medicaid programs with Section 1115 waiver approvals: Arizona, Arkansas,
California, Delaware, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Missouri, New York,
Oklahoma, Oregon, Rhode Island, Tennessee, Vermont and Wisconsin. Refer to the table on page 2-
33 for a listing of implemented Section 1115 waivers.
PHARMACY PLUS DEMONSTRATIONS UNDER SECTION 1115 AUTHORITY
Section 1115 demonstration authority may be used to extend pharmacy coverage to certain low-
income elderly and disabled individuals who are not otherwise eligible for Medicaid. This type of
Section 1115 waiver program is commonly referred to as “Pharmacy Plus.” Its purpose is to provide
a subsidized pharmacy benefit that is intended to assist individuals in maintaining their healthy status
and avoid spending down to Medicaid income and asset eligibility levels. The waivers will test how
provision of a pharmacy benefit to a non-Medicaid covered population will affect Medicaid costs,
utilization and future eligibility trends.

Pharmacy Plus demonstrations 1) cover an individual’s cost of drugs; 2) cover the individual’s cost
sharing obligation for private prescription programs; and 3) provide wrap-around coverage to bring
private sources of drug coverage up to the level of the Pharmacy Plus benefit. States may construct
their Pharmacy Plus programs to provide eligibility for individuals who are not eligible for full
Medicaid benefits and who have incomes below 200 percent of the Federal Poverty Level. Under a
Pharmacy Plus waiver, States may elect to provide a prescription and over-the-counter drug benefit
that is similar to, or different from, the benefits provided in the Medicaid State Plan. States may
choose to deliver the services via fee-for-service or capitation. Last, States may choose whether to
perform assets tests and income adjustments, and may also choose to enact an enrollment ceiling on
the number of individuals who participate in the demonstration.

Like all 1115 demonstrations, Pharmacy Plus waivers must be budget neutral to the Federal
government. Under the terms and conditions of an approved plan, which is usually granted for a 5-
year period, a ceiling cap is placed on Federal financial payments for services included in the budget
neutrality agreement. States are encouraged to involve the private sector in implementing these
programs and are encouraged to explore the use of pharmacy benefit managers (PBM). Premiums,
cost sharing (deductibles, co-payments and coinsurance), and benefit limitations are all available tools
for providing incentives and cost containment.

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-31
As of September 24, 2003, four States had received Pharmacy Plus demonstration approval: Florida,
Illinois, South Carolina and Wisconsin. Another 8 states had applications pending and one state
withdrew its request.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) establishes a
new Part D that provides a prescription drug benefit to all Medicare beneficiaries beginning in 2006.
When the new benefit begins, states with Pharmacy Plus waivers may want to eliminate or
substantially revise them because Medicare will be providing prescription drug coverage to seniors
now covered by Pharmacy Plus.

Refer to the table on page 2-36 for a complete status of the Pharmacy Plus Demonstrations Program.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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National Pharmaceutical Council Pharmaceutical Benefits 2003
2-33

Section 1915(b) Waivers, As of June 30, 2002
State Program(s) Approved
1915(b)
Statutes
Utilized Implemented Expiration
Alabama Patient 1
st
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
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
California
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
Prepaid Mental Health Plan 1, 4
3/1/96
6/30/03 Florida
Statewide Inpatient Psychiatric Program 4
4/1/99
12/31/03
Georgia Better Health Care 1
10/1/93
3/14/03
Non-Emergency Transportation Broker Program 4
10/1/97
9/7/03
Georgia
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 -- -- --
National Pharmaceutical Council Pharmaceutical Benefits 2003
2-34
State Program(s) Approved
1915(b)
Statutes
Utilized Implemented Expiration
Massachuse None -- -- --
Comprehensive Health Care 1, 2, 4 7/1/97 9/24/04
Michigan
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 None -- -- --
New Jersey New Jersey Care 2000+ 1915(b) 1, 2 10/1/00 9/30/02
New 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
Carolina Access 1915(b) 1 4/1/91 11/08/02
North
Carolina
Health Care Connection 1915(b) 1 7/1/96 11/08/02
North None -- -- --
Ohio PremierCare 1, 2, 4 7/1/01 6/30/03
Oklahoma None -- -- --
Oregon Transportation Program 4 9/1/94 7/25/03
Family Care Network 1 2/1/94 6/16/04 Pennsylvani
a
HealthChoices 1, 2, 3, 4 2/1/97 6/16/04
Puerto Rico None -- -- --
Rhode None -- -- --
South None -- -- --
South 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
NorthSTAR 1, 2, 4 11/1/99 11/5/03
STAR 1, 2, 3, 4 8/1/93 8/31/03
Texas
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
Non-Emergency Transportation 1, 4
7/1/01
9/18/04 Utah
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.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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Section 1115 Research and Demonstration Waivers
As of June 30, 2002
State Program Implemented Expiration
Arizona Arizona Health Care Cost Containment System (AHCCCS) 10/1/82 9/30/06
Arkansas ARKids First 9/1/97 9/30/05
Altamed Health Senior Buencare 11/01/98 11/24/02
Center For Elders Independence 4/1/95 11/24/02
On Lok Senior Health Services 11/1/83 11/24/02
Senior Care Action Network 1/1/85 7/31/03
California
Sutter Senior Care 5/1/94 11/24/02
Delaware Diamond State Health Plan 1/1/96 3/15/04
Hawaii Hawaii QUEST 8/1/94 3/31/03
Kentucky Kentucky Health Care Partnership Program 11/1/97 11/1/02
Maryland HealthChoice 6/2/97 5/31/05
Massachusetts Mass Health 7/1/97 6/30/05
MinnesotaCare Program for Families and Children 7/1/95 6/30/05
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.

National Pharmaceutical Council Pharmaceutical Benefits 2003
2-36
Pharmacy Plus Demonstrations Program Status
Pharmacy Waivers Under 1115 Authority


STATE PROGRAM NAME STATUS
Arkansas Arkansas RX Senior Care Pending
Connecticut ConnPACE Program Rx Pending
Delaware Delaware Pharmacy Assistance Program Disapproved
Florida Ron Silver Senior Rx Program Approved
Hawaii Prescription Plus Disapproved
Illinois
Prescription Drug Benefit for Illinois’ Low
Income
Approved
Maine Maine Health Prescription Drug Demonstration
Pending

Massachusetts Pharmacy Waiver Withdrawn
Michigan EPIC Ex Pending
New Jersey
Pharmaceutical Assistance for the Aged and
Disabled
Pending
North Carolina North Carolina Senior Care Pending
Rhode Island Rhode Island RX+
Pending

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

Wisconsin WI Senior Care Approved

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
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Section 3:
State Characteristics







National Pharmaceutical Council Pharmaceutical Benefits 2003
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National Pharmaceutical Council Pharmaceutical Benefits 2003
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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, insurance coverage, poverty status,
employment, and income data for each State are presented. The final group of tables show select
components of each State’s health care system including Medicare and Medicaid certified
facilities (hospitals, SNFs, ICFs/MR, home health agencies, and rural health clinics), licensed
pharmacies, and health manpower (physicians, Registered Nurses, and pharmacists).

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

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

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

The table showing the age distribution of the population is derived from the 2002 American
Community Survey conducted by the U.S. Bureau of the Census. It is the only 2002 age breakout
on a State-by-State basis that the Bureau had released while data collection for the 2003
Compilation was ongoing. Unfortunately, the approximately 5 million individuals residing in
“group quarters” were not included. Hence, the total population figure (and the corresponding
figures for each State) presented in this table is lower than the population total in the table
showing insurance status.

The data on insurance status was compiled from the March 2003 Supplement to the Current
Population Survey, a collaborative effort by the Census Bureau and BLS. Hence, the estimates on
the number of Medicare and Medicaid beneficiaries differ slightly from those published by CMS.
In addition, more detailed data on poverty, also compiled from The March 2003 Supplement to the
Current Population Survey have been included in this year’s Compilation.

HRSA’s Bureau of Health Professions, Division of Nursing is responsible for conducting the
National Sample Survey of Registered Nurses. This survey is the Nation’s most extensive and
comprehensive source of nursing statistics. The most recent iteration of this survey, which is
conducted every four years, is the 2000 version. Unfortunately, these data are somewhat out-of-
date. We, therefore, turned to another source, The Area Resource File (ARF), for data on the
number of requested nurses. However, as is often the case, data from different sources are not
exactly the same. The Area Resource File, for example, provides information on the number of
“full-time equivalent” registered nurses, not a simple body count of the number of full-time and
part-time RNs. Hence, the nursing numbers included in 2003 Compilation are lower than those
presented last year.

National Pharmaceutical Council Pharmaceutical Benefits 2003
3-4
Despite the limitations confronted while compiling these statistics, we believe that the data
presented in Section 3 provide a useful and meaningful picture of State characteristics. Users of
the Compilation are urged to carefully read the source information and notes at the bottom of each
table in order to understand the limitations of the data contained therein.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-5
Age Demographics, 2002*
State
Total
Population
Percent Ages
19 and under
Percent
Ages 20-44
Percent
Ages 45-64
Percent
Ages 65+
National Total 280,540,330 28.2% 36.2% 23.6% 12.0%
Alabama 4,370,221 27.8% 35.3% 24.1% 12.9%
Alaska 624,252 33.2% 35.2% 25.6% 6.1%
Arizona 5,346,616 30.0% 35.6% 21.9% 12.6%
Arkansas 2,634,848 28.0% 34.4% 24.2% 13.4%
California 34,292,871 30.0% 38.0% 21.6% 10.3%
Colorado 4,403,659 28.4% 38.2% 24.1% 9.3%
Connecticut 3,350,345 27.9% 34.1% 24.8% 13.1%
Delaware 782,221 26.3% 37.0% 24.0% 12.8%
District of Columbia 535,632 21.5% 42.8% 23.8% 12.0%
Florida 16,318,656 25.8% 33.3% 24.1% 16.8%
Georgia 8,326,251 29.6% 39.1% 22.1% 9.2%
Hawaii 1,208,537 26.7% 35.3% 24.7% 13.3%
Idaho 1,308,320 31.1% 34.4% 23.6% 10.9%
Illinois 12,279,027 28.7% 36.8% 23.0% 11.4%
Indiana 5,980,881 28.7% 36.0% 23.4% 11.9%
Iowa 2,832,392 26.8% 34.5% 24.7% 14.1%
Kansas 2,634,122 28.7% 35.4% 23.2% 12.7%
Kentucky 3,978,103 25.8% 36.9% 25.2% 12.0%
Louisiana 4,347,642 29.9% 35.4% 23.3% 11.3%
Maine 1,259,547 24.3% 34.6% 27.2% 13.8%
Maryland 5,321,993 28.3% 36.3% 24.4% 11.0%
Massachusetts 6,210,578 25.4% 37.3% 24.4% 13.0%
Michigan 9,797,198 28.6% 35.3% 24.1% 11.9%
Minnesota 4,882,303 28.1% 36.7% 23.9% 11.3%
Mississippi 2,775,227 30.0% 35.4% 22.9% 11.7%
Missouri 5,505,963 27.7% 35.4% 24.1% 12.8%
Montana 884,587 27.0% 32.7% 27.2% 13.1%
Nebraska 1,677,978 28.5% 35.3% 23.3% 12.8%
Nevada 2,139,794 28.9% 36.6% 23.6% 10.9%
New Hampshire 1,238,917 26.8% 36.0% 25.7% 11.4%
New Jersey 8,395,357 27.3% 35.6% 24.4% 12.6%
New Mexico 1,818,718 30.1% 34.4% 23.4% 12.1%
New York 18,571,545 26.9% 36.7% 23.9% 12.5%
North Carolina 8,063,874 27.7% 37.0% 23.7% 11.6%
North Dakota 610,245 26.4% 35.3% 24.3% 14.1%
Ohio 11,122,112 28.1% 35.1% 24.0% 12.8%
Oklahoma 3,379,515 28.2% 35.1% 24.0% 12.8%
Oregon 3,444,153 27.0% 35.4% 25.2% 12.3%
Pennsylvania 11,897,522 26.0% 34.0% 25.0% 14.9%
Rhode Island 1,030,762 24.7% 37.1% 24.2% 14.0%
South Carolina 3,971,899 26.8% 36.4% 25.1% 11.7%
South Dakota 731,963 29.0% 33.9% 23.4% 13.7%
Tennessee 5,644,716 27.0% 36.1% 24.8% 12.0%
Texas 21,215,494 31.4% 37.3% 21.8% 9.6%
Utah 2,275,861 34.5% 38.7% 18.4% 8.4%
Vermont 595,826 25.4% 34.8% 27.4% 12.5%
Virginia 7,063,247 27.4% 37.2% 24.5% 10.9%
Washington 5,930,307 27.9% 36.7% 24.5% 10.8%
West Virginia 1,758,096 24.3% 33.4% 27.3% 15.0%
Wisconsin 5,285,604 27.5% 35.7% 24.3% 12.5%
Wyoming 484,833 27.7% 33.9% 26.7% 11.6%
This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the Bureau of the Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples
during 2002.
*Sum of percentages may not equal 100 percent due to rounding.

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-6
Race Demographics, 2002*

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

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-7
Hispanic Demographics, 2002

State Total Population Hispanic Population Percent Hispanic
National Total 280,540,330 37,872,475 13.5%
Alabama 4,370,221 86,450 2.0%
Alaska 624,252 25,156 4.0%
Arizona 5,346,616 1,452,223 27.2%
Arkansas 2,634,848 92,400 3.5%
California 34,292,871 11,647,324 34.0%
Colorado 4,403,659 801,801 18.2%
Connecticut 3,350,345 334,926 10.0%
Delaware 782,221 40,625 5.2%
District of Columbia 535,632 51,068 9.5%
Florida 16,318,656 2,969,016 18.2%
Georgia 8,326,251 502,157 6.0%
Hawaii 1,208,537 87,769 7.3%
Idaho 1,308,320 111,295 8.5%
Illinois 12,279,027 1,663,514 13.5%
Indiana 5,980,881 231,613 3.9%
Iowa 2,832,392 87,447 3.1%
Kansas 2,634,122 184,148 7.0%
Kentucky 3,978,103 65,532 1.6%
Louisiana 4,347,642 106,445 2.4%
Maine 1,259,547 8,870 0.7%
Maryland 5,321,993 253,012 4.8%
Massachusetts 6,210,578 451,811 7.3%
Michigan 9,797,198 336,104 3.4%
Minnesota 4,882,303 157,540 3.2%
Mississippi 2,775,227 31,985 1.2%
Missouri 5,505,963 112,698 2.0%
Montana 884,587 17,398 2.0%
Nebraska 1,677,978 101,573 6.1%
Nevada 2,139,794 458,223 21.4%
New Hampshire 1,238,917 20,756 1.7%
New Jersey 8,395,357 1,198,470 14.3%
New Mexico 1,818,718 783,315 43.1%
New York 18,571,545 2,997,676 16.1%
North Carolina 8,063,874 434,048 5.4%
North Dakota 610,245 7,403 1.2%
Ohio 11,122,112 225,447 2.0%
Oklahoma 3,379,515 185,361 5.5%
Oregon 3,444,153 306,244 8.9%
Pennsylvania 11,897,522 388,046 3.3%
Rhode Island 1,030,762 96,510 9.4%
South Carolina 3,971,899 104,814 2.6%
South Dakota 731,963 10,404 1.4%
Tennessee 5,644,716 132,687 2.4%
Texas 21,215,494 7,191,546 33.9%
Utah 2,275,861 220,283 9.7%
Vermont 595,826 4,803 0.8%
Virginia 7,063,247 363,544 5.1%
Washington 5,930,307 480,917 8.1%
West Virginia 1,758,096 12,211 0.7%
Wisconsin 5,285,604 205,397 3.9%
Wyoming 484,833 32,470 6.7%
This information was taken from the 2002 American Community Survey conducted by the U.S. Bureau of The Census. The information
provided is limited to the household population and excludes the population living in institutions, college dormitories, and other group
quarters. This accounts for the difference in the estimates of the U.S. population from this source compared to other estimates presented by
the U.S. Census. The data are based on a sample and are subject to sampling variability. Data based on twelve monthly samples during
2002.

Source: U.S. Department of Commerce, Bureau of the Census, 2002 American Community Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-8
Insurance Status - Populations, 2002*

State

Total
Population
Medicaid
Population
Medicare
Population
Military
Insurance

Privately
Insured
Not
Insured
National Total 285,933,000 33,246,000 38,448,000 10,063,000 198,973,000 43,574,000
Alabama 4,440,000 459,000 754,000 171,000 3,143,000 564,000
Alaska 635,000 92,000 53,000 81,000 399,000 119,000
Arizona 5,442,000 666,000 792,000 363,000 3,555,000 916,000
Arkansas 2,692,000 396,000 487,000 203,000 1,644,000 440,000
California 35,159,000 4,985,000 3,777,000 1,046,000 22,891,000 6,398,000
Colorado 4,476,000 331,000 501,000 299,000 3,211,000 720,000
Connecticut 3,383,000 314,000 544,000 82,000 2,610,000 356,000
Delaware 798,000 86,000 112,000 30,000 608,000 79,000
District of Columbia 572,000 103,000 75,000 12,000 373,000 74,000
Florida 16,429,000 1,764,000 3,020,000 820,000 10,666,000 2,843,000
Georgia 8,426,000 863,000 869,000 309,000 5,924,000 1,354,000
Hawaii 1,224,000 128,000 173,000 104,000 899,000 123,000
Idaho 1,300,000 136,000 162,000 44,000 903,000 233,000
Illinois 12,504,000 1,180,000 1,618,000 142,000 9,086,000 1,767,000
Indiana 6,100,000 458,000 850,000 98,000 4,628,000 797,000
Iowa 2,903,000 275,000 436,000 75,000 2,314,000 277,000
Kansas 2,684,000 216,000 377,000 194,000 2,084,000 280,000
Kentucky 4,046,000 471,000 641,000 342,000 2,828,000 548,000
Louisiana 4,447,000 694,000 602,000 208,000 2,703,000 820,000
Maine 1,269,000 204,000 229,000 55,000 885,000 144,000
Maryland 5,458,000 355,000 653,000 211,000 4,203,000 730,000
Massachusetts 6,471,000 769,000 890,000 145,000 4,772,000 644,000
Michigan 9,910,000 1,158,000 1,279,000 89,000 7,494,000 1,158,000
Minnesota 5,054,000 489,000 586,000 118,000 4,158,000 397,000
Mississippi 2,787,000 559,000 387,000 108,000 1,703,000 465,000
Missouri 5,585,000 594,000 745,000 192,000 4,253,000 646,000
Montana 906,000 108,000 157,000 62,000 618,000 139,000
Nebraska 1,704,000 167,000 237,000 69,000 1,312,000 174,000
Nevada 2,121,000 127,000 265,000 85,000 1,464,000 418,000
New Hampshire 1,266,000 78,000 164,000 41,000 1,015,000 125,000
New Jersey 8,605,000 789,000 1,241,000 106,000 6,378,000 1,197,000
New Mexico 1,840,000 313,000 294,000 86,000 1,047,000 388,000
New York 19,283,000 2,964,000 2,617,000 278,000 12,635,000 3,042,000
North Carolina 8,162,000 942,000 1,190,000 449,000 5,393,000 1,368,000
North Dakota 633,000 56,000 94,000 35,000 481,000 69,000
Ohio 11,282,000 1,061,000 1,554,000 213,000 8,640,000 1,344,000
Oklahoma 3,477,000 411,000 511,000 205,000 2,280,000 601,000
Oregon 3,510,000 438,000 488,000 126,000 2,475,000 511,000
Pennsylvania 12,189,000 1,187,000 2,033,000 235,000 9,311,000 1,380,000
Rhode Island 1,056,000 165,000 161,000 16,000 763,000 104,000
South Carolina 3,997,000 607,000 678,000 183,000 2,701,000 500,000
South Dakota 744,000 74,000 102,000 38,000 570,000 85,000
Tennessee 5,672,000 1,091,000 734,000 212,000 3,883,000 614,000
Texas 21,529,000 2,425,000 2,339,000 762,000 12,738,000 5,556,000
Utah 2,310,000 219,000 192,000 60,000 1,743,000 310,000
Vermont 619,000 112,000 86,000 14,000 438,000 66,000
Virginia 7,118,000 496,000 891,000 716,000 5,203,000 962,000
Washington 6,001,000 782,000 684,000 301,000 4,214,000 850,000
West Virginia 1,751,000 299,000 360,000 80,000 1,107,000 255,000
Wisconsin 5,476,000 545,000 701,000 124,000 4,298,000 538,000
Wyoming 488,000 45,000 65,000 26,000 334,000 86,000
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one
category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement,
March 2003.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-9
Insurance Status - Percentages, 2002*
State

Total
Population
% Covered by
Medicaid
% Covered by
Medicare
% Covered by
Military
Insurance
% Covered by
Private
Insurance % Not Insured
National Total 285,933,000 11.6% 13.4% 3.5% 69.6% 15.2%
Alabama 4,440,000 10.3% 17.0% 3.9% 70.8% 12.7%
Alaska 635,000 14.5% 8.3% 12.8% 62.8% 18.7%
Arizona 5,442,000 12.2% 14.6% 6.7% 65.3% 16.8%
Arkansas 2,692,000 14.7% 18.1% 7.5% 61.1% 16.3%
California 35,159,000 14.2% 10.7% 3.0% 65.1% 18.2%
Colorado 4,476,000 7.4% 11.2% 6.7% 71.7% 16.1%
Connecticut 3,383,000 9.3% 16.1% 2.4% 77.2% 10.5%
Delaware 798,000 10.8% 14.0% 3.8% 76.2% 9.9%
District of Columbia 572,000 18.0% 13.1% 2.1% 65.2% 12.9%
Florida 16,429,000 10.7% 18.4% 5.0% 64.9% 17.3%
Georgia 8,426,000 10.2% 10.3% 3.7% 70.3% 16.1%
Hawaii 1,224,000 10.5% 14.1% 8.5% 73.4% 10.0%
Idaho 1,300,000 10.5% 12.5% 3.4% 69.5% 17.9%
Illinois 12,504,000 9.4% 12.9% 1.1% 72.7% 14.1%
Indiana 6,100,000 7.5% 13.9% 1.6% 75.9% 13.1%
Iowa 2,903,000 9.5% 15.0% 2.6% 79.7% 9.5%
Kansas 2,684,000 8.0% 14.0% 7.2% 77.6% 10.4%
Kentucky 4,046,000 11.6% 15.8% 8.5% 69.9% 13.5%
Louisiana 4,447,000 15.6% 13.5% 4.7% 60.8% 18.4%
Maine 1,269,000 16.1% 18.0% 4.3% 69.7% 11.3%
Maryland 5,458,000 6.5% 12.0% 3.9% 77.0% 13.4%
Massachusetts 6,471,000 11.9% 13.8% 2.2% 73.7% 10.0%
Michigan 9,910,000 11.7% 12.9% 0.9% 75.6% 11.7%
Minnesota 5,054,000 9.7% 11.6% 2.3% 82.3% 7.9%
Mississippi 2,787,000 20.1% 13.9% 3.9% 61.1% 16.7%
Missouri 5,585,000 10.6% 13.3% 3.4% 76.2% 11.6%
Montana 906,000 11.9% 17.3% 6.8% 68.2% 15.3%
Nebraska 1,704,000 9.8% 13.9% 4.0% 77.0% 10.2%
Nevada 2,121,000 6.0% 12.5% 4.0% 69.0% 19.7%
New Hampshire 1,266,000 6.2% 13.0% 3.2% 80.2% 9.9%
New Jersey 8,605,000 9.2% 14.4% 1.2% 74.1% 13.9%
New Mexico 1,840,000 17.0% 16.0% 4.7% 56.9% 21.1%
New York 19,283,000 15.4% 13.6% 1.4% 65.5% 15.8%
North Carolina 8,162,000 11.5% 14.6% 5.5% 66.1% 16.8%
North Dakota 633,000 8.8% 14.8% 5.5% 76.0% 10.9%
Ohio 11,282,000 9.4% 13.8% 1.9% 76.6% 11.9%
Oklahoma 3,477,000 11.8% 14.7% 5.9% 65.6% 17.3%
Oregon 3,510,000 12.5% 13.9% 3.6% 70.5% 14.6%
Pennsylvania 12,189,000 9.7% 16.7% 1.9% 76.4% 11.3%
Rhode Island 1,056,000 15.6% 15.2% 1.5% 72.3% 9.8%
South Carolina 3,997,000 15.2% 17.0% 4.6% 67.6% 12.5%
South Dakota 744,000 9.9% 13.7% 5.1% 76.6% 11.4%
Tennessee 5,672,000 19.2% 12.9% 3.7% 68.5% 10.8%
Texas 21,529,000 11.3% 10.9% 3.5% 59.2% 25.8%
Utah 2,310,000 9.5% 8.3% 2.6% 75.5% 13.4%
Vermont 619,000 18.1% 13.9% 2.3% 70.8% 10.7%
Virginia 7,118,000 7.0% 12.5% 10.1% 73.1% 13.5%
Washington 6,001,000 13.0% 11.4% 5.0% 70.2% 14.2%
West Virginia 1,751,000 17.1% 20.6% 4.6% 63.2% 14.6%
Wisconsin 5,476,000 10.0% 12.8% 2.3% 78.5% 9.8%
Wyoming 488,000 9.2% 13.3% 5.3% 68.4% 17.6%
*The sum of rows may be greater than the total State population because individuals may have dual coverage and appear in more than one
category.
Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2003 Annual Social and Economic Supplement,
March 2003.

National Pharmaceutical Council Pharmaceutical Benefits 2003
3-10
Poverty Status - Populations, 2002
State
Total
Population
Population
Below 100%
FPL*
Population
Below 135%
FPL*
Population
Below 150%
FPL*
Population
Below 200%
FPL*
National Total 285,317,000 34,570,000 52,736,000 61,054,000 87,028,000
Alabama 4,432,000 640,000 979,000 1,094,000 1,490,000
Alaska 632,000 56,000 89,000 106,000 153,000
Arizona 5,424,000 735,000 1,120,000 1,305,000 1,791,000
Arkansas 2,690,000 532,000 695,000 808,000 1,086,000
California 35,068,000 4,605,000 7,092,000 8,406,000 11,563,000
Colorado 4,470,000 436,000 670,000 779,000 1,159,000
Connecticut 3,377,000 279,000 434,000 518,000 763,000
Delaware 796,000 73,000 112,000 130,000 197,000
District of Columbia 570,000 97,000 133,000 149,000 191,000
Florida 16,391,000 2,058,000 3,297,000 3,818,000 5,438,000
Georgia 8,413,000 939,000 1,434,000 1,650,000 2,511,000
Hawaii 1,219,000 138,000 194,000 225,000 330,000
Idaho 1,296,000 147,000 235,000 292,000 437,000
Illinois 12,495,000 1,594,000 2,269,000 2,566,000 3,630,000
Indiana 6,086,000 552,000 908,000 1,097,000 1,730,000
Iowa 2,899,000 267,000 447,000 530,000 783,000
Kansas 2,681,000 269,000 407,000 496,000 725,000
Kentucky 4,033,000 571,000 849,000 976,000 1,370,000
Louisiana 4,445,000 777,000 1,137,000 1,336,000 1,688,000
Maine 1,265,000 170,000 245,000 280,000 408,000
Maryland 5,419,000 400,000 608,000 706,000 1,057,000
Massachusetts 6,469,000 648,000 977,000 1,134,000 1,563,000
Michigan 9,897,000 1,152,000 1,715,000 1,919,000 2,861,000
Minnesota 5,044,000 325,000 540,000 668,000 1,016,000
Mississippi 2,785,000 513,000 780,000 891,000 1,127,000
Missouri 5,581,000 551,000 864,000 1,012,000 1,487,000
Montana 902,000 122,000 202,000 244,000 331,000
Nebraska 1,700,000 181,000 289,000 328,000 474,000
Nevada 2,114,000 188,000 357,000 430,000 657,000
New Hampshire 1,264,000 73,000 117,000 147,000 242,000
New Jersey 8,585,000 681,000 1,060,000 1,237,000 1,862,000
New Mexico 1,837,000 328,000 475,000 540,000 747,000
New York 19,224,000 2,690,000 3,868,000 4,434,000 6,115,000
North Carolina 8,146,000 1,165,000 1,711,000 2,003,000 2,801,000
North Dakota 632,000 73,000 113,000 130,000 194,000
Ohio 11,253,000 1,099,000 1,727,000 2,054,000 3,034,000
Oklahoma 3,473,000 489,000 761,000 875,000 1,232,000
Oregon 3,503,000 380,000 638,000 761,000 1,059,000
Pennsylvania 12,168,000 1,152,000 1,902,000 2,209,000 3,238,000
Rhode Island 1,055,000 116,000 175,000 200,000 276,000
South Carolina 3,989,000 568,000 824,000 963,000 1,290,000
South Dakota 743,000 85,000 131,000 153,000 234,000
Tennessee 5,655,000 839,000 1,236,000 1,368,000 1,934,000
Texas 21,482,000 3,362,000 5,066,000 5,710,000 8,348,000
Utah 2,308,000 228,000 395,000 452,000 655,000
Vermont 616,000 61,000 99,000 115,000 164,000
Virginia 7,108,000 702,000 986,000 1,113,000 1,739,000
Washington 5,988,000 657,000 1,075,000 1,194,000 1,678,000
West Virginia 1,747,000 293,000 438,000 520,000 720,000
Wisconsin 5,463,000 467,000 786,000 893,000 1,300,000
Wyoming 488,000 44,000 72,000 90,000 151,000
*FPL- Federal Poverty Level

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
3-11
Poverty Status - Percentages, 2002
State
Total
Population
Percent
Below 100%
FPL*
Percent
Below 135%
FPL*
Percent
Below 150%
FPL*
Percent
Below 200%
FPL*
National Total 285,317,000 12.1% 22.1% 21.4% 30.5%
Alabama 4,432,000 14.5% 14.1% 24.7% 33.6%
Alaska 632,000 8.8% 20.6% 16.7% 24.2%
Arizona 5,424,000 13.5% 25.8% 24.1% 33.0%
Arkansas 2,690,000 19.8% 20.2% 30.0% 40.4%
California 35,068,000 13.1% 15.0% 24.0% 33.0%
Colorado 4,470,000 9.8% 12.9% 17.4% 25.9%
Connecticut 3,377,000 8.3% 14.0% 15.3% 22.6%
Delaware 796,000 9.1% 23.4% 16.3% 24.7%
District of Columbia 570,000 17.0% 20.1% 26.1% 33.5%
Florida 16,391,000 12.6% 17.0% 23.3% 33.2%
Georgia 8,413,000 11.2% 15.9% 19.6% 29.8%
Hawaii 1,219,000 11.3% 18.2% 18.5% 27.1%
Idaho 1,296,000 11.3% 18.2% 22.5% 33.7%
Illinois 12,495,000 12.8% 14.9% 20.5% 29.1%
Indiana 6,086,000 9.1% 15.4% 18.0% 28.4%
Iowa 2,899,000 9.2% 15.2% 18.3% 27.0%
Kansas 2,681,000 10.1% 21.0% 18.5% 27.0%
Kentucky 4,033,000 14.2% 25.6% 24.2% 34.0%
Louisiana 4,445,000 17.5% 19.4% 30.1% 38.0%
Maine 1,265,000 13.4% 11.2% 22.2% 32.2%
Maryland 5,419,000 7.4% 15.1% 13.0% 19.5%
Massachusetts 6,469,000 10.0% 17.3% 17.5% 24.2%
Michigan 9,897,000 11.6% 10.7% 19.4% 28.9%
Minnesota 5,044,000 6.5% 28.0% 13.2% 20.1%
Mississippi 2,785,000 18.4% 15.5% 32.0% 40.5%
Missouri 5,581,000 9.9% 22.4% 18.1% 26.7%
Montana 902,000 13.5% 17.0% 27.0% 36.7%
Nebraska 1,700,000 10.6% 16.9% 19.3% 27.9%
Nevada 2,114,000 8.9% 9.2% 20.3% 31.1%
New Hampshire 1,264,000 5.8% 12.4% 11.6% 19.1%
New Jersey 8,585,000 7.9% 25.9% 14.4% 21.7%
New Mexico 1,837,000 17.9% 20.1% 29.4% 40.7%
New York 19,224,000 14.0% 21.0% 23.1% 31.8%
North Carolina 8,146,000 14.3% 17.9% 24.6% 34.4%
North Dakota 632,000 11.6% 15.3% 20.6% 30.7%
Ohio 11,253,000 9.8% 21.9% 18.3% 27.0%
Oklahoma 3,473,000 14.1% 18.2% 25.2% 35.5%
Oregon 3,503,000 10.9% 15.6% 21.7% 30.2%
Pennsylvania 12,168,000 9.5% 16.5% 18.2% 26.6%
Rhode Island 1,055,000 11.0% 20.7% 18.9% 26.2%
South Carolina 3,989,000 14.3% 17.6% 24.2% 32.3%
South Dakota 743,000 11.5% 21.9% 20.5% 31.5%
Tennessee 5,655,000 14.8% 23.6% 24.2% 34.2%
Texas 21,482,000 15.6% 17.1% 26.6% 38.9%
Utah 2,308,000 9.9% 16.1% 19.6% 28.4%
Vermont 616,000 9.9% 13.9% 18.7% 26.7%
Virginia 7,108,000 9.9% 17.9% 15.7% 24.5%
Washington 5,988,000 11.0% 25.1% 19.9% 28.0%
West Virginia 1,747,000 16.8% 14.4% 29.8% 41.2%
Wisconsin 5,463,000 8.6% 14.7% 16.3% 23.8%
Wyoming 488,000 9.0% 22.1% 18.4% 30.9%
*FPL- Federal Poverty Level

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


National Pharmaceutical Council Pharmaceutical Benefits 2003
3-12
Employment Status, 2003*
State
Total
Population
Civilian
Labor Force
Population
Unemployed
Unemployment
Rate
National Total
221,168,000
146,510,000 8,774,000 6.0%
Alabama 3,442,000 2,147,000 125,000 5.8%
Alaska 459,000 332,000 27,000 8.0%
Arizona 4,131,000 2,690,000 151,000 5.6%
Arkansas 2,071,000 1,265,000 78,000 6.2%
California 26,490,000 17,460,000 1,177,000 6.7%
Colorado 3,440,000 2,478,000 150,000 6.0%
Connecticut 2,680,000 1,803,000 99,000 5.5%
Delaware 625,000 417,000 18,000 4.4%
District of Columbia 454,000 302,000 21,000 7.0%
Florida 13,211,000 8,164,000 420,000 5.1%
Georgia 6,431,000 4,414,000 207,000 4.7%
Hawaii 944,000 618,000 27,000 4.3%
Idaho 1,013,000 693,000 37,000 5.4%
Illinois 9,583,000 6,330,000 422,000 6.7%
Indiana 4,679,000 3,188,000 163,000 5.1%
Iowa 2,286,000 1,612,000 72,000 4.5%
Kansas 2,049,000 1,434,000 77,000 5.4%
Kentucky 3,153,000 1,956,000 120,000 6.2%
Louisiana 3,348,000 2,037,000 134,000 6.6%
Maine 1,039,000 693,000 35,000 5.1%
Maryland 4,181,000 2,904,000 131,000 4.5%
Massachusetts 5,028,000 3,416,000 198,000 5.8%
Michigan 7,706,000 5,042,000 368,000 7.3%
Minnesota 3,896,000 2,923,000 145,000 5.0%
Mississippi 2,138,000 1,312,000 83,000 6.3%
Missouri 4,352,000 3,021,000 170,000 5.6%
Montana 714,000 475,000 22,000 4.7%
Nebraska 1,318,000 976,000 39,000 4.0%
Nevada 1,686,000 1,141,000 59,000 5.2%
New Hampshire 1,005,000 719,000 31,000 4.3%
New Jersey 6,619,000 4,375,000 257,000 5.9%
New Mexico 1,401,000 897,000 57,000 6.4%
New York 14,891,000 9,315,000 589,000 6.3%
North Carolina 6,328,000 4,230,000 273,000 6.5%
North Dakota 490,000 346,000 14,000 4.0%
Ohio 8,771,000 5,915,000 363,000 6.1%
Oklahoma 2,646,000 1,696,000 96,000 5.7%
Oregon 2,770,000 1,859,000 152,000 8.2%
Pennsylvania 9,663,000 6,170,000 344,000 5.6%
Rhode Island 844,000 573,000 30,000 5.3%
South Carolina 3,142,000 2,003,000 136,000 6.8%
South Dakota 576,000 425,000 15,000 3.6%
Tennessee 4,501,000 2,909,000 169,000 5.8%
Texas 16,047,000 10,910,000 738,000 6.8%
Utah 1,660,000 1,184,000 67,000 5.6%
Vermont 494,000 351,000 16,000 4.6%
Virginia 5,532,000 3,773,000 154,000 4.1%
Washington 4,697,000 3,140,000 237,000 7.5%
West Virginia 1,442,000 787,000 48,000 6.1%
Wisconsin 4,224,000 3,078,000 174,000 5.6%
Wyoming 387,000 278,000 12,000 4.4%
*This information was compiled from the U.S. Department of Labor, Bureau of Labor Statistics News Release on State and
Regional Unemployment, 2003 Annual Averages, released on February 27, 2004. The table summarizes the employment
status of the civilian noninstitutional population, 16 years of age and over, by state.

Source: U.S. Department of Labor, Bureau of Labor Statistics, February 27, 2004.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-13
Medicaid/Medicare Certified Facilities, 2003
State Hospitals
Skilled Nursing
Facilities
ICF-MR
Facilities
Home Health
Agencies
Rural Health
Clinics
National Total* 5,988 14,926 6,606 7,163 3,401
Alabama 122 225 7 140 61
Alaska 24 14 0 15 6
Arizona 89 134 13 62 6
Arkansas 108 199 41 174 72
California 437 1,256 1,109 604 244
Colorado 84 194 3 129 37
Connecticut 46 252 120 83 0
Delaware 10 37 2 14 0
District of Columbia 14 20 126 15 0
Florida 235 689 107 421 148
Georgia 176 333 13 97 102
Hawaii 27 41 17 14 0
Idaho 47 77 66 49 42
Illinois 216 673 309 298 197
Indiana 157 489 562 161 50
Iowa 119 359 130 180 127
Kansas 150 263 37 131 172
Kentucky 116 296 14 108 105
Louisiana 214 285 480 228 52
Maine 41 120 21 31 46
Maryland 65 233 4 45 0
Massachusetts 112 468 7 114 0
Michigan 176 394 1 212 158
Minnesota 147 404 225 223 68
Mississippi 105 164 13 60 128
Missouri 137 477 20 160 248
Montana 64 100 2 46 40
Nebraska 94 177 4 62 76
Nevada 41 42 19 45 6
New Hampshire 30 70 1 36 19
New Jersey 106 356 9 52 0
New Mexico 53 71 44 58 10
New York 249 669 720 198 9
North Carolina 139 420 330 169 111
North Dakota 50 83 66 30 64
Ohio 211 929 421 351 16
Oklahoma 151 256 68 186 48
Oregon 62 121 1 59 36
Pennsylvania 246 723 194 279 44
Rhode Island 15 95 5 21 1
South Carolina 76 178 132 71 90
South Dakota 67 90 1 47 56
Tennessee 152 305 83 138 37
Texas 499 1,011 909 1,045 338
Utah 48 80 14 47 15
Vermont 16 42 1 12 18
Virginia 109 244 21 156 52
Washington 101 249 14 61 104
West Virginia 66 121 61 65 64
Wisconsin 140 365 37 123 59
Wyoming 29 33 2 38 19
*National total does not include certified facilities in Puerto Rico and U.S. territories.
Source: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, December
9, 2003.
National Pharmaceutical Council Pharmaceutical Benefits 2003
3-14
Licensed Pharmacies (As of June 30, 2003)*
State
Total
Pharmacies
Hospital/
Institutional
Pharmacies
Independent
Community
Pharmacies
Chain Pharmacies
(Four or More)
Out-of-State or
Non-Resident
Pharmacies
National Total 78,505 8,729 20,249 15,835 11,756
Alabama 1,873 165 744 578 361
Alaska 158 (G) 17 (H) 264
Arizona 1,872 149 204 1,033 257
Arkansas 745 186 415 330 182
California 6,204 602 202
Colorado 1,083 424
Connecticut 605 (D) 50 (D) 168 (D) 437 (D) 277 (D)
Delaware 165 11 31 134 258
District of Columbia 123 13 27 61 0
Florida 6,567 2,097 4,098 (A) (A) 341
Georgia 3,689 205 (P) (P)
Hawaii 224 162
Idaho 639 69 255 (A, E) 231
Illinois 2,451 342 2,183 (A) (A) 296
Indiana 1,367 205 371
Iowa 1,242 130 (F) 791 (A, F) (A) 301
Kansas 802 172 630 (A) 332
Kentucky 1,514 138 475 749 176
Louisiana 1,818 179 573 541 353
Maine 290 42 187
Maryland 1,425 (I) 66 155 689 296
Massachusetts 1,048 (J) 158 250 740 0
Michigan 2547 150
Minnesota 1,471 138 537 545 280
Mississippi 962 130 220
Missouri 1,543 (K) 173 646 661 371
Montana 317 99 153
Nebraska 487 255 (L)
Nevada 731 268
New Hampshire 269 32 39 177 245
New Jersey 2,489
New Mexico 612 61 298 (A) 283
New York 4,518 493 (Q) 1,993 2,029 91
North Carolina 2,062 (F) 161 561 968 259
North Dakota 530 43 149 32 249
Ohio 2,953 (N) 219 559 1,581 328
Oklahoma 1,304 81 (D) 860 (A) (A) 343
Oregon 1,119 122 310 457 242
Pennsylvania 3,148 291 0
Rhode Island 191 20 41 5 227
South Carolina
1,132 346
South Dakota 507 44 130 89 254
Tennessee 1,852 405 508 822 117
Texas 5,753 (B) 847 1,720 2,430 289
Utah 280 99 415 (A) A 246
Vermont 155 18 139 0
Virginia 1,515 426
Washington 1,588 228 (C) 345 747 268
West Virginia 544 308
Wisconsin 1,286 0
Wyoming 134 (F) 29 276
*Figures reported reflect number of pharmacies licensed by state boards of pharmacy. Individual columns will not sum to
total. Total includes other pharmacies not specified in the four practice settings. Blanks indicate that information was not
available.
Source: 2003-2004 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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LEGEND

A — Chains included in independent community pharmacies figure.
B — Also licenses 873 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies.
C — Includes 121 hospital, 23 nursing home, 18 home infusion, 8 nuclear, 40 HMO, and 18 other pharmacies.
D — Approximately.
E — Plus 22 limited service and 61 parenteral admixture pharmacies.
F — In-state.
G — Includes 21 wholesalers drug distributors.
H — Drug rooms.
I — Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV, nuclear, research, and other.
89 pharmacies have waiver (specialty) permits. Board issued 582 distributor permits.
J — Total also includes home IV and mail-order pharmacies.
K — Includes the following pharmacy categories: 30 long-term care, 17 home health, 8 radiopharmaceutical, 2 renal
dialysis, 1 sterile pharmaceuticals, 2 consultants pharmacies.
L — Nebraska “registers” out-of-state pharmacies.
N — Includes 263 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmacies serving nursing homes only.
P — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic
pharmacies, and 2 pharmacy schools).
Q — 16 nuclear pharmacies.











National Pharmaceutical Council Pharmaceutical Benefits 2003
3-16
Physicians, 2001
State Physicians
Physicians
Per 1,000 Pop.
Office Based
Physicians
Percent
Office Based
Primary Care
Physicians*
Percent
Primary Care
National Total 820,869 3.0 507,015 61.8% 313,078 38.1%
Alabama 10,009 2.3 6,743 67.4% 4,208 42.0%
Alaska 1,414 2.3 991 70.1% 756 53.5%
Arizona 12,660 2.4 7,872 62.2% 4,511 35.6%
Arkansas 5,856 2.2 3,889 66.4% 2,883 49.2%
California 99,547 3.0 62,387 62.7% 36,298 36.5%
Colorado 12,095 2.8 7,906 65.4% 4,893 40.5%
Connecticut 13,657 4.1 8,016 58.7% 4,227 31.0%
Delaware 2,152 2.8 1,387 64.5% 824 38.3%
District of Columbia 4,490 8.4 2,082 46.4% 1,180 26.3%
Florida 47,299 3.0 30,148 63.7% 15,311 32.4%
Georgia 19,837 2.4 13,015 65.6% 7,448 37.5%
Hawaii 4,044 3.4 2,606 64.4% 1,420 35.1%
Idaho 2,448 1.9 1,812 74.0% 1,181 48.2%
Illinois 36,361 3.0 21,875 60.2% 14,576 40.1%
Indiana 13,887 2.3 9,378 67.5% 6,356 45.8%
Iowa 6,041 2.1 3,727 61.7% 2,891 47.9%
Kansas 6,533 2.5 4,147 63.5% 2,965 45.4%
Kentucky 9,678 2.4 6,641 68.6% 4,076 42.1%
Louisiana 12,439 2.9 7,956 64.0% 4,466 35.9%
Maine 3,708 3.0 2,423 65.3% 1,653 44.6%
Maryland 23,857 4.6 13,018 54.6% 7,092 29.7%
Massachusetts 29,336 4.8 15,944 54.3% 8,752 29.8%
Michigan 25,710 2.6 15,280 59.4% 9,913 38.6%
Minnesota 14,752 3.1 9,283 62.9% 7,352 49.8%
Mississippi 5,544 2.0 3,741 67.5% 2,221 40.1%
Missouri 14,350 2.6 8,799 61.3% 5,209 36.3%
Montana 2,292 2.6 1,642 71.6% 1,013 44.2%
Nebraska 4,399 2.6 2,829 64.3% 2,286 52.0%
Nevada 4,280 2.1 3,050 71.3% 1,599 37.4%
New Hampshire 3,609 2.9 2,310 64.0% 1,423 39.4%
New Jersey 28,179 3.4 17,727 62.9% 9,672 34.3%
New Mexico 4,678 2.6 2,815 60.2% 1,996 42.7%
New York 79,541 4.3 42,839 53.9% 25,738 32.4%
North Carolina 21,899 2.8 13,922 63.6% 8,668 39.6%
North Dakota 1,602 2.6 1,094 68.3% 879 54.9%
Ohio 30,880 2.8 19,072 61.8% 12,208 39.5%
Oklahoma 6,572 2.0 4,278 65.1% 2,794 42.5%
Oregon 9,748 2.9 6,347 65.1% 3,861 39.6%
Pennsylvania 40,063 3.4 23,701 59.2% 14,387 35.9%
Rhode Island 3,942 3.9 2,254 57.2% 1,365 34.6%
South Carolina 9,939 2.5 6,600 66.4% 4,253 42.8%
South Dakota 1,755 2.4 1,220 69.5% 886 50.5%
Tennessee 15,695 2.8 10,437 66.5% 6,179 39.4%
Texas 48,339 2.3 31,647 65.5% 18,647 38.6%
Utah 5,165 2.3 3,337 64.6% 2,036 39.4%
Vermont 2,403 4.1 1,399 58.2% 1,029 42.8%
Virginia 20,880 3.0 13,050 62.5% 8,082 38.7%
Washington 17,404 3.0 11,170 64.2% 7,527 43.2%
West Virginia 4,498 2.6 2,812 62.5% 1,956 43.5%
Wisconsin 14,374 2.7 9,667 67.3% 6,666 46.4%
Wyoming 1,029 2.1 730 70.9% 557 54.1%
*Primary care physicians include General Practice, General Family Practice, General Internal Medicine, and General
Pediatrics.
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003.

National Pharmaceutical Council Pharmaceutical Benefits 2003
3-17
Other Providers, 2001/2003
State
# FTE
Registered
Nurses*
# FTE
Registered Nurses*
per 1,000 population
Pharmacists**
(Licensed by State)
Pharmacists**
per 1,000 population
National Total 962,195 3.4 356,201 1.2
Alabama 17,143 3.8 6,006 1.3
Alaska 2,339 3.7 632 1.0
Arizona 13,058 2.5 7,832 1.4
Arkansas 9,898 3.7 3,680 1.4
California 85,878 2.5 31,133 0.9
Colorado 12,034 2.7 5,586 1.2
Connecticut 9,930 2.9 4,454 1.3
Delaware 2,971 3.7 1,287 1.6
District of Columbia 5,011 8.7 1,564 2.8
Florida 56,078 3.4 20,052 1.2
Georgia 28,447 3.4 10,474 1.2
Hawaii 3,470 2.8 1,556 1.2
Idaho 3,599 2.7 1,569 1.1
Illinois 45,501 3.6 13,151 1.0
Indiana 21,436 3.5 8,480 1.4
Iowa 12,404 4.2 5,034 1.7
Kansas 9,102 3.4 3,584 1.3
Kentucky 16,213 4.0 5,008 1.2
Louisiana 17,274 3.9 5,890 1.3
Maine 5,265 4.1 1,267 1.0
Maryland 16,623 3.1 7,153 1.3
Massachusetts 24,133 3.8 9,940 1.5
Michigan 35,094 3.5 11,322 1.1
Minnesota 16,122 3.2 6,023 1.2
Mississippi 12,356 4.3 3,483 1.2
Missouri 23,650 4.2 7,149 1.3
Montana 3,205 3.5 1,503 1.6
Nebraska 7,249 4.2 2,664 1.5
Nevada 5,084 2.4 8,359 3.7
New Hampshire 4,206 3.3 1,920 1.5
New Jersey 28,082 3.3 16,245 1.9
New Mexico 5,258 2.9 2,434 1.3
New York 72,057 3.8 18,448 1.0
North Carolina 32,695 4.0 9,669 1.2
North Dakota 3,175 5.0 2,132 3.4
Ohio 43,869 3.9 14,476 1.3
Oklahoma 10,827 3.1 4,750 1.4
Oregon 11,674 3.4 4,091 1.1
Pennsylvania 48,786 4.0 17,219 1.4
Rhode Island 2,850 2.7 1,788 1.7
South Carolina 14,942 3.7 5,221 1.3
South Dakota 3,829 5.1 1,429 1.9
Tennessee 20,777 3.6 7,397 1.3
Texas 65,056 3.0 21,245 1.0
Utah 5,446 2.4 2,171 0.9
Vermont 1,656 2.7 830 1.3
Virginia 23,152 3.2 8,605 1.2
Washington 15,440 2.6 6,955 1.1
West Virginia 9,307 5.2 2,973 1.6
Wisconsin 16,878 3.1 5,737 1.0
Wyoming 1,666 3.4 997 2.0
*FTE- Full-time equivalent employees as of 2001
**As of June 30, 2003
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis,
Area Resource File, February 2003. 2003-2004 National Association of Boards of Pharmacy, Survey of Pharmacy Law.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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National Pharmaceutical Council Pharmaceutical Benefits 2003
4-1





Section 4:
Pharmacy Program
Characteristics







National Pharmaceutical Council Pharmaceutical Benefits 2003
4-2

National Pharmaceutical Council Pharmaceutical Benefits 2003
4-3

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

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT
On July 31, 1987, CMS published a notice of the final rule for limits on payments for drugs in the
Medicaid program. The regulations adopted in the rule became effective October 29, 1987 (52 FR
28648). In this final rule, CMS attempted to (1) respond to public comments on the NPRM (51 FR
2956); (2) provide maximum flexibility to the States in their administration of the Medicaid program;
(3) provide responsible but not burdensome Federal oversight of the Medicaid program; and (4) take
advantage of savings in the marketplace for multiple-source drugs.
To accomplish this, CMS adopted a Federal upper limit standard for certain multiple-source drugs,
based on application of a specific formula. The upper limit for other drugs is similar, in that it retains
the estimated acquisition cost (EAC) as the upper limit standard that State agencies must meet.
However, this standard is applied on an aggregate basis rather than on a prescription-specific basis.
State agencies are therefore encouraged to exercise maximum flexibility in establishing their own
payment methods (see the Federal Register, Vol. 52, No. 147, Friday, July 31, 1987, page 28648).
Multiple-Source Drugs
A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.
A specific upper limit for a multiple-source drug may be established if the following requirements are
met:
• All of the formulations of the drug approved by the Food and Drug Administration (FDA) have
been evaluated as therapeutically equivalent in the current edition of the publication, Approved
Drug Products with Therapeutically Equivalent Evaluations; and
• At least three suppliers list the drug (which is classified by the FDA as Category A in its
publication) in the current editions of published compendia of cost information for drugs
available for sale nationally.
The upper limit for a multi-source drug for which a specific limit has been established does not apply
if a physician certifies in his or her own handwriting that a specific brand is “medically necessary” for
a particular recipient.
The handwritten phrase “brand necessary,” “medically necessary,” or “brand medically necessary”
must appear on the face of the prescription. The rule specifically states that a check-off box on a
prescription form is not acceptable, but it does not address the use of two-line prescription forms.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-4

The formula to be used in calculating the aggregate upper limit of payment for certain multiple-source
drugs will be 150% of the least costly therapeutic equivalent that can be purchased by pharmacists in
quantities of 100 tablets or capsules (or if the drug is not commonly available in quantities of 100, the
package size commonly listed), or in the case of liquids, the commonly listed size, plus a reasonable
dispensing fee.
Other Drugs
A drug described as an “other drug” is (1) a brand name drug certified as medically necessary by the
physician, (2) a multiple-source drug not subject to the 150% formula; or (3) a single-source drug.
Payments for these drugs must not exceed, in the aggregate, payment levels determined by applying
the lower of:
• Estimated acquisition cost (EAC) plus reasonable dispensing fees; or
• The provider’s usual and customary charges to the general public.
States may continue to use their existing EAC program, or adopt another method, as long as their
aggregate expenditures do not exceed what would have been paid under EAC principles.
Other Requirements
The rule requires States to submit a State plan that describes their payment methods for prescribed
drugs. The rule does not prescribe a preferred payment method, as long as the State’s aggregate
spending in each category is equal to or below the upper limit requirements. States are also required
to submit assurances to CMS that the requirements are met.
The rule does not prescribe a preferred payment method for the States, but gives States the flexibility
to determine how they will pay for prescription drugs under Medicaid. As long as the State’s
aggregate spending is at or below the amount derived from the formula, the State is free to maintain
its current payment program or adopt other methods. States can alter payment rates for individual
drugs, balancing payment increases for certain products with payment decreases for other drugs so
that, in the aggregate, the program does not exceed the established limit. With the establishment of
upper limit payment maximums, some States may alter their current payment methods to comply with
the established limits.
State programs vary, depending upon whether or not State maximum allowable cost (MAC) programs
cover the same drugs listed by CMS. States with established MAC programs may be unaffected if
their MAC rates are already low, or they may have to make certain adjustments in their MAC levels
to meet the Federal aggregate expenditure limits. States without MAC programs may develop a new
payment method to increase the use of lower cost generic drug products in order to stay within the
upper payment limits, or may simply adopt CMS’ formula for listed drug products.
DRUG RECIPIENTS
Drug recipients are defined as individuals who received drugs, not as everyone eligible to receive
drugs. Today, all 50 States and the District of Columbia cover drugs under the Medicaid program.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-5

Drug Expenditures Trends*
State 2001 2002 % Change 2001-2002
National Total $24,656,812,921 $29,339,050,970 19.0%
Alabama $386,876,131 $452,269,953 16.9%
Alaska $55,754,050 $70,708,412 26.8%
Arizona $2,573,205 $3,725,371 44.8%
Arkansas $241,558,369 $273,257,660 13.1%
California $2,984,162,770 $3,591,537,830 20.4%
Colorado $166,000,664 $189,717,036 14.3%
Connecticut $304,780,286 $357,919,257 17.4%
Delaware $81,156,928 $97,750,161 20.4%
District of Columbia $63,504,500 $66,129,208 4.1%
Florida $1,475,766,739 $1,717,652,527 16.4%
Georgia $735,944,558 $873,703,133 18.7%
Hawaii

$74,869,859 $88,256,904 17.9%
Idaho $102,975,196 $119,177,013 15.7%
Illinois $884,018,166 $1,293,435,797 46.3%
Indiana $561,642,082 $631,637,846 12.5%
Iowa $234,716,795 $285,467,642 21.6%
Kansas $185,017,060 $213,778,616 15.5%
Kentucky $592,096,755 $652,904,065 10.3%
Louisiana $585,388,809 $714,107,841 22.0%
Maine $191,785,942 $220,420,714 14.9%
Maryland $244,203,084 $297,291,733 21.7%
Massachusetts $797,859,072 $958,972,520 20.2%
Michigan $584,670,445 $674,222,281 15.3%
Minnesota $265,726,228 $310,174,144 16.7%
Mississippi $493,177,297 $567,313,801 15.0%
Missouri $675,647,147 $790,853,387 17.1%
Montana $72,577,455 $83,587,410 15.2%
Nebraska $170,897,014 $207,782,737 21.6%
Nevada $61,500,721 $86,929,536 41.3%
New Hampshire $91,703,067 $99,682,997 8.7%
New Jersey $651,442,945 $694,669,924 6.6%
New Mexico $57,995,801 $73,877,785 27.4%
New York $2,986,292,455 $3,660,427,024 22.6%
North Carolina $984,653,306 $1,100,822,176 11.8%
North Dakota $44,067,986 $52,495,878 19.1%
Ohio $1,099,697,768 $1,333,992,298 21.3%
Oklahoma $171,188,873 $285,068,869 66.5%
Oregon $228,670,426 $279,029,096 22.0%
Pennsylvania $692,665,382 $718,210,352 3.7%
Rhode Island $102,708,476 $125,187,888 21.9%
South Carolina $438,897,100 $451,846,044 3.0%
South Dakota $51,748,770 $62,382,937 20.5%
Tennessee $681,454,847 $905,405,421 32.9%
Texas $1,325,987,804 $1,591,064,713 20.0%
Utah $117,170,006 $140,275,267 19.7%
Vermont $104,250,880 $114,157,870 9.5%
Virginia $417,689,526 $458,953,342 9.9%
Washington $458,332,414 $541,963,790 18.2%
West Virginia $259,638,952 $277,039,990 6.7%
Wisconsin $382,272,975 $442,718,195 15.8%
Wyoming $31,435,835 $39,094,579 24.4%
*Rebates have not been subtracted from these figures.

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
4-6

Ranking Based on Drug Expenditures*
State
2002
Payments
2002
Ranking
% of 2002 National
Medicaid Drug
Expenditures

2001
Payments
2001
Ranking
National Total $29,339,050,970 $24,656,812,921
New York $3,660,427,024 1 12.5% $2,986,292,455 1
California $3,591,537,830 2 12.2% $2,984,162,770 2
Florida $1,717,652,527 3 5.9% $1,475,766,739 3
Texas $1,591,064,713 4 5.4% $1,325,987,804 4
Ohio $1,333,992,298 5 4.5% $1,099,697,768 5
Illinois $1,293,435,797 6 4.4% $884,018,166 7
North Carolina $1,100,822,176 7 3.8% $984,653,306 6
Massachusetts $958,972,520 8 3.3% $797,859,072 8
Tennessee $905,405,421 9 3.1% $681,454,847 11
Georgia $873,703,133 10 3.0% $735,944,558 9
Missouri $790,853,387 11 2.7% $675,647,147 12
Pennsylvania $718,210,352 12 2.4% $692,665,382 10
Louisiana $714,107,841 13 2.4% $585,388,809 15
New Jersey $694,669,924 14 2.4% $651,442,945 13
Michigan $674,222,281 15 2.3% $584,670,445 16
Kentucky $652,904,065 16 2.2% $592,096,755 14
Indiana $631,637,846 17 2.2% $561,642,082 17
Mississippi $567,313,801 18 1.9% $493,177,297 18
Washington $541,963,790 19 1.8% $458,332,414 19
Virginia $458,953,342 20 1.6% $417,689,526 21
Alabama $452,269,953 21 1.5% $386,876,131 22
South Carolina $451,846,044 22 1.5% $438,897,100 20
Wisconsin $442,718,195 23 1.5% $382,272,975 23
Connecticut $357,919,257 24 1.2% $304,780,286 24
Minnesota $310,174,144 25 1.1% $265,726,228 25
Maryland $297,291,733 26 1.0% $244,203,084 27
Iowa $285,467,642 27 1.0% $234,716,795 29
Oklahoma $285,068,869 28 1.0% $171,188,873 33
Oregon $279,029,096 29 1.0% $228,670,426 30
West Virginia $277,039,990 30 0.9% $259,638,952 26
Arkansas $273,257,660 31 0.9% $241,558,369 28
Maine $220,420,714 32 0.8% $191,785,942 31
Kansas $213,778,616 33 0.7% $185,017,060 32
Nebraska $207,782,737 34 0.7% $170,897,014 34
Colorado $189,717,036 35 0.6% $166,000,664 35
Utah $140,275,267 36 0.5% $117,170,006 36
Rhode Island $125,187,888 37 0.4% $102,708,476 39
Idaho $119,177,013 38 0.4% $102,975,196 38
Vermont $114,157,870 39 0.4% $104,250,880 37
New Hampshire $99,682,997 40 0.3% $91,703,067 40
Delaware $97,750,161 41 0.3% $81,156,928 41
Hawaii $88,256,904 42 0.3% $74,869,859 42
Nevada $86,929,536 43 0.3% $61,500,721 45
Montana $83,587,410 44 0.3% $72,577,455 43
New Mexico $73,877,785 45 0.3% $57,995,801 46
Alaska $70,708,412 46 0.2% $55,754,050 47
Dist. of Columbia $66,129,208 47 0.2% $63,504,500 44
South Dakota $62,382,937 48 0.2% $51,748,770 48
North Dakota $52,495,878 49 0.2% $44,067,986 49
Wyoming $39,094,579 50 0.1% $31,435,835 50
Arizona $3,725,371 51 0.0% $2,573,205 51
*Rebates have not been subtracted from these figures.

Source: CMS, HCFA-64 Report, FY 2001 and FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-7

Drugs as a Percentage of Total Net Expenditures, 2002
State
Total Medicaid
Net Medical Assistance
Expenditures
Total Drug
Expenditures*
% of Total
Net Expenditures
National Total $245,697,620,676 $29,339,050,970 11.9%
Alabama $3,093,270,640 $452,269,953 14.6%
Alaska $685,772,985 $70,708,412 10.3%
Arizona $3,541,598,721 $3,725,371 0.1%
Arkansas $2,237,817,554 $273,257,660 12.2%
California $26,890,540,967 $3,591,537,830 13.4%
Colorado $2,323,068,699 $189,717,036 8.2%
Connecticut $3,456,338,545 $357,919,257 10.4%
Delaware $634,046,351 $97,750,161 15.4%
District of Columbia $1,021,772,693 $66,129,208 6.5%
Florida $9,871,508,234 $1,717,652,527 17.4%
Georgia $6,241,211,454 $873,703,133 14.0%
Hawaii

$740,007,314 $88,256,904 11.9%
Idaho $773,534,776 $119,177,013 15.4%
Illinois $8,809,060,004 $1,293,435,797 14.7%
Indiana $4,448,318,143 $631,637,846 14.2%
Iowa $2,575,146,342 $285,467,642 11.1%
Kansas $1,836,717,196 $213,778,616 11.6%
Kentucky $3,763,204,047 $652,904,065 17.3%
Louisiana $4,885,971,853 $714,107,841 14.6%
Maine $1,430,109,134 $220,420,714 15.4%
Maryland $3,613,476,100 $297,291,733 8.2%
Massachusetts $8,063,005,258 $958,972,520 11.9%
Michigan $7,562,053,407 $674,222,281 8.9%
Minnesota $4,414,511,470 $310,174,144 7.0%
Mississippi $2,877,013,521 $567,313,801 19.7%
Missouri $5,360,607,640 $790,853,387 14.8%
Montana $571,456,455 $83,587,410 14.6%
Nebraska $1,339,132,070 $207,782,737 15.5%
Nevada $808,198,344 $86,929,536 10.8%
New Hampshire $1,016,094,814 $99,682,997 9.8%
New Jersey $7,745,877,997 $694,669,924 9.0%
New Mexico $1,776,811,688 $73,877,785 4.2%
New York $36,295,107,368 $3,660,427,024 10.1%
North Carolina $6,723,598,560 $1,100,822,176 16.4%
North Dakota $461,401,546 $52,495,878 11.4%
Ohio $9,658,040,587 $1,333,992,298 13.8%
Oklahoma $2,260,403,490 $285,068,869 12.6%
Oregon $2,571,560,664 $279,029,096 10.9%
Pennsylvania $12,130,925,035 $718,210,352 5.9%
Rhode Island $1,358,500,649 $125,187,888 9.2%
South Carolina $3,292,901,444 $451,846,044 13.7%
South Dakota $549,884,391 $62,382,937 11.3%
Tennessee $5,787,079,096 $905,405,421 15.6%
Texas $13,523,486,149 $1,591,064,713 11.8%
Utah $984,160,785 $140,275,267 14.3%
Vermont $660,731,979 $114,157,870 17.3%
Virginia $3,812,166,436 $458,953,342 12.0%
Washington $5,168,511,470 $541,963,790 10.5%
West Virginia $1,584,166,286 $277,039,990 17.5%
Wisconsin $4,193,175,197 $442,718,195 10.6%
Wyoming $274,565,128 $39,094,579 14.2%
*Rebates have not been subtracted from these figures.

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


National Pharmaceutical Council Pharmaceutical Benefits 2003
4-8

Drugs as a Percentage of Total Net Expenditures, 2000-2002*
State 2000 2001 2002
National Total 10.5% 11.4% 11.9%
Alabama 12.4% 13.5% 14.6%
Alaska 9.3% 9.7% 10.3%
Arizona 0.1% 0.1% 0.1%
Arkansas 13.1% 13.0% 12.2%
California 11.7% 12.5% 13.4%
Colorado 7.4% 7.7% 8.2%
Connecticut 8.5% 9.5% 10.4%
Delaware 12.6% 13.7% 15.4%
District of Columbia 6.7% 6.5% 6.5%
Florida 18.1% 17.2% 17.4%
Georgia 13.4% 14.6% 14.0%
Hawaii

9.6% 11.8% 11.9%
Idaho 14.2% 14.9% 15.4%
Illinois 10.8% 11.4% 14.7%
Indiana 13.3% 14.0% 14.2%
Iowa 12.0% 14.1% 11.1%
Kansas 11.7% 11.0% 11.6%
Kentucky 15.3% 17.9% 17.3%
Louisiana 14.8% 13.9% 14.6%
Maine 14.4% 14.6% 15.4%
Maryland 6.8% 7.5% 8.2%
Massachusetts 11.0% 12.1% 11.9%
Michigan 5.9% 8.1% 8.9%
Minnesota 7.0% 6.9% 7.0%
Mississippi 18.6% 20.2% 19.7%
Missouri 15.1% 14.2% 14.8%
Montana 13.4% 15.0% 14.6%
Nebraska 13.7% 14.4% 15.5%
Nevada 8.4% 9.1% 10.8%
New Hampshire 10.3% 10.5% 9.8%
New Jersey 9.9% 9.1% 9.0%
New Mexico 4.0% 4.0% 4.2%
New York 8.4% 9.5% 10.1%
North Carolina 14.7% 16.0% 16.4%
North Dakota 9.1% 10.8% 11.4%
Ohio 11.8% 13.0% 13.8%
Oklahoma 10.2% 8.5% 12.6%
Oregon 8.0% 8.6% 10.9%
Pennsylvania 5.7% 6.3% 5.9%
Rhode Island 7.8% 8.6% 9.2%
South Carolina 13.1% 14.5% 13.7%
South Dakota 11.2% 11.1% 11.3%
Tennessee 5.5% 12.4% 15.6%
Texas 10.6% 11.4% 11.8%
Utah 12.5% 14.1% 14.3%
Vermont 16.6% 17.3% 17.3%
Virginia 14.2% 13.8% 12.0%
Washington 10.0% 10.6% 10.5%
West Virginia 15.6% 16.8% 17.5%
Wisconsin 10.6% 9.6% 10.6%
Wyoming 12.6% 12.9% 14.2%
*Percentages are based on figures that have not had rebates subtracted from them.

Source: CMS, HCFA-64 Report, FY 2000 - FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-9

Share of Drug Expenditures by Category, 2002
State
Central Nervous
System Drugs
Cardiovascular
Drugs
Anti-Infective
Agents
Gastrointestinal
Drugs
Hormones and
Synthetic
Substitutes
National Total $11,110,878,554 $3,309,235,175 $3,123,794,684 $2,220,293,730 $2,450,336,932
Alabama $162,427,968 $58,939,919 $53,191,197 $19,724,615 $47,715,140
Alaska $40,138,250 $6,871,390 $8,258,256 $8,448,493 $5,749,324
Arizona* - - - - -
Arkansas $104,327,247 $28,178,010 $34,062,548 $17,516,577 $25,063,050
California $1,326,623,035 $496,583,694 $340,238,011 $299,960,881 $408,010,804
Colorado $83,397,713 $18,457,938 $14,225,625 $19,891,233 $15,025,084
Connecticut $160,777,341 $40,992,549 $32,005,763 $30,864,193 $24,067,812
Delaware $33,137,878 $8,754,892 $14,857,621 $7,558,824 $7,523,594
District of Columbia $16,566,443 $8,980,540 $15,878,461 $2,293,635 $4,126,743
Florida $567,979,172 $187,207,113 $287,185,968 $128,405,638 $126,663,957
Georgia $293,303,215 $94,504,922 $116,609,831 $37,372,052 $73,825,742
Hawaii $34,086,249 $13,717,144 $7,463,253 $3,648,598 $8,519,468
Idaho $51,034,605 $7,528,366 $12,505,892 $8,638,278 $8,818,138
Illinois $350,382,552 $122,510,875 $119,743,795 $81,780,842 $91,373,328
Indiana $261,850,680 $56,525,273 $52,568,049 $43,805,799 $49,950,818
Iowa $133,389,066 $26,919,865 $25,133,166 $17,166,772 $23,699,984
Kansas $92,620,891 $18,956,370 $14,404,125 $16,375,484 $16,126,439
Kentucky $246,745,840 $76,276,780 $59,717,916 $47,258,191 $57,303,474
Louisiana $215,776,810 $77,561,164 $98,070,631 $50,354,434 $58,436,886
Maine $102,697,707 $32,706,097 $15,813,854 $20,571,791 $23,502,715
Maryland $155,536,684 $34,300,423 $25,569,033 $22,383,011 $18,483,071
Massachusetts $430,570,903 $92,069,851 $97,049,019 $71,551,884 $65,280,437
Michigan $340,976,049 $73,768,758 $39,031,663 $45,338,916 $48,709,565
Minnesota $168,448,868 $22,183,423 $20,695,558 $24,111,242 $22,047,764
Mississippi $163,971,736 $74,830,740 $57,550,451 $38,835,119 $47,224,420
Missouri $345,195,541 $88,695,064 $76,038,064 $40,234,018 $69,509,901
Montana $34,810,221 $6,010,486 $5,521,773 $7,116,556 $6,146,901
Nebraska $81,936,002 $16,357,515 $16,977,505 $18,138,100 $15,440,716
Nevada $38,425,453 $9,365,878 $9,266,546 $5,789,204 $6,733,244
New Hampshire $50,011,843 $8,064,813 $6,784,686 $7,427,069 $7,511,020
New Jersey $233,071,337 $84,618,207 $76,763,184 $55,305,576 $43,057,935
New Mexico $29,130,298 $9,205,694 $5,923,305 $8,455,563 $9,789,382
New York $1,140,536,063 $421,174,650 $582,777,416 $263,380,736 $292,497,125
North Carolina $378,957,583 $131,377,542 $110,556,228 $122,152,344 $91,412,449
North Dakota $24,261,002 $4,805,781 $3,723,614 $4,123,091 $4,136,352
Ohio $548,273,256 $136,785,856 $117,486,151 $133,074,736 $106,110,103
Oklahoma $104,495,550 $29,741,991 $25,469,725 $16,950,080 $22,005,051
Oregon $167,833,786 $19,501,122 $17,189,123 $12,676,327 $18,126,559
Pennsylvania $277,892,318 $76,953,109 $50,334,104 $66,460,266 $52,304,661
Rhode Island $54,554,473 $15,629,844 $10,756,138 $12,760,847 $9,079,709
South Carolina $166,326,864 $65,363,553 $58,789,210 $26,958,237 $48,429,827
South Dakota $24,744,099 $4,278,404 $5,738,550 $5,566,752 $4,721,494
Tennessee $498,494,118 $126,602,215 $39,685,343 $80,012,408 $63,222,119
Texas $534,365,292 $170,623,922 $188,773,209 $105,134,911 $144,900,535
Utah $66,525,169 $9,033,014 $11,164,654 $10,721,510 $10,004,484
Vermont $15,204,207 $1,996,150 $4,094,728 $1,825,472 $3,386,327
Virginia $169,780,908 $56,516,797 $34,656,425 $49,598,408 $33,627,141
Washington $240,264,995 $52,602,760 $42,461,101 $42,712,396 $44,968,562
West Virginia $114,111,323 $35,490,850 $27,406,002 $15,554,339 $28,201,869
Wisconsin $219,043,257 $46,738,020 $29,955,583 $40,886,751 $34,911,470
Wyoming $15,866,694 $2,375,842 $3,672,631 $3,421,531 $2,854,239
* Data not reported for Arizona. Arizona has an 115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-10

Share of Drug Expenditures by Category, 2002 (con't.)
State
Unclassified
Therapeutic
Agents
Autonomic
Drugs
Blood Formation
and Coagulation Other Total
National Average $1,359,408,404 $1,310,216,943 $990,931,837 $3,558,911,926 $29,434,008,185
Alabama $22,738,666 $25,079,219 $14,344,026 $73,878,759 $478,039,509
Alaska $3,581,523 $3,755,322 $5,983,211 $7,629,178 $90,414,947
Arizona* - - - - -
Arkansas $13,863,613 $14,761,594 $12,118,144 $36,775,275 $286,666,058
California $157,970,901 $120,211,219 $209,658,251 $346,042,559 $3,705,299,355
Colorado $10,839,480 $9,701,591 $3,878,876 $20,711,072 $196,128,612
Connecticut $14,860,816 $13,959,149 $9,952,330 $36,195,541 $363,675,494
Delaware $4,793,777 $4,361,417 $2,059,247 $12,024,599 $95,071,849
District of Columbia $2,027,293 $1,757,168 $2,061,662 $8,100,729 $61,792,674
Florida $93,146,712 $79,021,471 $65,139,602 $214,181,262 $1,748,930,895
Georgia $35,344,409 $51,251,712 $23,350,249 $135,189,926 $860,752,058
Hawaii $5,739,678 $3,682,979 $3,725,363 $9,623,486 $90,206,218
Idaho $4,702,849 $4,537,192 $2,090,222 $10,675,638 $110,531,180
Illinois $51,201,123 $49,711,098 $42,312,778 $125,591,419 $1,034,607,810
Indiana $30,428,285 $34,113,121 $30,588,581 $88,424,694 $648,255,300
Iowa $14,503,456 $14,515,299 $4,634,670 $30,708,063 $290,670,341
Kansas $8,882,991 $10,341,541 $2,710,267 $22,665,160 $203,083,268
Kentucky $32,858,754 $44,179,459 $16,546,274 $92,326,826 $673,213,514
Louisiana $28,664,540 $37,300,313 $22,766,784 $126,322,534 $715,254,096
Maine $11,567,546 $13,021,181 $7,032,641 $23,157,560 $250,071,092
Maryland $12,230,384 $9,621,667 $12,500,270 $27,905,071 $318,529,614
Massachusetts $39,070,997 $34,788,062 $25,993,252 $93,515,983 $949,890,388
Michigan $36,673,123 $28,611,197 $21,000,992 $78,003,615 $712,113,878
Minnesota $14,145,281 $12,275,238 $10,275,040 $28,487,965 $322,670,379
Mississippi $26,530,965 $26,109,283 $10,028,232 $71,978,643 $517,059,589
Missouri $39,157,120 $42,009,219 $27,370,560 $107,787,109 $835,996,596
Montana $4,849,421 $3,999,013 $1,873,361 $8,043,097 $78,370,829
Nebraska $8,345,459 $9,248,417 $4,526,460 $26,832,410 $197,802,584
Nevada $4,479,913 $4,540,225 $3,355,258 $10,558,557 $92,514,278
New Hampshire $4,030,559 $5,036,489 $1,726,064 $11,498,389 $102,090,932
New Jersey $33,208,357 $28,777,427 $31,413,603 $82,236,456 $668,452,082
New Mexico $4,858,911 $3,660,437 $2,321,704 $10,427,651 $83,772,945
New York $164,083,098 $144,160,697 $128,216,711 $448,781,131 $3,585,607,627
North Carolina $52,831,364 $47,151,722 $34,051,151 $154,246,658 $1,122,737,041
North Dakota $2,190,494 $2,402,271 $1,200,697 $6,203,497 $53,046,799
Ohio $61,882,420 $73,814,087 $31,269,079 $171,884,121 $1,380,579,809
Oklahoma $15,423,385 $14,719,001 $12,077,645 $32,175,743 $273,058,171
Oregon $11,165,553 $10,626,003 $3,269,333 $17,340,074 $277,727,880
Pennsylvania $36,543,215 $37,155,760 $28,115,340 $81,438,693 $707,197,466
Rhode Island $5,349,865 $4,968,045 $2,243,417 $12,019,287 $127,361,625
South Carolina $23,527,729 $22,180,993 $12,869,914 $73,393,454 $497,839,781
South Dakota $2,662,003 $3,005,290 $2,132,526 $8,156,411 $61,005,529
Tennessee $42,907,863 $35,886,456 $11,623,384 $74,216,876 $972,650,782
Texas $71,446,566 $79,465,180 $47,090,505 $281,968,505 $1,623,768,625
Utah $5,777,363 $5,309,763 $1,236,279 $15,712,079 $135,484,315
Vermont $1,538,173 $1,484,182 $910,603 $4,175,415 $34,615,257
Virginia $21,636,958 $22,121,039 $14,515,501 $57,867,501 $460,320,678
Washington $25,745,981 $22,298,725 $12,901,679 $54,928,168 $538,884,367
West Virginia $14,341,914 $16,315,461 $3,412,406 $35,444,231 $290,278,395
Wisconsin $23,072,206 $21,426,205 $9,215,035 $47,029,239 $472,277,766
Wyoming $1,985,352 $1,787,344 $1,242,658 $4,431,617 $37,637,908
* Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-11

Share of Prescriptions Processed, 2002
State
Central Nervous
System Drugs
Cardiovascular
Drugs
Anti-Infective
Agents
Gastrointestinal
Drugs
Hormones and
Synthetic
Substitutes
National Average 161,232,219 72,443,028 44,093,996 32,548,275 49,926,307
Alabama 2,941,431 1,474,573 1,048,966 502,468 1,071,095
Alaska 538,815 180,198 117,690 97,338 140,539
Arizona* - - - - -
Arkansas 1,603,598 760,062 702,941 271,296 565,683
California 15,214,602 7,876,231 4,083,588 3,385,060 5,529,844
Colorado 1,339,641 511,136 301,986 254,879 446,353
Connecticut 2,021,686 847,007 256,096 352,779 521,491
Delaware 488,341 174,105 163,401 86,189 151,233
District of Columbia 238,638 192,385 75,916 34,750 85,750
Florida 8,038,952 4,449,917 2,573,795 1,684,045 2,578,311
Georgia 4,836,548 2,272,159 2,201,615 798,841 1,726,279
Hawaii 460,387 280,308 85,657 131,081 164,060
Idaho 730,380 186,130 241,834 90,662 219,364
Illinois 5,998,874 3,043,522 2,011,538 1,612,006 2,087,064
Indiana 4,105,446 1,344,857 1,021,660 961,743 1,083,084
Iowa 2,042,876 676,484 526,890 289,881 574,214
Kansas 1,283,667 478,864 292,629 224,830 403,111
Kentucky 3,958,848 1,798,630 1,260,103 1,031,820 1,255,859
Louisiana 3,565,125 1,748,774 1,618,788 627,664 1,234,697
Maine 1,816,121 992,273 346,253 307,138 669,930
Maryland 2,040,489 771,138 235,643 276,028 437,447
Massachusetts 6,184,586 2,193,033 1,121,462 871,999 1,597,184
Michigan 5,334,314 1,975,384 749,240 804,253 1,233,184
Minnesota 2,002,604 505,679 313,581 461,421 449,417
Mississippi 2,383,531 1,565,659 1,009,586 446,750 917,779
Missouri 4,817,043 2,017,339 1,126,028 822,151 1,473,030
Montana 524,752 149,104 123,537 95,044 154,526
Nebraska 1,273,870 419,270 399,375 343,820 369,585
Nevada 506,986 207,748 116,449 70,849 154,274
New Hampshire 782,217 221,431 135,110 168,121 180,316
New Jersey 3,019,679 1,720,151 565,815 618,302 871,468
New Mexico 514,776 232,761 120,054 123,271 264,285
New York 14,908,099 8,342,535 4,737,922 3,717,304 5,014,585
North Carolina 5,676,633 3,110,086 1,789,714 1,261,734 2,123,893
North Dakota 354,179 138,692 90,114 53,653 117,790
Ohio 8,874,351 3,367,729 2,171,902 2,251,991 2,532,337
Oklahoma 1,359,234 619,655 469,747 253,620 454,955
Oregon 2,482,014 536,975 271,375 274,184 497,490
Pennsylvania 4,061,265 1,930,258 844,456 920,012 1,260,625
Rhode Island 759,101 288,310 107,145 155,871 178,022
South Carolina 2,488,867 1,551,714 956,429 414,746 1,121,193
South Dakota 328,166 113,324 132,161 61,797 110,042
Tennessee 8,328,542 3,188,238 663,010 1,211,895 1,650,584
Texas 8,145,506 2,954,622 4,157,104 1,525,126 2,404,342
Utah 985,750 205,220 259,890 170,618 248,371
Vermont 233,990 44,219 73,282 24,002 63,883
Virginia 2,658,974 1,275,731 549,649 755,313 763,085
Washington 3,607,572 1,292,270 681,200 772,019 1,140,120
West Virginia 1,978,691 838,280 608,930 296,680 625,931
Wisconsin 3,167,088 1,321,310 496,952 541,168 945,241
Wyoming 225,374 57,548 85,788 40,063 63,362
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-12

Share of Prescriptions Processed, 2002 (con't)
State
Unclassified
Therapeutic
Agents
Autonomic
Drugs
Blood Formation
and Coagulation Other Total
National Average 12,417,152 28,118,352 8,829,418 109,663,158 519,271,905
Alabama 236,233 593,690 176,967 2,577,154 10,622,577
Alaska 32,981 84,604 21,891 216,774 1,430,830
Arizona* - - - - -
Arkansas 147,559 304,771 78,382 1,211,543 5,645,835
California 1,251,287 2,391,533 1,171,076 9,602,912 50,506,133
Colorado 102,310 246,770 78,758 763,212 4,045,045
Connecticut 123,141 286,590 118,220 953,334 5,480,344
Delaware 39,794 100,817 17,248 332,518 1,553,646
District of Columbia 21,194 39,581 14,437 214,858 917,509
Florida 814,906 1,488,860 462,674 5,505,188 27,596,648
Georgia 386,418 1,116,911 277,778 4,310,917 17,927,466
Hawaii 68,661 80,472 24,987 314,766 1,610,379
Idaho 45,247 110,953 22,090 335,525 1,982,185
Illinois 475,449 1,227,016 444,852 5,101,759 22,002,080
Indiana 265,303 693,573 221,927 2,856,633 12,554,226
Iowa 119,840 312,212 102,265 1,048,931 5,693,593
Kansas 86,239 209,318 62,517 706,425 3,747,600
Kentucky 350,628 828,775 218,980 3,124,789 13,828,432
Louisiana 283,139 799,945 225,964 3,561,044 13,665,140
Maine 139,597 319,159 82,503 836,581 5,509,555
Maryland 120,094 241,386 123,481 845,278 5,090,984
Massachusetts 350,189 882,646 224,809 2,622,424 16,048,332
Michigan 359,466 673,362 278,304 2,470,691 13,878,198
Minnesota 98,300 273,845 73,086 908,532 5,086,465
Mississippi 255,373 450,278 142,959 2,095,665 9,267,580
Missouri 334,079 848,195 263,580 3,036,239 14,737,684
Montana 36,544 92,105 19,000 260,368 1,454,980
Nebraska 84,578 209,544 64,395 978,024 4,142,461
Nevada 46,298 100,059 19,587 262,239 1,484,489
New Hampshire 42,495 110,132 31,078 421,656 2,092,556
New Jersey 303,410 504,862 182,297 2,056,526 9,842,510
New Mexico 42,822 87,788 34,673 415,945 1,836,375
New York 1,383,908 3,156,479 756,500 12,587,023 54,604,355
North Carolina 527,568 1,035,032 280,164 4,328,993 20,133,817
North Dakota 23,616 52,035 19,627 214,883 1,064,589
Ohio 605,376 1,656,240 489,554 6,456,527 28,406,007
Oklahoma 131,804 278,564 51,310 851,206 4,470,095
Oregon 97,919 260,718 65,043 738,907 5,224,625
Pennsylvania 371,915 710,505 424,057 2,555,642 13,078,735
Rhode Island 50,658 111,718 34,459 372,418 2,057,702
South Carolina 228,975 458,400 129,353 2,036,447 9,386,124
South Dakota 25,509 59,709 19,269 243,295 1,093,272
Tennessee 416,508 848,942 296,281 3,008,859 19,612,859
Texas 587,114 1,735,053 384,211 9,091,697 30,984,775
Utah 63,353 132,311 29,355 486,901 2,581,769
Vermont 20,430 35,855 4,869 99,712 600,242
Virginia 215,740 438,542 166,555 1,879,125 8,702,714
Washington 220,230 573,523 157,276 1,919,907 10,364,117
West Virginia 149,046 344,864 70,280 1,116,604 6,029,306
Wisconsin 217,841 480,948 159,848 1,586,155 8,916,551
Wyoming 16,068 39,162 10,642 140,407 678,414
*Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, State Drug Utilization Data, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-13

Medicaid Average Cost Per Prescription, 2002*
State
Drug
Payments
Prescriptions
Processed
Average
Prescription Cost
National Average $29,434,008,185 519,271,905 $56.68
Alabama $478,039,509 10,622,577 $45.00
Alaska $90,414,947 1,430,830 $63.19
Arizona** - - -
Arkansas $286,666,058 5,645,835 $50.77
California $3,705,299,355 50,506,133 $73.36
Colorado $196,128,612 4,045,045 $48.49
Connecticut $363,675,494 5,480,344 $66.36
Delaware $95,071,849 1,553,646 $61.19
District of Columbia $61,792,674 917,509 $67.35
Florida $1,748,930,895 27,596,648 $63.37
Georgia $860,752,058 17,927,466 $48.01
Hawaii $90,206,218 1,610,379 $56.02
Idaho $110,531,180 1,982,185 $55.76
Illinois $1,034,607,810 22,002,080 $47.02
Indiana $648,255,300 12,554,226 $51.64
Iowa $290,670,341 5,693,593 $51.05
Kansas $203,083,268 3,747,600 $54.19
Kentucky $673,213,514 13,828,432 $48.68
Louisiana $715,254,096 13,665,140 $52.34
Maine $250,071,092 5,509,555 $45.39
Maryland $318,529,614 5,090,984 $62.57
Massachusetts $949,890,388 16,048,332 $59.19
Michigan $712,113,878 13,878,198 $51.31
Minnesota $322,670,379 5,086,465 $63.44
Mississippi $517,059,589 9,267,580 $55.79
Missouri $835,996,596 14,737,684 $56.73
Montana $78,370,829 1,454,980 $53.86
Nebraska $197,802,584 4,142,461 $47.75
Nevada $92,514,278 1,484,489 $62.32
New Hampshire $102,090,932 2,092,556 $48.79
New Jersey $668,452,082 9,842,510 $67.91
New Mexico $83,772,945 1,836,375 $45.62
New York $3,585,607,627 54,604,355 $65.67
North Carolina $1,122,737,041 20,133,817 $55.76
North Dakota $53,046,799 1,064,589 $49.83
Ohio $1,380,579,809 28,406,007 $48.60
Oklahoma $273,058,171 4,470,095 $61.09
Oregon $277,727,880 5,224,625 $53.16
Pennsylvania $707,197,466 13,078,735 $54.07
Rhode Island $127,361,625 2,057,702 $61.90
South Carolina $497,839,781 9,386,124 $53.04
South Dakota $61,005,529 1,093,272 $55.80
Tennessee $972,650,782 19,612,859 $49.59
Texas $1,623,768,625 30,984,775 $52.41
Utah $135,484,315 2,581,769 $52.48
Vermont $34,615,257 600,242 $57.67
Virginia $460,320,678 8,702,714 $52.89
Washington $538,884,367 10,364,117 $52.00
West Virginia $290,278,395 6,029,306 $48.14
Wisconsin $472,277,766 8,916,551 $52.97
Wyoming $37,637,908 678,414 $55.48
*Rebates have not been subtracted from these figures.
**Data not reported for Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, State Drug Utilization Data, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-14

National Pharmaceutical Council Pharmaceutical Benefits 2003
4-15

MEDICAID DRUG REBATES
In 1990, Congress considered a number of proposals designed to reduce and control Federal and State
expenditures for prescription drug products provided to Medicaid patients (S.2605, the
Pharmaceutical Access and Prudent Purchasing Act; S.3029, the Medicaid Anti-Discriminatory Drug
Act, sponsored by Senator David Pryor; and H.R.5589, the Medicaid Prescription Drug Fair Access
and Pricing Act, sponsored by Representatives Ron Wyden and Jim Cooper). A vigorous
Congressional debate ensued over which of these approaches to pursue. Several pharmaceutical
manufacturers voluntarily offered rebates to the States in exchange for open access for their products,
while the Pharmaceutical Manufacturers Association proposed a set rebate amount in exchange for
open formularies. Numerous public interest groups offered opinions on the proposals and in some
cases proposals of their own.
The Congressional debate ended in both the House and Senate offering somewhat similar proposals.
During the ensuing Conference between the House and Senate, the Office of Management and Budget
(OMB) argued for the inclusion of several proposals into the provisions in budget bill, the Omnibus
Budget Reconciliation Act of 1990 (OBRA ’90). The resulting Public Law 101-508, enacted
November 5, 1990, required a drug manufacturer to enter into and have in effect a national rebate
agreement with the Secretary of the Department of Health and Human Services (HHS) for States to
receive Federal funding for outpatient drugs dispensed to Medicaid patients. (For a detailed account
of the debate and genesis of various provisions see Robert Betz’s analysis of the Medicaid Best Price
Law and its effect on pharmaceutical manufacturers’ pricing policies.*

)
The requirement for rebate agreements does not apply to the dispensing of a single-source or
innovator multiple-source drug if the State has determined that the drug is essential, rated 1-A by the
FDA, and prior authorization is obtained for the exception. Existing rebate agreements qualify under
the law if the State agrees to report all rebates to HHS and the agreement provides for a minimum
aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products.
OBRA ‘90 was amended by the Veterans Health Care Act of 1992 which also required a drug
manufacturer to enter into discount pricing agreements with the Department of Veterans Affairs and
with covered entities funded by the Public Health Service in order to have its drugs covered by
Medicaid. The Medicaid rebate law, as amended, is included as Appendix C.
The drug rebate program is administered by CMS’ Center for Medicaid and State Operations
(CMSO). Currently, the rebate for covered outpatient drugs is as follows:
• For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1
percent of the average manufacturer’s price (AMP) or the difference between the AMP and
the manufacturer’s “best price,” and (2) an additional rebate for any price increase for a
product that exceeds the increase in the Consumer Price Index (CPI-U) for all items since the
fall of 1990. AMP is the average price paid by wholesalers for products distributed to the
retail class of trade. The best price is the lowest price offered to any other customer,
excluding Federal Supply Schedule prices, prices to State pharmaceutical assistance
programs, and prices that are nominal in amount, and includes all discounts and rebates.
• For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of
each product’s AMP.


Robert Betz, “The Medicaid Best Price Law and Its Effect on Pharmaceutical Manufacturer’s Pricing Policies and Behavior for
Name Brand, Outpatient Pharmaceutical Products,” unpubl. Ph.D. dissertation, The George Washington University, May 21,
2000.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-16


National Pharmaceutical Council Pharmaceutical Benefits 2003
4-17

Medicaid Drug Rebates, 2002

State
Allocation of
Drug Rebate Monies
1
Total Rebates
2
Federal Share
2
National Total $5,917,504,760 $3,407,724,441
Alabama Medicaid Drug Budget $84,994,286 $59,956,556
Alaska Medicaid General $14,347,654 $8,232,684
Arizona* - - -
Arkansas Medicaid Drug Budget $56,688,398 $41,263,780
California Medicaid Drug Budget $946,651,118 $501,389,213
Colorado General Fund $39,054,140 $19,757,318
Connecticut General Fund $62,627,160 $31,353,041
Delaware Medicaid General $16,990,455 $8,583,285
District of Columbia Medicaid General $11,445,790 $8,012,876
Florida Medicaid Drug Budget $353,649,807 $200,302,136
Georgia Medicaid General $205,469,531 $121,227,024
Hawaii Medicaid Drug Budget $15,267,796 $8,601,876
Idaho Medicaid General $22,939,130 $16,291,370
Illinois Medicaid Drug Budget $190,316,986 $95,869,844
Indiana General Fund $126,512,101 $78,488,107
Iowa General Fund $50,092,788 $31,591,633
Kansas Medicaid General $29,755,595 $17,938,406
Kentucky General Fund $133,330,557 $93,351,276
Louisiana Medicaid Drug Budget $113,729,749 $80,081,323
Maine Medicaid Drug Budget $47,395,300 $31,642,678
Maryland Medicaid General $54,261,949 $27,263,281
Massachusetts Medicaid General $191,118,385 $95,707,811
Michigan General Fund $172,522,597 $97,412,881
Minnesota General Fund $62,655,474 $31,327,739
Mississippi Medicaid General $115,221,421 $87,844,768
Missouri Medicaid Drug Budget $147,281,505 $90,586,777
Montana General Fund $15,955,235 $11,659,478
Nebraska Medicaid Drug Budget $47,855,128 $28,770,955
Nevada General Fund $13,547,604 $6,803,437
New Hampshire General Fund $20,888,707 $10,500,160
New Jersey Medicaid Drug Budget $127,373,014 $63,850,343
New Mexico General Fund $13,274,387 $9,695,612
New York General Fund $663,973,100 $331,986,551
North Carolina Medicaid General $207,064,443 $127,702,769
North Dakota Medicaid Drug Budget $11,651,682 $8,159,556
Ohio Medicaid General $263,267,258 $154,748,494
Oklahoma Medicaid General $51,471,649 $36,251,483
Oregon General Fund $54,474,938 $32,343,683
Pennsylvania Outpatient Appropriation $154,338,235 $84,595,091
Rhode Island General Fund $26,213,636 $13,749,052
South Carolina Medicaid Drug Budget $98,272,773 $68,818,366
South Dakota Medicaid Drug Budget $12,056,925 $8,004,147
Tennessee Medicaid General $180,613,885 $114,942,676
Texas Medicaid Drug Budget $305,110,523 $184,019,819
Utah General Fund $36,756,960 $25,760,249
Vermont Medicaid General $24,488,863 $15,514,120
Virginia General Fund, Medicaid General $76,776,155 $39,595,957
Washington General Fund $100,874,789 $51,143,700
West Virginia Medicaid General $48,976,536 $36,864,639
Wisconsin Medicaid General $89,226,751 $52,764,907
Wyoming Medicaid Drug Budget $8,681,912 $5,401,514
*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Sources:
1
As reported by State drug program administrators in the 2003 NPC Survey.
2
CMS, CMS-64 Report, FY 2002, includes reported state supplemental rebates for CA, FL, MD, and MI.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-18

Medicaid Drug Rebate Trends, 1998-2002
State 1998 1999 2000 2001 2002
National Total $2,469,136,949 $3,338,497,983 $3,980,646,518 $4,948,222,331 $5,917,504,760
Alabama $36,537,095 $49,785,076 $60,984,826 $76,624,463 $84,994,286
Alaska $5,026,624 $7,050,981 $8,594,014 $11,337,883 $14,347,654
Arizona* - -
- - -
Arkansas $22,518,230 $37,931,853 $40,814,931 $45,744,406 $56,688,398
California $362,808,597 $539,928,783 $600,895,711 $786,113,991 $946,651,118
Colorado $20,424,896 $25,151,080 $28,832,989 $34,264,574 $39,054,140
Connecticut $32,128,587 $38,656,394 $49,164,014 $61,916,192 $62,627,160
Delaware $7,096,836 $9,787,444 $13,780,359 $17,042,045 $16,990,455
District of Columbia $7,100,983 $8,379,982 $9,215,651 $10,446,499 $11,445,790
Florida $150,733,077 $195,512,719 $248,637,014 $297,362,792 $353,649,807
Georgia $64,320,077 $95,237,778 $91,886,605 $110,087,285 $205,469,531
Hawaii $5,992,722 $8,378,292 $10,947,632 $14,363,603 $15,267,796
Idaho $8,614,444 $11,901,778 $13,984,004 $18,841,154 $22,939,130
Illinois $100,811,862 $121,540,781 $143,590,170 $170,733,612 $190,316,986
Indiana $50,710,861 $62,691,135 $84,453,135 $103,148,144 $126,512,101
Iowa $25,265,390 $32,369,409 $36,040,216 $42,602,101 $50,092,788
Kansas $19,852,439 $26,878,486 $31,022,023 $39,731,568 $29,755,595
Kentucky $57,082,387 $72,676,810 $93,688,165 $104,759,238 $133,330,557
Louisiana $65,994,910 $76,147,317 $84,800,897 $115,254,842 $113,729,749
Maine $19,650,719 $30,032,364 $31,598,262 $41,847,632 $47,395,300
Maryland $25,017,660 $32,311,299 $42,081,781 $34,263,429 $54,261,949
Massachusetts $89,011,664 $140,102,747 $146,225,538 $180,517,139 $191,118,385
Michigan $72,526,027 $75,674,128 $75,687,945 $111,716,756 $172,522,597
Minnesota $31,058,740 $37,389,033 $43,228,324 $54,548,714 $62,655,474
Mississippi $39,983,265 $49,332,307 $61,260,326 $88,481,567 $115,221,421
Missouri $66,460,159 $84,620,799 $110,025,619 $133,927,028 $147,281,505
Montana $7,378,206 $9,290,653 $10,985,923 $13,359,968 $15,955,235
Nebraska $16,545,572 $21,609,490 $31,004,940 $30,219,685 $47,855,128
Nevada $5,143,136 $7,727,267 $4,863,879 $16,330,579 $13,547,604
New Hampshire $9,676,461 $12,956,727 $15,073,211 $13,934,765 $20,888,707
New Jersey $70,992,525 $90,472,488 $105,535,091 $124,127,231 $127,373,014
New Mexico $10,670,766 $7,972,600 $8,901,456 $12,110,896 $13,274,387
New York $251,273,382 $356,088,488 $470,317,992 $543,984,948 $663,973,100
North Carolina $81,211,796 $111,326,116 $140,047,825 $207,551,841 $207,064,443
North Dakota $4,990,065 $5,954,387 $6,503,601 $8,780,182 $11,651,682
Ohio $110,484,575 $148,477,399 $171,685,793 $217,702,350 $263,267,258
Oklahoma $23,329,251 $31,992,100 $37,135,809 $40,177,945 $51,471,649
Oregon $14,433,179 $21,360,688 $32,056,386 $34,991,037 $54,474,938
Pennsylvania $95,692,149 $119,340,064 $118,989,849 $129,265,110 $154,338,235
Rhode Island $11,041,552 $14,440,971 $19,223,034 $21,467,002 $26,213,636
South Carolina $39,156,574 $55,971,288 $73,052,676 $95,438,155 $98,272,773
South Dakota $5,070,643 $5,971,015 $7,198,848 $9,405,933 $12,056,925
Tennessee** $840 $22,434,760 $41,302,450 $102,644,077 $180,613,885
Texas $145,635,499 $185,695,267 $222,314,531 $268,557,241 $305,110,523
Utah $9,988,037 $15,145,126 $21,889,639 $21,949,963 $36,756,960
Vermont $8,868,263 $10,579,999 $17,869,053 $22,045,277 $24,488,863
Virginia $51,079,391 $67,715,512 $75,630,717 $79,484,868 $76,776,155
Washington $39,191,376 $54,331,249 $69,782,396 $91,250,830 $100,874,789
West Virginia $26,753,285 $35,941,495 $46,762,149 $52,402,218 $48,976,536
Wisconsin $40,776,543 $51,869,264 $66,358,433 $79,554,207 $89,226,751
Wyoming $3,025,632 $4,364,795 $4,720,686 $5,809,366 $8,681,912
*Does not apply for Arizona. Arizona has an 1115 waiver for which special rules apply.
Source: CMS, HCFA-64 Report, FY 1998-FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-19

Medicaid Drug Rebate Trends
Annual Percent Change, 1997-2002

State
% Change
97-98
% Change
98-99
% Change
99-00
% Change
00-01
% Change
01-02
National Total 11.6% 35.2% 19.2% 24.3% 19.6%
Alabama -22.5% 36.3% 22.5% 25.6% 10.9%
Alaska 2.6% 40.3% 21.9%
31.9%
26.5%
Arizona* - - - - -
Arkansas -8.1% 68.4% 7.6% 12.1% 23.9%
California 17.9% 48.8% 11.3% 30.8% 20.4%
Colorado 20.5% 23.1% 14.6% 18.8% 14.0%
Connecticut 17.6% 20.3% 27.2% 25.9% 1.1%
Delaware 21.3% 37.9% 40.8% 23.7% -0.3%
District of Columbia 6.5% 18.0% 10.0% 13.4% 9.6%
Florida 17.3% 29.7% 27.2% 19.6% 18.9%
Georgia 7.6% 48.1% -3.5% 19.8% 86.6%
Hawaii 28.8% 39.8% 30.7% 31.2% 6.3%
Idaho 2.9% 38.2% 17.5% 34.7% 21.8%
Illinois 18.4% 20.6% 18.1% 18.9% 11.5%
Indiana 16.2% 23.6% 34.7% 22.1% 22.7%
Iowa 16.1% 28.1% 11.3% 18.2% 17.6%
Kansas 68.3% 35.4% 15.4% 28.1% -25.1%
Kentucky -4.7% 27.3% 28.9% 11.8% 27.3%
Louisiana 20.8% 15.4% 11.4% 35.9% -1.3%
Maine 7.7% 52.8% 5.2% 32.4% 13.3%
Maryland -27.6% 29.2% 30.2% -18.6% 58.4%
Massachusetts 21.9% 57.4% 4.4% 23.5% 5.9%
Michigan -2.1% 4.3% 0.0% 47.6% 54.4%
Minnesota -2.6% 20.4% 15.6% 26.2% 14.9%
Mississippi 7.7% 23.4% 24.2% 44.4% 30.2%
Missouri 21.7% 27.3% 30.0% 21.7% 10.0%
Montana 8.9% 25.9% 18.2% 21.6% 19.4%
Nebraska 10.8% 30.6% 43.5% -2.5% 58.4%
Nevada -4.6% 50.2% -37.1% 235.8% -17.0%
New Hampshire 10.1% 33.9% 16.3% -7.6% 49.9%
New Jersey 6.4% 27.4% 16.6% 17.6% 2.6%
New Mexico -20.2% -25.3% 11.7% 36.1% 9.6%
New York 25.5% 41.7% 32.1% 15.7% 22.1%
North Carolina 18.8% 37.1% 25.8% 48.2% -0.2%
North Dakota 7.3% 19.3% 9.2% 35.0% 32.7%
Ohio 31.2% 34.4% 15.6% 26.8% 20.9%
Oklahoma 12.3% 37.1% 16.1% 8.2% 28.1%
Oregon 4.2% 48.0% 50.1% 9.2% 55.7%
Pennsylvania -17.2% 24.7% -0.3% 8.6% 19.4%
Rhode Island 9.1% 30.8% 33.1% 11.7% 22.1%
South Carolina 13.0% 42.9% 30.5% 30.6% 3.0%
South Dakota 2.6% 17.8% 20.6% 30.7% 28.2%
Tennessee** - - 84.1% 148.5% 76.0%
Texas 11.5% 27.5% 19.7% 20.8% 13.6%
Utah 19.3% 51.6% 44.5% 0.3% 67.5%
Vermont 7.4% 19.3% 68.9% 23.4% 11.1%
Virginia 12.9% 32.6% 11.7% 5.1% -3.4%
Washington 2.3% 38.6% 28.4% 30.8% 10.5%
West Virginia 2.6% 34.3% 30.1% 12.1% -6.5%
Wisconsin 9.8% 27.2% 27.9% 19.9% 12.2%
Wyoming 12.9% 44.3% 8.2% 23.1% 49.4%
*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.
**Tennessee did not report data for 1997.
Source: CMS, CMS-64 Report, FY 1997 – FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-20

Rebates as Percent Drug Expenditures, 2002
*Does not apply to Arizona. Arizona has an 1115 waiver for which special rules apply.

Source: CMS, CMS-64 Report, FY 2002

State Drug Expenditures Rebates
Rebates as % Drug
Expenditure
National Total $29,339,050,970 $5,917,504,760 20.2%
Alabama $452,269,953 $84,994,286 18.8%
Alaska $70,708,412 $14,347,654 20.3%
Arizona* $3,725,371 - -
Arkansas $273,257,660 $56,688,398 20.7%
California $3,591,537,830 $946,651,118 26.4%
Colorado $189,717,036 $39,054,140 20.6%
Connecticut $357,919,257 $62,627,160 17.5%
Delaware $97,750,161 $16,990,455 17.4%
District of Columbia $66,129,208 $11,445,790 17.3%
Florida $1,717,652,527 $353,649,807 20.6%
Georgia $873,703,133 $205,469,531 23.5%
Hawaii $88,256,904 $15,267,796 17.3%
Idaho $119,177,013 $22,939,130 19.2%
Illinois $1,293,435,797 $190,316,986 14.7%
Indiana $631,637,846 $126,512,101 20.0%
Iowa $285,467,642 $50,092,788 17.5%
Kansas $213,778,616 $29,755,595 13.9%
Kentucky $652,904,065 $133,330,557 20.4%
Louisiana $714,107,841 $113,729,749 15.9%
Maine $220,420,714 $47,395,300 21.5%
Maryland $297,291,733 $54,261,949 18.3%
Massachusetts $958,972,520 $191,118,385 19.9%
Michigan $674,222,281 $172,522,597 25.6%
Minnesota $310,174,144 $62,655,474 20.2%
Mississippi $567,313,801 $115,221,421 20.3%
Missouri $790,853,387 $147,281,505 18.6%
Montana $83,587,410 $15,955,235 19.1%
Nebraska $207,782,737 $47,855,128 23.0%
Nevada $86,929,536 $13,547,604 15.6%
New Hampshire $99,682,997 $20,888,707 21.0%
New Jersey $694,669,924 $127,373,014 18.3%
New Mexico $73,877,785 $13,274,387 18.0%
New York $3,660,427,024 $663,973,100 18.1%
North Carolina $1,100,822,176 $207,064,443 18.8%
North Dakota $52,495,878 $11,651,682 22.2%
Ohio $1,333,992,298 $263,267,258 19.7%
Oklahoma $285,068,869 $51,471,649 18.1%
Oregon $279,029,096 $54,474,938 19.5%
Pennsylvania $718,210,352 $154,338,235 21.5%
Rhode Island $125,187,888 $26,213,636 20.9%
South Carolina $451,846,044 $98,272,773 21.7%
South Dakota $62,382,937 $12,056,925 19.3%
Tennessee $905,405,421 $180,613,885 19.9%
Texas $1,591,064,713 $305,110,523 19.2%
Utah $140,275,267 $36,756,960 26.2%
Vermont $114,157,870 $24,488,863 21.5%
Virginia $458,953,342 $76,776,155 16.7%
Washington $541,963,790 $100,874,789 18.6%
West Virginia $277,039,990 $48,976,536 17.7%
Wisconsin $442,718,195 $89,226,751 20.2%
Wyoming $39,094,579 $8,681,912 22.2%
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-21


MEDICAID DRUG COVERAGE
In general, all prescription products sold by a manufacturer that has signed a drug rebate agreement
are covered outpatient drugs reimbursable by Medicaid. A State Medicaid program may require prior
approval before dispensing of any drug product and may design and implement a formulary intended
to limit coverage for specific drugs. Drug formularies and prior authorization programs must meet
specific requirements established in Medicaid law.
A State Medicaid program can restrict coverage for a drug product through a formulary, if based on
official labeling or information in designated official medical compendia, “the excluded drug does not
have a significant, clinically meaningful therapeutic advantage in terms of safety, effectiveness or
clinical outcome of such treatment” over other drug products, and there is a written explanation
(available to the public) of the basis for the exclusion. However, drug products excluded from the
formulary under these conditions, nevertheless, must be available through prior authorization.
Drugs in certain specific classes may be restricted or excluded from coverage without regard to the
formulary conditions and need not be available through prior authorization. These classes include:
• Drugs used for anorexia, weight gain, fertility, hair growth, cosmetic effect, symptomatic
relief of cough or colds, or for cessation of smoking.
• Vitamins and minerals (except prenatal prescription vitamins and fluoride preparations) or
non-prescription drugs.
• Drugs that require tests or monitoring services to be purchased exclusively from the
manufacturer or his designee.
• Barbiturates or benzodiazepines.
PRIOR AUTHORIZATION
Whether or not a drug product is on a formulary, States may require physicians to request and receive
official permission before a particular product can be dispensed. This procedure is called Prior
Authorization or Prior Approval.
States may not operate prior authorization plans unless the State provides for a response within 24
hours of a request and provides for a 72-hour emergency supply of the medication.
The Congressional intent for the prior authorization provision was not to encourage the use of such
programs, but rather to make them available to the States for the purpose of controlling utilization of
products that have very narrow indications or high abuse potential.
The majority of States report the establishment of prior authorization programs and have plans to
apply prior authorization to a select number of drugs. Some States will do so only after their Drug
Utilization Review (DUR) program has identified areas of therapeutic concern.
DRUG UTILIZATION REVIEW
DUR Program. Each State must establish a Drug Utilization Review (DUR) Program in order to
assure that prescriptions are appropriate, medically necessary, and not likely to result in adverse
medical results. A DUR Program consists of prospective and retrospective components as well as
components to educate physicians and pharmacists on common drug therapy problems.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-22

Specifically, the program educates physicians and pharmacists how to identify and reduce fraud,
abuse, gross overuse, or inappropriate or medically unnecessary care; potential and actual severe
adverse reactions to drugs, including education on therapeutic appropriateness, overutilization and
underutilization, appropriate use of generic products, therapeutic duplication, drug-disease
contraindications, drug-drug interactions, incorrect drug dosage or duration of drug treatment, drug-
allergy interactions, and clinical abuse or misuse.
The two primary objectives of DUR systems are (1) to improve quality of care; and (2) to assist in
containing health care costs. While there is a general belief that DUR is cost beneficial, it is difficult
to isolate concrete evidence that supports this view. The primary issue facing Medicaid DUR
programs is whether or not the systems currently in place (or envisioned) meet the two objectives
outlined above.
Prospective DUR. Prospective DUR is to be conducted at the point of sale (POS) before delivery of a
medication by the pharmacist to the Medicaid recipient or caregiver. The State is to establish
standards for counseling patients and will require the pharmacist to offer to discuss matters, which, in
the exercise of the pharmacist’s professional judgment are deemed significant, including the
following:
• Name and description of the medication;
• The route of administration, dosage form, dosage, and duration of therapy;
• Special directions and precautions for preparation, administration and use by the patient;
• Common severe side or adverse effects or interactions and therapeutic contraindications that
may be encountered, including their avoidance, and the action required if they occur;
• Techniques for self-monitoring prescription therapy;
• Proper storage;
• Prescription refill information; and
• Action to be taken in the event of a missed dose.
State law must also require pharmacists to make a reasonable effort to obtain, record, and maintain at
least the following information for each Medicaid recipient:
• Name, address, telephone number, date of birth (or age) and gender;
• Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
• Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.
State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-23

Pharmacy Advisory Committees
State Pharmacy Advisory Committee Meetings
Preferred Product Introduction
Process
Alabama Pharmacy & Therapeutic Committee Quarterly Introductory letter
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas None - Introductory letter
California Medi-Cal Contract Drug Advisory Committee Ad Hoc Petition with specific content requirements
Colorado None - Introductory letter
Connecticut Pharmacy and Therapeutic Committee (2004) Quarterly Introductory letter
Delaware DUR Board advises Bi-Monthly Introductory letter
District of Columbia N/A - Introductory letter
Florida Pharmacy and Therapeutic Committee - Introductory letter
Georgia Yes Quarterly Introductory letter
Hawaii None - Introductory letter, Formulary kit
Idaho Pharmacy Committee Weekly Introductory letter, Formulary kit
Illinois None - Contact First DataBank
Indiana DUR Board advises Monthly Electronic form
Iowa DUR Board advises Monthly Introductory letter
Kansas DUR Board advises Bi-Monthly Introductory letter
Kentucky Pharmacy & Therapeutic Advisory Committee Bi-Monthly Introductory letter, Package insert
Louisiana Pharmacy Advisory Committee Semiannually Introductory letter
Maine DUR Committee Monthly Introductory letter
Maryland None - Introductory letter
Massachusetts DUR Committee Quarterly Introductory letter
Michigan Pharmacy and Therapeutics Committee Quarterly State form, Introductory letter
Minnesota Drug Formulary Committee Quarterly Introductory letter
Mississippi Pharmacy and Therapeutics Committee Bi-Monthly Introductory letter
Missouri DUR Board & Prior Authorization Committee Quarterly AMPC format dossier
Montana DUR Board advises Monthly Introductory letter
Nebraska None - Introductory letter
Nevada DUR Board Quarterly Introductory letter
New Hampshire None - Information packet
New Jersey None - Introductory letter
New Mexico None - Contact First DataBank
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina Medical Care Advisory Committee - Introductory letter, Package insert
North Dakota None - Manufacturer’s preference
Ohio Pharmacy & Therapeutic Committee Quarterly Introductory letter
Oklahoma DUR Board Monthly E-mail to medicaidrx@ohca.state.ok.us
Oregon DUR Board Quarterly Introductory letter
Pennsylvania Medical Assistance Advisory Committee Monthly Introductory letter
Rhode Island None - Introductory letter
South Carolina None - Formulary packet
South Dakota None - Introductory letter
Tennessee* TennCare Pharmacy Advisory Committee Quarterly Introductory letter
Texas None - State form
Utah DUR Board Monthly Introductory letter, FDA information
Vermont DUR Committee Bi-Monthly Introductory letter
Virginia Pharmacy Liaison Committee Quarterly Introductory letter
Washington Pharmacy and Therapeutics Committee Quarterly AMCP format dossier
West Virginia Medical Services Fund Advisory Council Quarterly Introductory product packet
Wisconsin None -
Introductory letter, First DataBank
notification
Wyoming DUR Board Bi-Monthly Introductory letter
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-24

Pharmacy Benefit Design - Coverage
State Cosmetics Fertility Drugs Experimental Drugs
Alabama Not Covered Not Covered Not Covered
Alaska Covered with Restrictions Not Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Not Covered Not Covered Not Covered
Colorado Not Covered Not Covered Not Covered
Connecticut Not Covered Not Covered Not Covered
Delaware Not Covered Not Covered Not Covered
District of Columbia Covered with Restrictions Not Covered Not Covered
Florida Not Covered Not Covered Not Covered
Georgia Not Covered Not Covered Not Covered
Hawaii Not Covered Not Covered Not Covered
Idaho Not Covered Not Covered Not Covered
Illinois Not Covered Not Covered Not Covered
Indiana Not Covered Not Covered Not Covered
Iowa Not Covered Not Covered Not Covered
Kansas Not Covered Not Covered Not Covered
Kentucky Not Covered Not Covered Not Covered
Louisiana Not Covered Not Covered Not Covered
Maine Not Covered Not Covered Not Covered
Maryland Not Covered Not Covered Not Covered
Massachusetts Not Covered Not Covered Not Covered
Michigan Not Covered Not Covered Not Covered
Minnesota Not Covered Not Covered Not Covered
Mississippi Not Covered Not Covered Not Covered
Missouri Not Covered Not Covered Not Covered
Montana Not Covered Not Covered Not Covered
Nebraska Not Covered Not Covered Not Covered
Nevada Not Covered Not Covered Not Covered
New Hampshire Not Covered Not Covered Not Covered
New Jersey Not Covered Not Covered Not Covered
New Mexico Not Covered Not Covered Not Covered
New York Not Covered Not Covered Not Covered
North Carolina Not Covered Not Covered Not Covered
North Dakota Not Covered Not Covered Not Covered
Ohio Not Covered Not Covered Not Covered
Oklahoma Not Covered Not Covered Not Covered
Oregon Not Covered Not Covered Not Covered
Pennsylvania Not Covered Not Covered Not Covered
Rhode Island Not Covered Not Covered Not Covered
South Carolina Not Covered Not Covered Not Covered
South Dakota Not Covered Not Covered Not Covered
Tennessee* Not Covered Not Covered Not Covered
Texas Not Covered Not Covered Not Covered
Utah Not Covered Not Covered Not Covered
Vermont Not Covered Not Covered Not Covered
Virginia Not Covered Not Covered Not Covered
Washington Not Covered Not Covered Not Covered
West Virginia Not Covered Not Covered Not Covered
Wisconsin Not Covered Not Covered Not Covered
Wyoming Not Covered Not Covered Not Covered
*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 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-25

Pharmacy Benefit Design - Coverage (con’t)
State Prescribed Insulin
Disposable Needles for
Insulin Use
Syringe Combinations
for Insulin Use
Blood Glucose Test
Strips
Alabama Covered Covered Covered Covered as DME
Alaska Covered Covered as DME Covered Not Covered
Arizona* - - - -
Arkansas Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
California Covered Covered Covered Covered
Colorado Covered DME DME DME
Connecticut Covered Covered Covered Covered
Delaware Covered Covered Covered Covered
District of Columbia Covered Covered Covered Not Covered
Florida Covered Covered Covered Covered
Georgia Covered Covered Covered Covered with Restrictions
Hawaii Covered Covered as DME Covered as DME Covered as DME
Idaho Covered Covered Covered Covered as DME
Illinois Covered Covered Covered with Restrictions Covered
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered as DME Covered as DME Covered as DME
Kentucky Covered Not Covered Covered Not Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered with Restrictions Covered
Maryland Covered Covered Covered Covered as DME
Massachusetts Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Michigan Covered Covered Covered Covered
Minnesota Covered Not Covered Covered Not Covered
Mississippi Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Covered Covered
Montana Covered Not Covered Not Covered

Not Covered
Nebraska Covered, PA Required Covered as DME Covered (med. necess.) Covered as DME
Nevada Covered Covered Covered Covered
New Hampshire Covered Covered Covered Covered
New Jersey Covered Covered Covered Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Covered as DME Covered as DME Covered as DME
North Dakota Covered Covered Covered Covered
Ohio Covered Covered as DME Covered as DME Covered as DME
Oklahoma Covered Covered as DME Covered as DME Covered as DME
Oregon Covered Covered as DME Covered as DME Covered as DME
Pennsylvania Covered Covered Covered Covered
Rhode Island Covered Covered Covered Covered as DME
South Carolina Covered Covered Covered Covered as DME
South Dakota Covered Covered Covered Covered
Tennessee* Covered Covered Covered Covered
Texas Covered Covered Covered Not Covered
Utah Covered Covered Covered with Restrictions Covered
Vermont Covered Covered Covered Covered
Virginia Covered Covered Covered Covered
Washington Covered Covered Covered Covered
West Virginia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with 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 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-26

Pharmacy Benefit Design - Coverage (con’t)
State
Urine Ketone
Test Strips
Total
Parenteral Nutrition
Interdialytic Parenteral
Nutrition
Alabama Covered as DME Covered as DME Covered as DME
Alaska Not Covered Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered PA Required Not Covered
Colorado DME PA Required Not Covered
Connecticut Covered Covered with Restrictions Covered with Restrictions
Delaware Covered Covered Covered with Restrictions
District of Columbia Not Covered Covered with Restrictions Covered with Restrictions
Florida Covered with Restrictions Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered as DME Covered, PA Required Covered, PA Required
Idaho Covered as DME Covered Not Covered
Illinois Covered Covered with Restrictions Covered with Restrictions
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered as DME Covered as DME Covered with Restrictions
Kentucky Not Covered Covered, PA Required Covered, PA Required
Louisiana Covered Covered as DME Covered as DME
Maine Covered Not Covered Not Covered
Maryland Covered as DME Covered Covered
Massachusetts Covered with Restrictions Covered with Restrictions Not Covered
Michigan Covered Covered with Restrictions, PA
required
Covered with Restrictions, PA
required
Minnesota Not Covered Covered Covered
Mississippi Not Covered Covered Covered
Missouri Covered Covered Covered
Montana Not Covered Not Covered Not Covered
Nebraska Covered as DME Covered as DME Covered as DME
Nevada Covered Covered as DME Covered as DME
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered Covered Covered
North Carolina Covered as DME Covered Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered as DME Covered Covered
Oklahoma Covered as DME Covered with Restrictions N/A
Oregon Covered as DME Covered, PA Required Covered, PA Required
Pennsylvania Covered Covered Covered
Rhode Island Covered Covered as DME, PA required Covered as DME, PA Required
South Carolina Covered as DME Covered as DME Covered as DME
South Dakota Covered Not Covered Not Covered
Tennessee* Covered Covered Covered
Texas Not Covered Not Covered Not Covered
Utah Covered Covered as DME Covered as DME
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered Covered Covered
West Virginia Covered with Restrictions Covered as DME Not Covered
Wisconsin Covered Covered Covered
Wyoming Covered Covered as DME Covered as DME
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

PA= Prior Authorization, DME = Durable Medical Equipment

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-27

Coverage of Injectables

Reimbursement for Non Self-Administered Medicines via
the Prescription Drug Program (PDP) or Physician Payment (PP)
State Physicians Office Home Health Care Extended Care Facility
Alabama PDP PDP PDP
Alaska PP PDP PDP
Arizona* - - -
Arkansas PP PDP PDP
California PP PDP PDP
Colorado PP PDP PDP
Connecticut PP PP PP
Delaware PDP PDP PDP
District of Columbia PP PDP PDP
Florida PDP and PP PDP PDP
Georgia PP PDP PDP
Hawaii PDP and PP PDP PDP
Idaho PP PDP PDP
Illinois PDP and PP PDP PDP
Indiana PDP and PP PDP and PP PDP and PP
Iowa PDP and PP - -
Kansas PP PDP PDP
Kentucky PDP and PP PDP PDP
Louisiana PDP and PP - -
Maine PDP PDP PDP
Maryland PDP and PP PDP PDP
Massachusetts PDP and PP PDP PDP
Michigan PP PDP PDP
Minnesota PP PDP and PP PDP
Mississippi PP PDP PDP
Missouri PDP PDP PDP
Montana PP PDP PDP
Nebraska PP PDP PDP
Nevada PP PDP PDP
New Hampshire PP PDP PDP
New Jersey PP PDP PDP
New Mexico PDP and PP PDP and PP PDP and PP
New York PP PDP Included in facility rate
North Carolina PDP and PP PDP PDP
North Dakota PDP and PP PDP and PP PDP and PP
Ohio PP PDP PDP
Oklahoma PP PDP and PP PDP and PP
Oregon PP PP PP
Pennsylvania PDP PDP PDP
Rhode Island PP PDP PDP
South Carolina PP PDP PDP
South Dakota PP PP PP
Tennessee* PP PDP PDP
Texas PP PP PP
Utah PDP and PP PDP PDP
Vermont PP PP PP
Virginia PDP and PP PDP and PP PDP and PP
Washington PP PDP PDP
West Virginia PDP and PP PDP PDP
Wisconsin PDP and PP PDP PDP
Wyoming PP PP PP
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-28

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

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-29

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

PA= Prior Authorization

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-30

Coverage of Over-the-Counter Medications (Con’t)
State
Digestive Products
(non- H2 antagonists)

H2 Antagonists Feminine Products Topical Products
Alabama Covered Covered Not Covered Covered with Restrictions
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Covered Limited Coverage Limited Coverage
California Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered with Restrictions Covered with Restrictions Not Covered Covered
Delaware Covered Covered Not Covered Covered
District of Columbia Covered with Restrictions Not Covered Not Covered Not Covered
Florida Not Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Georgia Not Covered Not Covered Not Covered Not Covered
Hawaii Covered Limited Coverage N/A Limited Coverage
Idaho Not Covered Not Covered Not Covered Not Covered
Illinois PA Required Not Covered Not Covered PA Required
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Not Covered Not Covered Not Covered Covered with Restrictions
Kansas Not Covered Covered Not Covered Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered Covered with Restrictions Covered Covered
Maryland Not Covered Not Covered Limited Coverage Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Mississippi Limited Coverage Not Covered Limited Coverage Limited Coverage
Missouri Limited Coverage Not Covered Not Covered Limited Coverage
Montana Covered with Restrictions Covered with Restrictions Not Covered Not Covered
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Nevada Covered Covered Not Covered Covered with Restrictions
New Hampshire Covered Covered Covered Covered
New Jersey Not Covered Not Covered Not Covered Covered
New Mexico Covered Covered Not Covered Covered with Restrictions
New York Limited Coverage Not Covered Limited Coverage Limited Coverage
North Carolina Not Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Not Covered Not Covered
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Limited Coverage Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Not covered Covered with Restrictions Covered Covered
Rhode Island Covered Not Covered Not Covered Covered with Restrictions
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Not Covered Not Covered Not Covered Not Covered
Tennessee* Covered Covered Not Covered Covered
Texas Covered Covered Not Covered Covered
Utah Not Covered Not Covered Limited Coverage Limited Coverage
Vermont PA Required PA Required PA Required PA Required
Virginia Covered Covered Covered Covered
Washington Limited Coverage Limited Coverage Limited Coverage Limited Coverage
West Virginia Limited Coverage Not Covered Limited Coverage Limited Coverage
Wisconsin Covered with Restrictions Not Covered Covered with Restrictions Covered with Restrictions
Wyoming Not Covered Covered Covered Covered
*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 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-31

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

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-32

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. 1,550 94%
Arizona* - - -
Arkansas M.D. 155,00 72%
California M.D., R.Ph. 2,400,000 90%
Colorado M.D. 32,000 87%
Connecticut M.D., R.Ph. N/A N/A
Delaware M.D. 36,000 90%
District of Columbia M.D., R.Ph. 9,000 70%
Florida M.D., R.Ph., Pharm. Tech. 440,000 78%
Georgia M.D., R.Ph. 104,000 92%
Hawaii M.D., R.Ph. N/A 99%
Idaho M.D., R.Ph. 24,500 77%
Illinois M.D., R.Ph. 500,000 20%
Indiana M.D., Other Providers N/A N/A
Iowa M.D., R.Ph. 56,000 93%
Kansas M.D., R.Ph. N/A N/A
Kentucky M.D., R.Ph. 285,000 58%
Louisiana M.D. 171,000 95%
Maine M.D. 65,000 82%
Maryland M.D., R.Ph 5,300 99%
Massachusetts M.D. 137,000 67%
Michigan M.D. 120,000 95%
Minnesota M.D., R.Ph., Pharm. Tech. N/A N/A
Mississippi M.D. 216,000 90%
Missouri M.D., R.Ph., Physician Extender 35,000 N/A
Montana M.D., R.Ph., Pharm. Tech. 16,000 70%
Nebraska M.D., R.Ph. 24,000 40%
Nevada M.D. - -
New Hampshire M.D. 870 88%
New Jersey R.Ph., DME Supplier 351,000 97%
New Mexico M.D., R.Ph., Pharm. Tech. 1,300 N/A
New York Ordering Provider 180,000 100%
North Carolina M.D. N/A N/A
North Dakota M.D., R.Ph., Pharm. Tech. N/A N/A
Ohio M.D. 120,000 Most
Oklahoma M.D., R.Ph. 117,000 59%
Oregon M.D. 43,000 66%
Pennsylvania M.D., Other Licensed Prescriber N/A N/A
Rhode Island M.D., R.Ph. N/A N/A
South Carolina M.D. 37,700 60%
South Dakota M.D., R.Ph. 28 100%
Tennessee* M.D. 450,000 66%
Texas M.D., R.Ph., Other Licensed Provider 3,000 75%
Utah M.D. 12,000 50%
Vermont M.D. N/A 99%
Virginia M.D., R.Ph. 50,000 64%
Washington R.Ph., Pharm. Tech. N/A 80%
West Virginia M.D., R.Ph. 160,000 78%
Wisconsin R.Ph. 182,000 97%
Wyoming M.D., R.Ph., Pharm. Tech. 8,200 81%
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-33

Prior Authorization Process and Procedures (Con’t)
State Reviewer Review Time Response Vehicle
Alabama R.N., M.D., R.Ph. 24 hours Phone, fax, mail, e-mail
Alaska R.N., R.Ph., Pharm. Tech. 24 hours Phone, fax
Arizona* - - -
Arkansas Voice Response 1-3 minutes Voice response system
California R.Ph. One business day Fax or telephone inquiry system
Colorado Pharm. Tech. 24 hours Phone, fax
Connecticut R.Ph. 2 hours Fax, POS system
Delaware R.Ph. 1 working day Mail
District of Columbia R.Ph., Pharm. Tech. Minutes to 24 hours Phone, fax
Florida R.Ph., Pharm. Tech. 30 minutes-24 hours Phone, fax, mail
Georgia PBM 24 hours or less Phone, mail
Hawaii Pharm. Tech., L.P.N. 24 hours Fax
Idaho M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax, mail
Illinois M.D., R.Ph. 4-8 hours Automated phone
Indiana Medicaid Director or designee 10 days Phone, letter
Iowa R.Ph. 24 hours or less Phone, fax
Kansas R.N., R.Ph. 24 hours or less Phone, mail
Kentucky R.N., R.Ph. 4-24 hours Phone, fax
Louisiana R.Ph. 3-5 minutes Phone, fax
Maine M.D. 4 hours Mail
Maryland M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Massachusetts R.Ph. 24 hours Phone, mail
Michigan M.D., R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Minnesota R.N. Within minutes Phone, mail
Mississippi R.N., R.Ph., Pharm. Tech. 6 hours Phone, fax, mail
Missouri M.D., R.Ph., Pharm. Tech. < 5 minutes Phone, fax, mail
Montana M.D., R.Ph., Pharm. Tech. 24 hours or less Mail
Nebraska M.D., R.Ph., Pharm, Tech. 24 hours Phone, fax, mail
Nevada R.Ph., Pharm. Tech. 24 hours Phone
New Hampshire R.Ph., Pharm. Tech. 24 hours Phone, fax with written follow-up of denials
New Jersey R.N., R.Ph., First Health Minutes Phone
New Mexico R.Ph. 24 hours Phone
New York Voice interactive system Processed during call PA issued to prescriber by phone
North Carolina ACS (PBM) 24 hours Phone, fax, e-mail
North Dakota R.Ph. 24 hours Fax
Ohio R.Ph., Pharm. Tech. Immediate Phone
Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours Fax, mail
Oregon R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Pennsylvania R.N., M.D. Immediately to 24 hours Phone
Rhode Island R.Ph., Pharm. Tech. Immediately to 24 hours Online adjudication or verbally
South Carolina R.Ph., First Health Per OBRA ‘90 guidelines Phone, fax
South Dakota R.Ph. 24 hours Phone, fax, mail, e-mail
Tennessee* R.Ph. Same day Fax
Texas R.Ph. 72 hours Phone, fax
Utah Nurse 8-12 hours Phone, fax, mail
Vermont R.N. 24 hours Phone, mail
Virginia M.D., R.Ph., Pharm. Tech. Less than 3 minutes Phone, fax, mail
Washington
M.D., Drug Utilization Review
Team**
<24 hours Phone, fax; denial through mail
West Virginia R.Ph. 3 minutes to 2 hours Phone, fax
Wisconsin R.Ph., Done electronically Immediate Online
Wyoming ACS Clinical Supervisor 24 hours Phone, fax, mail, e-mail
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**Reviewer also includes Medical Claims Examiner.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-34

Prior Authorization
State Anabolic Steroids
Analgesics,
Antipyretics, NSAIDs Anorectics
Alabama Covered Covered, PA Required Covered
Alaska Covered Covered, PA Required Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Not Covered
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Covered, PA Required Not Covered, PA Required
District of Columbia Not Covered Partial Coverage, PA Required Partial Coverage, PA Required
Florida Covered, PA Required Covered Not Covered
Georgia Covered, PA Required Covered, PA Required Not covered
Hawaii Covered, PA Required Covered, PA Required Covered, PA Required
Idaho Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Illinois N/A Covered Not Covered
Indiana** N/A N/A N/A
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Covered Partial Coverage, PA Required
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland Covered Covered Not Covered
Massachusetts Covered Partial Coverage, PA Required Not Covered
Michigan Partial Coverage, PA Required Covered Not Covered
Minnesota Covered Partial Coverage, PA Required Not Covered
Mississippi Covered Covered, PA Required Not Covered
Missouri Partial Coverage Partial Coverage Not Covered
Montana Covered Partial Coverage, PA Required Partial Coverage, PA Required
Nebraska Covered Partial Coverage, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Jersey Partial Coverage Covered PA for ADD Diagnosis
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered Covered
North Dakota Covered Covered, PA Required Partial Coverage, PA Required
Ohio Not Covered Covered Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered Not Covered
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered Covered
Tennessee* Covered Covered, PA Required Covered
Texas Covered Covered Covered
Utah Not Covered Covered, PA Required Not Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Partial Coverage, PA Required Not Covered
Wisconsin Covered Covered, PA Required Covered, PA Required
Wyoming Not Covered Covered, Some require PA Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
** All coverage in accordance with OBRA'90 and OBRA'93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-35

Prior Authorization (con’t)
State Antihistamines
Anxiolytics,
Sedatives, and Hypnotics
Prescribed
Cold Medications
Alabama Covered, PA Required Covered Partial Coverage
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Partial Coverage, PA Required Covered Partial Coverage
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered Covered Covered, PA Required
Connecticut Covered Covered Covered
Delaware Covered Covered Covered
District of Columbia Covered Covered Covered
Florida Covered Covered Partial Coverage
Georgia Covered Covered, PA Required Partial Coverage
Hawaii Partial Coverage, PA Required Covered N/A
Idaho Partial Coverage, PA Required Covered Partial Coverage
Illinois Partial Coverage Partial Coverage Not Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered Covered
Kansas Covered Partial Coverage, PA Required Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Covered, PA Required
Louisiana Covered, PA Required Covered, PA Required Partial Coverage
Maine Covered, PA Required Covered, PA Required Not Covered
Maryland Covered Covered Covered
Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Michigan Covered Covered Partial Coverage
Minnesota Covered, PA Required Covered Covered
Mississippi Covered, PA Required Covered Partial Coverage
Missouri Partial Coverage Covered, PA Required Partial Coverage
Montana Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Nebraska Covered, PA Required Partial Coverage Covered
Nevada Covered Covered Covered
New Hampshire Covered Covered Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Partial Coverage, PA Required Covered Partial Coverage
North Carolina Covered Covered Covered
North Dakota Covered, PA Required Covered Not Covered
Ohio Partial Coverage, PA Required Covered Partial Coverage, PA Required
Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered Covered
South Carolina Covered Covered Covered
South Dakota Covered Covered Covered
Tennessee* Covered, PA Required Covered Not Covered
Texas Covered Covered Covered
Utah Covered Covered Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Covered, PA Required
West Virginia Covered Partial Coverage Partial Coverage
Wisconsin Covered, PA Required Covered Covered
Wyoming Covered Covered Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-36

Prior Authorization (con’t)
State Growth Hormones
Miscellaneous
GI Products
Prescribed
Smoking Deterrents
Alabama Covered, PA Required Covered Not Covered
Alaska Covered, PA Required Covered Not Covered
Arizona* - - -
Arkansas Covered Covered, PA Required Partial Coverage, PA Required
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Covered, PA Required Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Covered, PA Required Covered Covered, PA Required
District of Columbia Partial Coverage, PA Required Partial Coverage, PA Required Covered
Florida Covered Covered Covered
Georgia Covered, PA Required Covered Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Partial Coverage, PA Required Partial Coverage, PA Required Not Covered
Illinois Covered Covered Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Not Covered
Kansas Covered, PA Required Covered Partial Coverage
Kentucky Covered, PA Required Covered, PA Required Not Covered
Louisiana Covered, PA Required Covered, PA Required Covered
Maine Covered, PA Required Covered, PA Required Covered, PA Required
Maryland Covered, PA Required Covered Covered
Massachusetts Covered, PA Required Partial Coverage, PA Required Not Covered
Michigan Covered Covered Partial Coverage, PA Required
Minnesota Covered Covered, PA Required Covered
Mississippi Covered Covered, PA Required Covered
Missouri Partial Coverage Partial Coverage, PA Required Not Covered
Montana Partial Coverage, PA Required Covered Partial Coverage, PA Required
Nebraska Covered, PA Required Covered, PA Covered Not Covered
Nevada Partial Coverage, PA Required Covered Covered
New Hampshire Covered Covered, PA Required Covered
New Jersey Partial Coverage Covered Partial Coverage
New Mexico Covered Covered Covered
New York Covered, PA Required Partial Coverage Covered
North Carolina Covered, PA Required Covered Covered, PA Required
North Dakota Covered Covered, PA Required Covered
Ohio Not Covered Partial Coverage, PA Required Partial Coverage, PA Required
Oklahoma Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Oregon Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Covered
Rhode Island Covered, PA Required Covered, PA Required Not Covered
South Carolina Covered Covered Not Covered
South Dakota Covered, PA Required Covered Partial Coverage
Tennessee* Covered Covered Not Covered
Texas Covered, PA Required Covered Covered
Utah Partial Coverage, PA Required Covered Not Covered
Vermont Covered Covered Covered
Virginia Covered Covered Covered
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Wisconsin Covered PA Required Covered Covered
Wyoming Covered Covered, PA Required on PPIs Not Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**All coverage in accordance with OBRA ’90 and OBRA ’93.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-37

Drug Utilization Review
State State Contact Telephone
In-House or
Contracted
PRODUR
Implemented
Alabama Louise Jones 334-242-5039 Contracted Jul-96
Alaska Dave Campana, R.Ph. 907-334-2425 Contracted Jun-95
Arizona* - - - -
Arkansas Pamela Ford, P. D. 501-683-4120 Contracted Mar-97
California Vic Walker, R.Ph., B.C.P.P. 916-552-9500 Contracted Aug-95
Colorado Catherine Traugott 303-866-2468 Contracted Dec-98
Connecticut James Zakszewski, R.Ph. 860-424-4961 Contracted Sep-96
Delaware Cynthia Denemark, R.Ph. 302-453-8453 Contracted Feb-94
District of Columbia Donna Bovell, R.Ph. 202-442-5988 In-House Sep-96
Florida Linda Barnes 850-487-4441 Contracted Jul-93
Georgia Jean Cox, R.Ph. 404-657-7241 In-House Oct-00
Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997
Idaho Tamara Eide, Pharm.D., B.C.P.S. 208-364-1821 Contracted Jan-98
Illinois Marvin Hazelwood 217-524-5565 In-House Jan-93
Indiana Karen Clifton 317-232-4307 Contracted Mar-96
Iowa Julie Kuhle, R.Ph. 515-270-0713 Contracted Jul-97
Kansas Vicki Schmidt 785-274-4287 Contracted Nov-96
Kentucky Debra Bahr, R.Ph. 502-564-7940 In-House 1987
Louisiana Mary J. Terrebonne, P.D. 225-342-9768 Contracted Apr-66
Maine Jude Walsh 207-287-1815 Contracted Dec-95
Maryland Judith Geisler, P.D. 410-767-1455 Contracted Jan-93
Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95
Michigan Debera Eggleston, M.D. 517-335-5181 Contracted Jul-00
Minnesota Mary Beth Reinke, Pharm.D., R. Ph. 651-215-1239 In-House Feb-96
Mississippi Judith P. Clark, R.Ph. 601-359-5253 Contracted Oct-93
Missouri Jayne Zemmer 573-751-1612 In-House Feb-93
Montana Mark Eichler, R.Ph. 406-443-4020 Contracted Sep-94
Nebraska Beth Wilson 402-420-1500 Contracted Apr-95
Nevada Dionne Coston, R.N. 702-684-3775 Contracted 2003
New Hampshire Lisè Farrand 603-271-4419 Contracted Jul-95
New Jersey Edward Vaccaro, R.Ph. 609-588-2726 In-House Oct-96
New Mexico Neal Solomon, M.P.H., R.Ph. 505-827-3174 Both Oct-93
New York Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95
North Carolina Sharman Leinwand, R.Ph., M.P.H. 919-857-4034 Contracted Oct-96
North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-1544 In-House Jul-96
Ohio Jan Lawson 614-466-9698 Both Feb-00
Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000
Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-494-1589 Contracted Mar-94
Pennsylvania N/A - Contracted Jun-93
Rhode Island Paula Avarista, R.Ph. 401-4642-6390 Contracted Dec-94
South Carolina Caroline Sojourner, R.Ph. 803-898-2876 Contracted Nov-00
South Dakota Michael Jockheck, R.Ph. 605-773-6439 In-House 1996
Tennessee* Jeffrey G. Stockard, D.Ph. 615-532-3107 Contracted Jul-01
Texas Barbara Dean 512-491-1101 In-House Feb-95
Utah Duane Parke 801-538-6452 In-House 1994
Vermont Scott Strenio, M.D. 802-741-7975 Contracted Nov-93
Virginia Javier Menendez, R.Ph. 804-783-2196 Contracted Jul-94
Washington Nicole Nguyen, Pharm.D. 360-725-1757 In-House Mar-96
West Virginia Vicki M. Cunningham, R.Ph. 304-588-1700 Contracted Mar-95
Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3348 Contracted 2001
Wyoming Debra Devereuax, R.Ph. 307-766-6750 Contracted Oct-95
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

PRODUR = Prospective Drug Utilization Review System
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-38

Prescribing/Dispensing Limits
State
Limits on
Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 30 day supply per Rx
Alaska Yes 30 day supply per Rx, maximum number units for 50 classes and 40 narcotics
Arizona* - -
Arkansas Yes 31 day supply per Rx; 3 Rx per month (extension to 6); 5 refills per Rx within 6 months
California Yes 6 Rx per month, maximum 100 day supply for most medications
Colorado Yes 30 day quantity supply per Rx; 100 day supply for maint. meds. Other limits for stadol & oxycontin
Connecticut Yes 240 units or 30 day supply, 5 refills per RX except 12 month limit on oral contraceptives
Delaware Yes 34 day supply or 100 unit doses per Rx (whichever is greater)
District of Columbia Yes 30 day supply per Rx, 3 refills per Rx within 4 mths. Max/min quantities for certain meds
Florida Yes 4 brand name Rxs per month (with exceptions)
Georgia Yes 31 day supply per Rx; 5 (adult)/6 (child) Rx per month; Per Rx limit: $2999.99 (potential override)
Hawaii Yes 30 day supply or 100 unit doses per Rx. Maximum quantities for some drugs
Idaho Yes 34 day supply per Rx (with exceptions); 3 cycles of birth control; limits on refills/early refills
Illinois Yes Medically appropriate monthly quantity
Indiana No -
Iowa Yes Maximum 30 day supply except select maintenance drugs (90 days)
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 30 day supply, max. 5 refills in 6 months; one dispensing fee per month for maintenance medication
Louisiana Yes 30 day supply or 100 unit doses (whichever is greater); 5 refills per Rx within 6 mos., max. 8 scripts per
recipient per month
Maine Yes 34 day supply (brand), 90 day supply (generic); Maximum 11 refills per prescription
Maryland Yes 34 day supply per Rx; Maximum 11 refills per Rx, Refills may not exceed 360 day supply
Massachusetts Yes 30 day supply, Maximum 5 refills per prescription
Michigan Yes 100 day supply, Quantity limits for selected drugs (e.g., sedative hypnotics)
Minnesota Yes 34 day supply
Mississippi Yes 34 day supply or 100 unit doses (whichever is greater); 5 Rx per month; 5 refills maximum
Missouri No -
Montana Yes 34 day supply
Nebraska Yes 90 day/100 unit doses, 5 refills per Rx 6 mos. for controlled substances, 31 days for injectibles
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications.
New Hampshire Yes 30 day supply, 90 day supply on maintenance medications
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No 34 day supply, except contraceptives (100 days)
New York Yes 5 refills per Rx; annual limit on number of Rx and OTC drugs avail. (potential override)
North Carolina Yes 34 day supply per Rx, with exceptions; 6 Rx per month
North Dakota Yes 34 day supply per Rx; max 12 refills per script; Limits on refills by Class
Ohio No -
Oklahoma Yes 3 Rx per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 34 day supply (15 day supply for initial Rx for chronic conditions), duration limits on selected drugs
Pennsylvania Yes 34 day supply or 100 unit doses per Rx (whichever is greater); 5 refills within 6 mos., 6 Rx per month
Rhode Island Yes 30 day supply per Rx (non-maintenance); 5 refills per Rx
South Carolina Yes 34 day supply w/ unlimited Rx (children); 4 Rx per month (adult), (potential override)
South Dakota No -
Tennessee* Yes 31 day supply, 1 year for non-controlled medications
Texas Yes 3 Rx per month (unlimited Rxs for nursing home recipients or those < 21), max 5 refills
Utah Yes 7 Rx per month, 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 60 day supply for maintenance medications, 5 refills per Rx
Virginia Yes 34 day supply per Rx
Washington Yes 34 day supply per Rx; usually 2 refills per month; 4 refills for antibiotics or scheduled drugs
West Virginia Yes 34 day supply; 5 refills per Rx with quantity limits on some drugs
Wisconsin Yes 34 day supply per Rx with exceptions, maximum 11 refills during 12-month period
Wyoming Yes Quantity limits on some medications as deemed clinically appropriate.
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.

Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-39

PHARMACY PAYMENT AND PATIENT COST SHARING
Medicaid Payment for Outpatient Prescription Drugs. Federal Medicaid regulations prescribe the
principles that apply to State Medicaid programs when they pay a pharmacy for outpatient drugs.
These regulations don’t just indicate the FFP cannot be based on amounts that exceed drug costs as
determined under the federal formula; they indicate the actual method for paying for prescription
drugs.
Medicaid Managed Care Organizations (MCOs). If the recipient is enrolled in a Medicaid managed
care organization, payment is made to the MCO in accordance with its contract with the State
Medicaid agency to the extent the contract covers outpatient prescribed drugs.
Medicaid Payment to Pharmacies. Each State’s Medicaid State Plan must comprehensively describe
its payment for prescription drugs. Its aggregate Medicaid expenditures for “multiple source drugs”
must not exceed the Federal Upper Limits published by CMS (see Appendix D) and its payment level
for other drugs must not exceed, in the aggregate, the lower of (1) EAC plus a reasonable dispensing
fee, or (2) providers’ charges to the general public.
PATIENT COST SHARING
States are permitted to require certain recipients to share some of the costs of Medicaid by imposing
on them such payments as enrollment fees, premiums, deductibles, coinsurance, copayments, or
similar cost-sharing charges (42 CFR 447.50). For States that impose cost-sharing payments, the
regulations specify the standards and conditions under which States may impose cost-sharing, set
forth minimum amounts and the methods for determining maximum amounts, and describe
limitations on availability that relate to cost-sharing requirements.
With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:
• Services furnished to individuals under 18 years of age (or up to 21 at State option);
• Pregnancy-related services (or, at State option, any service provided to pregnant women);
• Services provided to certain institutionalized individuals, who are required to spend all of
their income for medical care except for a personal needs allowance;
• Emergency services;
• Family planning services and supplies;
• Services furnished to categorically needy HMO enrollees (or, at State option, services
provided to both categorically needy and medically needy HMO enrollees).
In addition, the law prohibits imposing more than one type of charge on any service.
While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-40

of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-41

Pharmacy Payment and Patient Cost Sharing
State Dispensing Fee Ingredient Reimbursement Basis Copayment
Alabama $5.40 AWP- 10%; WAC+9.2% $0.50 - $3.00
Alaska $3.45 minimum AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 B; AWP-14%, G; AWP-20% $0.50 - $5.00
California $4.05 AWP-10% $1.00
Colorado $4.00; $1.89 for Institutions AWP-13.5% or WAC+18%, whichever is lowest;
AWP-35% (for generics)
$3.00
Connecticut $3.30 AWP-12% $1.50
Delaware $3.65 AWP-14; AWP-16% (LTC)% None
DC $4.50 AWP-10% $1.00
Florida $4.23-$4.73 (LTC) AWP-13.25%; WAC+7% None
Georgia $4.63 + $0.50 (for generics) AWP-10% G/P: $0.50, B/NP: $0.50 - $3.00
Hawaii $4.67 AWP-10.5% None
Idaho $4.94 ($5.54 for unit dose) AWP-12% None
Illinois G: $5.10, B: $4.00 B: AWP-11%, G: AWP-20% $1.00
Indiana $4.90 B: AWP-13.5%, G: AWP-20% $0.50 - $3.00
Iowa $4.26 AWP-12% $0.50-$3.00
Kansas $3.40 B: AWP-15%, G: AWP-27% IV AWP-50%, blood
AWP-30%
$3.00
Kentucky $4.51 AWP-12% $1.00
Louisiana $4.45 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 - $12.50 AWP-15% $2.50,
Max $25/recipient/pharm./month
Maryland $3.69-$5.65 Lowest of :WAC+9%, direct+9%, AWP-11% $2.00 for Brand not on PDL
Massachusetts $3.50 - $5.00 WAC+6% B: $3.00, G: $1.00
Michigan $3.77 AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) $1.00 (adults)
Minnesota $3.65 AWP-11.5% B: $3.00, G: $1.00
Mississippi $3.91 AWP-12% $1.00 - $3.00
Missouri $4.09 - $8.19 AWP-10.43%, WAC+10% $0.50 - $2.00, $5.00 for some
1115 waiver pop.
Montana $2.00 - $4.70 AWP-15% $1.00 - $5.00
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% None
New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00
New Jersey $3.73 - $4.07 AWP-10%, WAC+30%, AAC for injectables None
New Mexico $3.65 AWP-12.5% None (except $2.00 for CHIP and
working disabled)
New York B: $3.50 G: $4.50 AWP-12% G: $0.50, B: $2.00
North Carolina B: $4.00 G: $5.60 AWP-10% G: $1.00, B: $3.00
North Dakota $5.10 AWP-10% $3.00 (Brand)
Ohio $3.70 WAC + 9% None
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00
Oregon Retail: $3.50 Inst./NF: $3.80 AWP-15% (retail), AWP-11% (institutional) B: $3.00, G: $2.00
Pennsylvania $4.00 ($5.00 for compounds) AWP-10% $1.00 ($2.00 for General Assist.)
Rhode Island OP: $3.40, LTC: $2.85 WAC+5% None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% $2.00
Tennessee* $2.50 AWP-13% Medicaid: None;
Other: $5/$10 Based on Income
Texas (EAC+$5.14)/0.98 & delivery fee AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 (urban), $4.40 (rural) AWP-15% $3.00
Vermont $4.25 AWP-11.9% B: $3.00, G: $1.00
Virginia $3.75 AWP-10.25% B: $3.00, G: $1.00
Washington $4.20-$5.20 (based on annual # of Rx) AWP-14% None
West Virginia $3.90 (+ extra $1.00 for compounding) AWP-12% $0.50 - $2.00
Wisconsin $4.88 (to a maximum $40.11) AWP-12% $1.00-$3.00, max
$5/recip/pharm/mo
Wyoming $5.00 AWP-11% $2.00
WAC = Wholesalers Acquisition Cost; AWP = Average Wholesale Price; EAC = Estimated Acquisition Cost; AAC= Actual Acquisition Cost;
G = Generic; B = Brand Name; OP = Outpatient; LTC = Long Term Care; P = Preferred; NP = Non-Preferred; PDL= Preferred Drug List
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make formulary/drug decisions.
Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-42

Maximum Allowable Cost (MAC) Programs
State
Federal
Upper Limits
State-Specific
Upper Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason for medical necessity
Arizona* - - -
Arkansas Yes Yes MedWatch form for prior authorization
California Yes Yes Medically necessary and other products unavailable at MAC rate
Colorado Yes Yes Prior authorization with medical necessity
Connecticut No Yes -
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia Yes No Brand medically necessary plus prior authorization
Florida Yes Yes MedWatch form and prior authorization request
Georgia Yes Yes Prior authorization
Hawaii Yes Yes Prior authorization
Idaho Yes Yes Failure of 2 generics plus MedWatch form
Illinois Yes Yes Prior authorization request by M.D. or R.Ph.
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary, MedWatch form and prior authorization
Kansas Yes Yes Dispense as written
Kentucky Yes Yes Brand necessary, brand medically necessary, PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes Brand medically necessary and reason for medical necessity
Massachusetts Yes Yes Dispense as written, brand medically necessary, prior authorization
Michigan Yes Yes Brand medically necessary and prior authorization
Minnesota Yes Yes Dispense as written. No pre-printed DAW allowed.
Mississippi Yes No Brand medically necessary or prior authorization for brand multi-source
Missouri Yes Yes Prior authorization and MedWatch form
Montana Yes No Brand necessary, prior authorization
Nebraska Yes Yes Medically necessary
Nevada No No Brand medically necessary
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes Yes Medically necessary, brand medically necessary
New York Yes No Prior authorization
North Carolina Yes Yes Brand medically necessary in writing on prescription
North Dakota Yes Yes Dispense as written
Ohio Yes Yes Prior authorization
Oklahoma Yes Yes Brand medically necessary
Oregon Yes Yes Brand medically necessary and documentation of generic intolerance
Pennsylvania Yes Yes Brand necessary, brand medically necessary, plus prior authorization
Rhode Island Yes No Brand medically necessary with medical justification
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and P.A.
South Dakota Yes Yes Brand medically necessary
Tennessee* Yes Yes -
Texas Yes Yes Dispense as written, medically necessary, brand medically necessary
Utah Yes Yes Dispense as written, medically necessary, brand medically necessary
Vermont Yes Yes Dispense as written
Virginia No Yes Dispense as written
Washington Yes Yes Medically necessary, brand medically necessary
West Virginia Yes No Brand medically necessary (hand written by prescriber)
Wisconsin No Yes Brand medically necessary
Wyoming Yes Yes Brand medically necessary
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.


Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-43

Mandatory Substitution
State
Incentive Fee for
Generic Substitution
Dispensing of Generic
Multi-Source Required
Dispensing of Lowest Cost
Multi-Source Required
Alabama No No No
Alaska No Yes No
Arizona* - - -
Arkansas $2.00 Yes Yes
California No No Yes
Colorado No No No
Connecticut $0.50 Yes No
Delaware No Yes No
District of Columbia No Yes Yes
Florida No Yes No
Georgia $0.50 Yes (brand PA required) No
Hawaii No - No
Idaho No Yes No
Illinois No No Yes
Indiana No Yes Yes
Iowa No Yes Yes
Kansas No No No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes No
Maryland Yes Yes Yes
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No Yes No
Missouri No Yes Yes
Montana No Yes No
Nebraska No No No
Nevada No Yes No
New Hampshire No Yes No
New Jersey No Yes No
New Mexico No No No
New York $1.00 Yes No
North Carolina No Yes Yes
North Dakota No No No
Ohio No No No
Oklahoma No Yes No
Oregon No Yes No
Pennsylvania No Yes No
Rhode Island No Yes No
South Carolina No Yes No
South Dakota $10.00 No No
Tennessee* Yes Yes Yes
Texas No Yes No
Utah No Yes Yes
Vermont No Yes No
Virginia No Yes No
Washington No Yes No
West Virginia No Yes No
Wisconsin No Yes No
Wyoming No Yes No
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.


Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-44

Counseling Requirements and Payment for Cognitive Services
State Patient Counseling Required
1

Medicaid Payment
for Cognitive Services
2

Alabama All Yes (Clozaril case management)
Alaska All No
Arizona All -
Arkansas All No
California All No
Colorado Medicaid Only No
Connecticut Medicaid Only No
Delaware All No
District of Columbia Medicaid Only, New Prescriptions No
Florida All Yes (HIV, mental health, diabetes, hypertension)
Georgia All No
Hawaii Medicaid Only No
Idaho All No
Illinois All No
Indiana All No
Iowa All No
Kansas All No
Kentucky All No
Louisiana All No
Maine All No
Maryland Medicaid Only, New Prescriptions No
Massachusetts All No
Michigan All No
Minnesota All Yes (Clozaril monitoring)
Mississippi All Yes
Missouri All
Yes (diabetes, asthma, heart failure, and depression
education)
Montana All No
Nebraska All No
Nevada All No
New Hampshire All No
New Jersey All Yes
New Mexico All No
New York All No
North Carolina All No
North Dakota All No
Ohio All No
Oklahoma All No
Oregon All No
Pennsylvania All No
Rhode Island All No
South Carolina Medicaid Only No
South Dakota All No
Tennessee All No
Texas All No
Utah All No
Vermont All No
Virginia All No
Washington All Yes (emergency contraceptive counseling)
West Virginia All No
Wisconsin All Yes
Wyoming All No

Source:
1
2002-2003 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law;
2
As reported by State drug
program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
4-45

Prescription Price Updating
State Contact Telephone Updated
Alabama Beverly Churchwell 334-242-5034 Biweekly
Alaska Dave Campana 907-334-2425 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California EDS Federal Corp. 916-636-1000 Monthly
Colorado Martha Warner 303-866-3176 Weekly
Connecticut James Heuschkel 860-424-5347 Weekly
Delaware Dan Cohn 302-453-8453 Weekly
District of Columbia Glenn Sharp 804-965-7447 Monthly
Florida First DataBank 650-588-5454 Weekly
Georgia Express Scripts 952-837-5326 Weekly
Hawaii First DataBank 800-633-3453 Weekly
Idaho Katie Ayad 208-364-1970 Biweekly
Illinois First DataBank 650-588-5454 Weekly
Indiana First DataBank 650-588-5454 Weekly
Iowa Sherry Swanson 515-327-0950 Weekly
Kansas Mary H. Obley 785-296-8406 Weekly
Kentucky Unisys Provider Services 502-226-1140 Weekly
Louisiana Maggie Vick, Unisys Corp. 225-237-3251 Weekly
Maine Jude Walsh 207-287-1815 Weekly
Maryland First DataBank 650-588-5454 Weekly
Massachusetts First DataBank 650-588-5454 Weekly
Michigan First Health Service Corp. 877-864-9014 Weekly
Minnesota First DataBank 650-588-5454 Weekly
Mississippi Judith P. Clark, R.Ph. 601-359-5253 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska First DataBank 650-588-5454 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire First Health Services Corp. 800-884-2822 Weekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Neil Solomon, M.P.H., R.Ph. 505-874-3174 Weekly
New York Carl Cioppa, Pharm.D.. 518-474-9219 Monthly
North Carolina Sharon Greeson, R.Ph.. 919-816-4475 Weekly
North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-1544 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma First DataBank 800-633-3453 Weekly
Oregon First Health Service Corp. 503-391-1980 Biweekly
Pennsylvania First DataBank 800-633-3453 Monthly
Rhode Island Paula Avarista, R.Ph. 401-462-6390 Biweekly
South Carolina First DataBank 650-588-5454 Weekly
South Dakota Mark Petersen, R.Ph. 605-773-3495 Biweekly
Tennessee* First DataBank 650-588-5454 Weekly
Texas Martha McNeill, R.Ph. 512-491-1157 Continuously
Utah RaeDell Ashley, R.Ph. 801-538-6495 Bimonthly
Vermont Christine Dapkiewicz 802-879-4450 Biweekly
Virginia Javier Menendez, R.Ph. 804-786-2196 Weekly
Washington Tom Zuchlewski 360-725-1837 Weekly
West Virginia Becky Garrigan 770-352-8592 Weekly
Wisconsin First DataBank 800-633-3453 Biweekly
Wyoming First DataBank 800-633-3453 Weekly
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.


Source: As reported by State drug program administrators in the 2003 NPC Survey.
National Pharmaceutical Council Pharmaceutical Benefits 2003
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National Pharmaceutical Council Pharmaceutical Benefits 2003
5-1




Section 5:
State Pharmacy Program
Profiles






National Pharmaceutical Council Pharmaceutical Benefits 2003
5-2

National Pharmaceutical Council Pharmaceutical Benefits 2003
5-3
Profiles of State Medicaid Drug Programs
In the following State profiles, we present a general overview of the characteristics of State
programs together with detailed information on the pharmaceutical benefits provided. Specifically,
the following information is provided for each State:
A. Benefits Provided and Groups Eligible
B. Expenditures for Drugs
C. Administration
D. Provisions Relating to Drugs, including:
• Drug Benefit Product Coverage
• Over-the-Counter Product Coverage
• Therapeutic Category Coverage
• Coverage of Injectables, Vaccines, and Unit Dosing
• Formulary/Prior Authorization
• Prescribing or Dispensing Limitations
• Drug Utilization Review
• Dispensing Fee
• Ingredient Reimbursement Basis
• Prescription Charge Formula
• Maximum Allowable Cost
• Incentive Fee
• Patient Cost Sharing
• Cognitive Services
E. Use of Managed Care
F. State Contacts
National Pharmaceutical Council Pharmaceutical Benefits 2003
5-4


National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-1
ALABAMA
1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

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

TOTAL $392,482,787 464,695 $452,269,953

RECEIVING CASH ASSISTANCE TOTAL $282,959,267 214,351
Aged $38,349,615 26,574
Blind/Disabled $227,824,175 126,146
Child $9,041,169 45,067
Adult $7,744,308 16,564

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $44,308,667 201,784
Aged $711,972 619
Blind/Disabled $830,003 695
Child $41,406,319 190,910
Adult $1,360,373 9,560

TOTAL OTHER EXPENDITURES/RECIPIENTS* $65,214,853 48,560
*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
** 2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.


1
The State of Alabama did not respond to the 2003 NPC Survey. Using CMS data and other source materials, we have, to the extent possible, updated the Profile and
the tables in other sections of the Compilation. Users should check with the Alabama Medicaid program to assess the accuracy and currency of the information
included.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-2
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
C. ADMINISTRATION
Alabama Medicaid Agency.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin, disposable needles used for
insulin; and syringe combinations for insulin
(considered OTC). Products covered as DME: blood
glucose test strips; urine ketone test strips; total
parenteral nutrition; and interdialytic parenteral
nutrition. Prior authorization required for: Retin A,
Accutane, Dipyridamole. Products not covered:
cosmetics; fertility drugs; experimental drugs; drugs
for anorexia or weight gain; hair growth products;
and DESI drugs.

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

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

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

Vaccines: Vaccines reimbursable as part of the
EPSDT service and the Vaccines for Children
Program. Adult vaccines are available through the
Health Department.

Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary with preferred drug list.
Prior authorization required for non-preferred drugs.
Anti-psychotics and HIV/AIDs drugs are exempted
from the prior authorization requirements. (For
additional information see: www.medicaid.state.al.us.
Prior Authorization: State currently has a formal
prior authorization procedure. Review by Medicaid’s
Medical Director required for appeal of prior
authorization decisions.
Prescribing or Dispensing Limitations
Prescription Refill Limit: 30 day supply, maximum of
five refills.
Drug Utilization Review
PRODUR system implemented in July 1996. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $5.40.
Ingredient Reimbursement Basis: AWP-10%, WAC
+ 9.2%.
Prescription Charge Formula: Medicaid pays for
prescribed legend and non-legend drugs authorized
under the program based upon and shall not exceed
the lowest of:
1. The Maximum Allowable Cost (MAC) of the
drug plus a dispensing fee,
2. The Estimated Acquisition Cost (EAC) of the
drug plus a dispensing fee, or
3. The provider’s usual and customary charge to
the public for the drug.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Necessary” in the physician’s own handwriting.
Incentive Fee: None.
Patient Cost Sharing: Tiered copayment.
Drug Ingredient Cost Copayment
$0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-3
$25.01 to $50.00 $2.00
$50.01 or more $3.00
Exemptions: No copayment amount is to be collected
by the pharmacy or paid by the recipient for
recipients under age 18, pregnant or living in nursing
facilities.
Cognitive Services: Clozaril care management fee of
$3.00.
E. USE OF MANAGED CARE
Does not use MCOs to deliver services to Medicaid
recipients.
F. STATE CONTACTS
State Drug Program Administrator
Louise F. Jones
Pharmacy Program Manager
Alabama Medicaid Agency
501 Dexter Avenue
P.O. Box 5624
Montgomery, AL 36103-5624
T: 334/242-5039
F: 334/353-7014
E-mail: lljones@medicaid.state.al.us
Internet address: www.medicaid.state.al.us
Prior Authorization Contact
Louise F. Jones
334/242-5039
DUR Contact
Louise Jones
334/242-5039
Medicaid DUR Board
John Searcy, M.D.
Jimmy Jackson, R.Ph.
Johnny Brooklere, R.Ph.
John E. Brandon, M.D.
Kathy B. Portner, M.D.
Richard Freeman, M.D.
Gary Magouirk, M.D.
Roger Lander, Pharm.D. (Vice-chair)
Frank Skinner, R.Ph.
W. Thomas Geary, Jr., M.D. (Chair)
Steven Rostand, M.D.
Margaret Thrower, Pharm.D.
Rob Colburn, R.Ph.
Jefferson Underwood, III, M.D.


New Brand Name Products Contact
Louise F. Jones
334/242-5039
Prescription Price Updating
Beverly R. Churchwell, Administrator
Alabama Medicaid Agency
501 Dexter Avenue
P.O. Box 5624
Montgomery, AL 36103-5424
T: 334/242-5034
F: 334/353-7014
E-mail: bchurchwell@medicaid.state.al.us
Medicaid Drug Rebate Contact
Gladys Gray, Associate Director
Alabama Medicaid Agency
501 Dexter Avenue
P.O. Box 5624
Montgomery AL 36103-5624
T: 334/242-2327
F: 334/353-7014
E-mail: ggray@medicaid.state.al.us
Claims Submission Contact
Cyndi Crocket, Supervisor
EDS
301 Technacenter Dr.
Montgomery, AL 36117
334/215-0111
Medicaid Managed Care Contact
Kim Davis-Allen, Director
Managed Care
Alabama Medicaid Agency
501 Dexter Avenue
Montgomery, AL 36103-5624
334/242-5011
Mail Order Pharmacy Program
None
Disease Management Program/Initiative
Contact
Mary H. Finch
Associate Medical Director
Alabama Medicaid Agency
501 Dexter Avenue
Montgomery, AL 36103-5624
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-4
334/242-5610
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-5
Alabama Medicaid Agency Officials
Mike Lewis
Commissioner
Alabama Medicaid Agency
501 Dexter Avenue
P.O. Box 5624
Montgomery, AL 36103-5624
T: 334/242-5600
F: 334/242-0556
E-mail: Almedicaid@medicaid.state.al.us
Internet address: www.medicaid.state.al.us

John Searcy, M.D.
Medical Director
Alabama Medicaid Agency
501 Dexter Avenue
P.O. Box 5624
Montgomery, AL 36103
334/242-5619
Title XIX Medical Care Advisory Committee
Alabama State Government Representatives
Dr. Milissa Mauser-Galvin
Executive Director, Department of Senior Services
P.O. Box 301851
Montgomery, AL 36130-1851
334/242-5743

Bill Fuller, Commissioner
Alabama Department of Human Resources
50 Ripley Street, 2
nd
Floor
Montgomery, AL 36130
334/242-1160

Kathy Sawyer, Commissioner
Alabama Department of Health and Mental
Retardation
P.O. Box 301410
Montgomery, AL 36130-1410
334/242-3107

Donald Williamson, M.D.
State Health Officer
P.O. Box 303017
Montgomery, AL 36130-3017
334/206-5200

Steve Shivers
Alabama Department of Rehabilitation Services
2129 East South Boulevard
Montgomery, AL 36116-2455
334/281-8780




Medical Association of State of Alabama
Marsha D. Raulerson, M.D.
1205 Belleville Avenue
Brewton, AL 36426-1304
251/867-3609

Wilburn Smith, Jr., M.D.
2023 Normandie Drive
Montgomery, AL 36111
334/281-2633

Cary J. Kuhlmann, Executive Director
Medical Association of the State of Alabama
P.O. Box 1900-C
Montgomery, AL 36104
334/263-6441

Alabama Nursing Home Association
Mr. Louis E. Cottrell, Jr., Executive Director
4156 Carmichael Road
Montgomery, AL 36106
334/271-6214

Alabama State Medical Association
Roosevelt McCorvey, M.D.
3088 Rosa L. Parks Avenue
Montgomery, AL 36105
334/262-0259

J.A. Powell, M.D.
2212 Mallard Lane SE
Decatur, AL 35602
256/340-1068

Alabama Chap. Am. Academy of Family Physicians
Holly Midgley, Executive Vice President
P.O. Box 1900
19 South Jackson Street
Montgomery, AL 36102-1900
334/263-6441

Alabama Pharmacy Association
William S. Eley, II, Executive Director
1211 Carmichael Road
Montgomery, AL 36106
334/271-4222
Page Dunlap
P.O. Box 354
Hartselle, AL 35640
256/773-5421

Alabama Chap. American Academy of Pediatrics
Karin Scott, Executive Director
735 Montgomery Highway, Suite 323
Birmingham, AL 35216
205/824-0888

National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-6

Alabama Dietetic Association
Gayle Mask
Alabama Department of Public Health
RSA Tower, Suite 1300
P.O. Box 303017
Montgomery, AL 36130-3017
334/206-2922

Alabama Hospital Association
J. Michael Horsley, President
East Station
P.O. Box 210759
Montgomery, AL 36121
334/272-8781

Jody Pigg, CEO
Baptist Health Services
P.O. Box 11010
Montgomery, AL 36111-0010
334/273-4404

Alabama Optometric Association
Amanda Jones, Executive Director
400 South Union Street, Suite 435
Montgomery, AL 36104
334/834-1057

Alabama Association of Home Health Agencies
Melane Golson
Office of Executive Director
P.O. Box 40
Montgomery, AL 36101
334/395-9949

Alabama Primary Health Care Association
Al Fox, Executive Director
6008 East Shirley Lane, Suite A
Montgomery, AL 36117
334/271-7068

Alabama Academy of Ophthalmology
Leigh Jones
P.O. Box 11455
Montgomery, AL 36111-0455
334/269-9900

Assisted Living Association of Alabama
Frank Holden, President
400 S. Union Street, Suite 235
Montgomery, AL 36104
334/262-5523

Alabama Hospice Organization
David Stone, Executive Director
P.O. Box 1835
Calera, AL 35040
205/668-0460

Alabama State Nurses Association
Karen Pakkala, Executive Director
360 North Hill Street
Montgomery, AL 36104-3658
334/262-8321

Consumer Representatives
Lawrence F. Gardella
Senior Staff Attorney
Montgomery Regional Office
Legal Services Corporation of Alabama
600 Bell Building, 207 Montgomery Street
Montgomery, AL 36104
334/832-4570

Bill Chandler
General Director
Montgomery YMCAs
P.O. Box 2336
Montgomery, AL 36102-2336
334/269-4362
Teresa Easterling
325 Spigener Road
Titus, AL 36080
334/567-5020

Linda McWilliams
Top of Alabama Regional Council of Governments
(TARCOG)
115 Washington Street, SE
Huntsville, AL 35801
205/533-3330

Rogene W. Parris
2061 Fire Pink Court
Birmingham, AL 35244
205/987-0338

Louise Pittman
3355 Lexington Road
Montgomery, AL 36106
334/264-8780
Pharmacy and Therapeutics Committee
A. Z. Holloway, M.D.
Richard Freeman, M.D.
Ben Main, R.Ph.
Gary Magouirk, M.D.
David Herrick, M.D.
Jackie Feldman, M.D.
Melanie Smith, R.Ph.
Mary McIntyre, M.D.
Jefferson Underwood, III, M.D.
Rob Colburn, R.Ph.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alabama-7
Executive Officers of State Medical and
Pharmaceutical Societies
Medical Association of the State of Alabama (MASA)
Cary Kuhlmann
Executive Director
19 S. Jackson Street
P.O. Box 1900
Montgomery, AL 36102-1900
T: 334/954-2500
F: 334/269-5200
E-mail: cary@masalink.org
Internet address: www.masalink.org

Alabama Osteopathic Medical Association
E. Jason Hatfield, D.O.
Secretary -Treasurer
P.O. Box 1857
U.S. Highway 43
Winfield, AL 35594
T: 205/487-7556
F: 205/487-7559
Internet address: www.aloma.org

Alabama State Medical Association
Joel Powell, M.D., President
1408 5
th
Avenue, SE, Suite 1
Decatur, AL 35601
T: 256/340-9445
F: 256/350-0499

Alabama Pharmacy Association (APA)
William S. Eley, II
Executive Director
1211 Carmichael Way
Montgomery, AL 36106-3672
T: 334/271-4222
F: 334/271-5423
E-mail: aparx@aparx.org
Internet address: www.aparx.org

State Board of Pharmacy
Jerry Moore
Executive Director
1 Perimeter Park South, Suite 425 S
Birmingham, AL 35243
T: 205/967-0130
F: 205/967-1009
E-mail: 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
Tom Cooper, CEO
500 North East Blvd.
Montgomery, AL 36117
T: 334/272-8781
F: 334/270-9527
E-mail: tcooper@alaha.org
Internet address: www.alaha.org






























National Pharmaceutical Council Pharmaceutical Benefits 2003
Alaska-1
ALASKA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult

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


B. DRUG PAYMENTS AND RECIPIENTS
2001 2002**
Expenditure Recipients Expenditure Recipients

TOTAL $64,923,574 65,278 $70,708,412

RECEIVING CASH ASSISTANCE TOTAL $52,946,651 33,640
Aged $9,954,837 4,747
Blind/Disabled $33,634,846 8,964
Child $1,778,759 9,519
Adult $7,578,209 10,410

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $5,303,090 25,775
Aged $6,244 8
Blind/Disabled $368 2
Child $4,319,775 20,919
Adult $976,703 4,846

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

*Total Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alaska-2
C. ADMINISTRATION
Department of Health and Social Services, Division of
Medical Assistance.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
cosmetics (covered with restrictions); prescribed
insulin; disposable needles used for insulin (covered
under DME); syringe combinations used for insulin;
and total parental nutrition. Prior authorization
required for: Clorazil; Lupron Depot; ADC infant
vitamins; some DME; Synagis; Pauretin; and Actig
Naltrexone. Products not covered: fertility drugs;
experimental drugs; blood glucose test strips; urine
ketone test strips; and intedialytic parenteral nutrition.

Over-the Counter Product Coverage: Products
covered with restrictions: feminine products; topical
products (vasatrace ointment). Products not covered:
allergy, asthma, and sinus products; analgesics; cough
and cold preparations, digestive products; and smoking
deterrent products.
Therapeutic Category Coverage: Categories covered:
anabolic steroids; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; hypotensive
agents; miscellaneous GI drugs; sympathominetics
(adrenergic); and thyroid agents. Prior authorization
required for: analgesics, antipyretics, and NSAIDs;
growth hormones. Categories not covered: anoretics;
prescribed cold medications; amphetamines (except for
narcolepsy and hyperactivity); prescribed smoking
deterrents; cough suppressants; DESI drugs; vitamins
(except prenatal); and vitamins with fluoride.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used in
physicians’ offices.
Vaccines: Vaccines reimbursable at cost as part of
EPSDT services, the Children’s Health Insurance
Program, and the Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: No formulary. Preferred drug list (PDL)
managed by restrictions on use, therapeutic
substitution, preferred products, and physician
profiling.
Prior Authorization: State currently has a formal prior
authorization procedure. Request for fair hearing
required for appealing coverage of an excluded
product and PA decision. Medical necessity form
required.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: Prescriptions are limited to
30-day supplies. Dispensing of generic multi-source
product is required. Maximum number of units for
about 50 therapeutic classes and 40 narcotic
analgesics.
Drug Utilization Review
PRODUR system implemented in June 1995. State
currently has a DUR Board that meets nine times per
year.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: No less than $3.45 and no more than
the 90
th
percentile of all dispensing fees determined
under the formula:
1) $23,192 added to the number resulting from
multiplying total prescriptions filled by that
pharmacy in the previous calendar year by 5.070;
2) to 1), add the result of multiplying total Medicaid
prescriptions filled in the previous calendar year
by 12.44;
3) from 2), subtract the result of multiplying the total
floor space volume of the pharmacy in sq. ft. by
2.103;
4) divide 3) by total prescriptions filled by that
pharmacy
5) add $0.73 to 4)
Ingredient Reimbursement Basis: EAC = AWP - 5%.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” and the reason of
necessity.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alaska-3
Incentive Fee: None.
Cognitive Services: Does not pay for cognitive
services.
Patient Cost Sharing: $2.00 copayment for branded
and generic products.
E. USE OF MANAGED CARE
Does not use MCOs to deliver services to Medicaid
recipients.
F. STATE CONTACTS
Medicaid Drug Program Administrator
Dave Campana, R.Ph.
Pharmacy Program Manager
Division of Medical Assistance
4501 Business Park Blvd., Suite 24
Anchorage, AK 99503
T: 907/334-2425
F: 907/561-1684
E-mail: david_campana@health.state.ak.us
Health and Social Services Department
Officials
Joel Gilbertson, Commissioner
Department of Health and Social Services
P.O. Box 110601
Juneau, AK 99811-0601
T: 907/465-3030
F: 907/465-3068
E-mail: joel_gilbertson@health.state.ak.us

Dwayne Peeples, Director
Division of Medical Assistance, DHSS
P.O. Box 110660
Juneau, AK 99811-0660
T: 907/465-3355
F: 907/465-2204
E-mail: dwayne_peeples@health.state.ak.us
Prior Authorization Contact
Dave Campana, R.Ph.
907/334-2425
DUR Contact
Dave Campana, R.Ph.
907/334-2425
New Brand Name Products Contact
Dave Campana, R.Ph.
907/334-2425
Prescription Price Updating
Dave Campana, R.Ph.
907/334-2425
Medicaid Drug Rebate Contact
Amanda Burger
Division of Medical Assistance
4501 Business Park Blvd., Suite 24
Anchorage, AK 99503
T: 907/334-2409
F: 907/561-1684
E-mail: amanda.burger@health.state.ak.us
Claims Submission Contact
Linda Walsh
Systems Administrator
Division of Medical Assistance
4501 Business Park Blvd, Suite 24
Anchorage, AK 99503
T: 907/334-2441
F: 907/561-1684
E-mail: linda_walsh@health.state.ak.us
Disease Management Program/Initiative
Contact
Pam Muth
Deputy Director
Division of Medical Assistance
4501 Business Park Blvd, Suite 24
Anchorage, AK 99503
907/334-2400
E-mail: pam_muth@health.state.ak.us
Mail Order Pharmacy Benefit
Yes, for Medicaid recipients living in rural areas.
Alaska DUR Committee
Dave Campana, R.Ph.
Anchorage, AK 99503

Richard Reem, M.D.
Fairbanks, AK 99701-3639

Heide Brainerd, P.H.
Anchorage, AK

Arthur Hansen, D.D.S.
Fairbanks, AK 99712
National Pharmaceutical Council Pharmaceutical Benefits 2003
Alaska-4
Greg Polston, M.D.
Fairbanks, AK.

Charlene Hampton, R.Ph.
Anchorage, AK

Alexander von Hafften, M.D.
Anchorage, AK
Executive Officers of State Medical and
Pharmaceutical Societies
Alaska State Medical Association
Jim Jordan, Executive Director
4107 Laurel Street
Anchorage, AK 99508
T: 907/562-0304
F: 907/561-2063
E-mail: asma@alaska.net

Alaska Osteopathic Medical Association
Holly Macriss
AOA Northwest Regional Manager
1900 Point West Way, Suite 188
Sacramento, CA 95815-4705
T: 800/891-0333
F: 916/564-5105
E-mail: hmcriss@osteopathic.org
Internet address: www.do-online.org/aoawesternregion

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

Alaska State Board of Pharmacy
Barbara Roche
Licensing Examiner
P.O. Box 110806
Juneau, AK 99811-0806
T: 907/465-2589
F: 907/465-2974
E-mail: barbara_roche@dced.state.ak.us
Internet address: www.dced.state.ak.us/occ/ppha.htm

Alaska State Hospital and Nursing Home Association
Rod L. Betit
President/CEO
426 Main Street
Juneau, AK 99801
T: 907/586-1790
F: 907/463-3573
E-mail: rbetit@ashnha.com
Internet address: www.ashnha.com


National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-1
ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
AHCCCS FEATURES
The Arizona Health Care Cost-Containment System
(AHCCCS) is a Title XIX (Medicaid) 1115 Research
and Demonstration Waiver project, jointly funded by
the federal government and the State of Arizona.
Begun in October 1982, it serves as a model for
providing medical services to the indigent in a
managed care system rather than through fee-for-
service arrangements. Typically, Medicaid programs
have incorporated the traditional hallmarks of the
U.S. health care system: namely, independent
providers and fee-for-service reimbursement. In
contrast, organized health plans and capitation mark
the AHCCCS model.
In traditional Medicaid programs, the States assume
responsibility for contracting with individual
pharmacies and reimbursing them. In the AHCCCS
model however, the State contracts instead with pre-
paid health plans, HMOs and HMO-like entities.
These plans are paid on a capitation basis and are
responsible for providing all of the services covered
by the program. Thus, with the exception of
behavioral health drugs which are carved out of
managed care, the delivery of pharmacy services is
the responsibility of each prepaid plan.
GENERAL INFORMATION
The Arizona Health Care Cost Containment System
(AHCCCS), developed in Senate Bill 1001, was
passed by the Legislature and signed by the Governor
in November 1981. It contained six major
mechanisms for restraining health care costs at the
same time ensuring that appropriate levels of quality
health care services are provided to eligible persons
in a dignified fashion. The goal of these 6 items was
to contribute to the establishment of health care
financing that is less expensive than conventional
fee-for-service systems. The six mechanisms were:
• Primary Care Physicians Acting as
Gatekeepers
• Prepaid Capitated Financing
• Competitive Bidding Process
• Cost Sharing
• Limitations on Freedom-of-Choice
• Capitation of the State by the Federal
Government
Primary Care Physicians as Gatekeepers
AHCCCS legislation provided that all members must
be under the care and supervision of a primary care
physician who assumed the role of gatekeeper. A
statewide network of primary care physicians was
established to perform the gatekeeping function for
the system.
Prepaid Capitated Financing
It was the intent of the AHCCCS legislation that
health plans and their providers offer all covered
services to groups of members within a geographical
area for a fixed price, for a definite period. The law
allowed for the establishment of a statewide bidding
process to accomplish this. Services are provided on
a county-by-county basis, by prepaid health plans.
Providers may bid on a prepaid capitated basis for
covered services to be provided within a particular
county. The law allows for expansion and
contraction of bids to achieve the best possible
system. In the event there are insufficient bids for a
given area, the legislation permits capped fee-for-
service arrangements. It is intended, however, that
capped fee-for-service will be authorized as a last
resort only.
In essence, AHCCCS prepaid health plans (PHPs),
health maintenance organizations (HMOs), and other
types of organized health delivery systems charge a
fixed fee per individual enrolled (i.e., a capitation
rate) and assume responsibility for providing a broad
array of health care services to members. The plan or
contractor is then “at risk” to deliver the necessary
services within the capitated amount. AHCCS
receives Federal, State, and county funds to operate,
plus some monies from Arizona’s tobacco tax.
Competitive Bidding Process
The statewide competitive aspect of the bid process
for selecting providers and offering prepaid capitated
services is the most unique feature of the AHCCCS
model. A competition of this magnitude had never
been attempted in any other State. The AHCCCS
administration believes competitive bidding for
health care service contracts, as opposed to
conventional negotiation processes, provides
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-2
accessible cost-effective delivery of health care
without sacrificing quality performance.
The AHCCCS administration issues an invitation to
qualified health plans once every five years.
Qualified health plans may bid to offer the full range
of AHCCCS services in one or more counties.
Cost Sharing
The fourth major device for containing costs in the
AHCCCS model is a provision for cost sharing by
users. A statewide co-payment schedule was
developed for this purpose, and the medically needy
participate in coinsurance cost sharing. It is expected
that the imposition of nominal co-payments will
ensure optimal effectiveness in the area of service
utilization. The co-payment schedule accomplishes
three objectives: curtailment of over-utilization;
enhancement of patient dignity; and service
utilization by members for truly needed health care.
There is no co-payment for drugs and medication,
prenatal care including all obstetrical visits, members
in long care facilities and for visits scheduled by the
primary care physician or practitioner, and not at the
request of the member.
Limitations On Freedom-of-Choice
The fifth major item for containing costs is a
restriction on provider/physician selection by
AHCCCS members. Unlike conventional delivery
models, Arizona does not rely on fee-for-service
arrangements. The goal is to have the State
completely blanketed with prepaid capitated
arrangements. Members are linked to selected or
assigned plans for definite durations of time.
Freedom-of-choice is permitted to the extent
practicable for members to select the particular group
with which to enroll, as well as the primary care
physician within the selected group. Capped fee-for-
service health service arrangements are used as a last
resort, and only in areas not covered by prepaid
capitated plans.
CAPITATION BY THE FEDERAL
GOVERNMENT
The State of Arizona will itself be capitated by the
Federal Government and therefore will be at financial
risk for containing health care costs. Capitation rates
will be established according to sound actuarial
principles, and will represent no more than 95
percent of the estimated cost of services delivered in
Arizona under conventional fee-for-service
arrangements. Capitation provides a key incentive
for the State to monitor health care costs on a careful
and continuous basis.
IMPLEMENTATION OF AHCCCS
AHCCCS is based on plans that have been tested, in
part, on smaller scales in different areas of the
country. By combining a number of key mechanisms
on a statewide basis, AHCCCS represents a novel
health care model. The purpose of this section is to
present a discussion of how the key concepts
embodied in the AHCCCS legislation will be
implemented and rendered operational.
Provider Participation
Providers may participate in AHCCCS in 2 different
ways. First, they may contract with prepaid capitated
plans as either full or partial benefit providers.
The second mode of participation is on a capped fee-
for-service basis. Here, providers agree to accept
capped fee payments as payments in full for services
provided on a FFS basis.
Functions of the AHCCCS Administration
The Arizona Health Care Containment System
Administration (AHCCCSA) contracts with full
benefit capitated health plans to serve AHCCCS
members through a network of providers.
Contracting Health Plans
Under the Contracting Health Plan arrangement,
plans are defined in terms of explicit groups of
providers organized as entities that are more formal.
These consortia, or formal entities, are capable of
providing the full range of AHCCCS benefits within
a defined service area for all AHCCCS members who
elect to join the plans, up to a predetermined
capacity. This is the dominant mode of operation
within AHCCCS -- with two or more competing
plans wherever possible.
The Contracting Health Plans are delivery systems,
not simply insurance plans, but they need not be
Health Maintenance Organizations by any legal or
conventional definition of the term. The AHCCCS
legislation provides for the creation of provider
consortia for the purpose of participation in the
program. The Contracting Health Plan may be a
loosely organized system, but it must be capable of
providing the full range of AHCCCS benefits to a
defined population at a capitation rate.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-3
The Organizational Role of AHCCCS
Administration
The AHCCCS Administration has been charged with
the general implementation and monitoring of the
AHCCCS program.
The AHCCCS Administration develops the Rules
and Regulations; manages the health plan bidding
processes; awards the contracts; provides technical
assistance to providers for the purpose of forming
consortia to contract with AHCCCS; and monitors
the overall operation of the program.
The Operational Role of the AHCCCS
Administration
Organizationally, the AHCCCS Administration
assumes responsibility for the oversight of every day
operations.
The AHCCCS Administration has overall
responsibility for the following activity areas:
• Eligibility Oversight
• Procurement of Health Plans
• Quality Management
• Health Plan Oversight
• Provider, Member Call Center
• Grievances and Complaints
• Fee-for-Service for IHS
AHCCCS became effective December 1, 1981, and
services commenced October 1, 1982. Services
include: inpatient, outpatient, laboratory, x-ray,
prescription drugs, medical supplies, prosthetic
devices, emergency dental care including extractions
and dentures, treatment of eye conditions and
EPSDT.
Though AHCCCS was a three-year experiment that
was to end in October 1985, the Federal government
continues to extend funding for the program. In
1988, AHCCCS received a five-year extension from
the Federal government and in 1993, it received an
additional one-year extension. In 1994, AHCCCS
received a three-year extension and in 1998, it
received a one-year extension. Since then, AHCCCS
has received additional extensions. Currently,
AHCCCS is operating under a five year waiver
extension that will expire on September 30, 2006.
Some 20 years after it first began, AHCCCS has
grown in numbers from the first wave of 180,000
enrollees to more than 963,000 beneficiaries, (Oct.
2003) representing 18 percent of Arizona’s
population. AHCCCS has also become a model as
managed care is increasingly by being implemented
in other States’ Medicaid programs.
(Additional information about AHCCCS can be
found on the agency’s website at
www.ahcccs.state.az.us)
MEDICAL PLANS AND
ADMINISTRATORS
AHCCCS Contracted Health Plans
Arizona Physicians IPA, Inc.
3141 North 3rd Avenue
Phoenix, AZ 85013
602/264-1232

Care
1st
Health Plan of Arizona, Inc.
2355 E. Camelback Rd.
Suite 300
Phoenix, AZ 85016
602/778-1800

CIGNA Community Choice
11001 North Black Canyon Highway
Phoenix, AZ 85029
602/371-2621

DES/CMDP
CMDP-942-C
Century Plaza Building, 10th Floor
3225 North Central Avenue
Phoenix, AZ 85012
602/351-2245

Family Health Plan of NE Arizona
258 Justin Drive
P.O. Box 2069
Cottonwood, AZ 86326
928/448-3585

Health Choice Arizona
Suite 260
1600 West Broadway
Tempe, AZ 85282-1136
480/968-6866

Maricopa Health Plan
2502 East University Drive
Phoenix, AZ 85034
602/344-8700

Mercy Care Plan
Suite 400
2800 North Central
Phoenix, AZ 85004
602/263-3000




National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-4
Phoenix Health Plan/Community Connection
1209 South 7
th
Avenue
Phoenix, AZ 85007
602/824-3700

Pima Health System
Suite A-200
5055 East Broadway
Tucson, AZ 85711
602/512-5500

University Family Care
575 East River Road
Tucson, AZ 85704
888/708-2930

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

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

Navajo Area Indian Health Services (IHS)
P.O. Box 9020
Window Rock, AZ 86515-9020
928/871-5811
ALTCS Contractor List
Arizona Physicians IPA
Suite A
242 West 28
th
Street
Yuma, AZ 85364
520/783-5691

Cochise Health Systems
Cochise County Health & Social Services
1415 West Melody Lane, Building A
Bisbee, AZ 85603-4249
520/432-9600

DES/DDD
1789 West Jefferson, 4th Floor
Phoenix, AZ 85007
602/542-0419

Evercare Select
314 N. 3
rd
Avenue
Phoenix, AZ 85013
602/331-5100



Maricopa Long Term Care Plan
Suite 125
2502 East University Drive
Phoenix, AZ 85034
602/344-8700

Mercy Care Plan
Suite 400
2800 North Central
Phoenix, AZ 85004
602/263-3000

Pima Long Term Care
Pima Health System
Suite A-200, 5055 East Broadway
Tucson, AZ 85711
520/512-5500

Pinal/Gila LTC
P.O. Box 2140
971 North Pinal Parkway
Florence, AZ 85232-2140
520/868-6775

Yavapai County LTC
Yavapai County Department of Medical Assistance
595 White Spar Road
Prescott, AZ 86303
520/771-3560

AHCCCS FFS (ALTCS)
Ventilator Dependent
Office of Medical Management
602/417-4370
STATE CONTACTS
AHCCCS Officials
Phyllis Biedess, Director
AHCCCS
801 E. Jefferson Street
Phoenix, AZ 85034
T: 602/417-4680
F: 602/252-6536
E-mail: PXBiedess@ahcccs.state.az.us
Internet address: www.ahcccs.state.az.us

Dell Swan
Pharmacy Program Administrator
AHCCCS
801 East Jefferson Street
MD 4100
Phoenix, AZ 85034
612/417-4000
E-mail: dwswan@ahcccs.state.az.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-5
Executive Officers of State Medical and
Pharmaceutical Societies
Arizona Medical Association, Inc.
Chic Older
Executive Vice President
810 West Bethany Home Road
Phoenix, AZ 85013
T: 602/246-8901
F: 602/242-6283
E-mail: chicolder@azmedassn.org
Internet address: www.azmedassn.org

Arizona Pharmacy Association
Kathy Boyle
Executive Director
1845 E. Southern Ave.
Tempe, AZ 85282-5831
T: 480/838-3385
F: 480/838-3557
E-mail: azpa@azpharmacy.org
Internet address: www.azpharmacy.org

Arizona Osteopathic Medical Association
Amanda Weaver
Executive Director
5150 N. 16
th
St., Suite A-122
Phoenix, AZ 85016
T: 602/266-6699
F: 602/266-1393
E-mail: mweaver@az-osteo.org
Internet address: www.az-osteo.org

Arizona Board of Pharmacy
Hal Wand
Executive Director
4425 W. Olive Avenue, Suite 140
Glendale, AZ 85302
T: 623/463-2727
F: 623/934-0583
E-mail: info@azsbp.com
Internet address: www.pharmacy.state.az.us

Arizona Hospital and Healthcare Association
John R. Rivers, FACHE
President/CEO
2901 North Central Avenue
Suite 900
Phoenix, AZ 85012
T: 602/445-4300
F: 602/445-4299
E-mail: jrivers@azha.org
Internet address: www.azha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Arizona-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arkansas-1
ARKANSAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001

2002**
Expended Recipients Expended Recipients
TOTAL $248,392,084 321,920 $273,257,660

RECEIVING CASH ASSISTANCE, TOTAL $142,811,387 111,016
Aged $18,083,097 13,278
Blind/Disabled $117,036,376 68,665
Child $4,248,875 19,495
Adult $3,443,039 9,578

MEDICALLY NEEDY, TOTAL $7,660,175 13,964
Aged $130,249 203
Blind/Disabled $2,721,983 2,036
Child $1,664,186 5,912
Adult $3,143,757 5,813

POVERTY RELATED, TOTAL $21,594,533 100,643
Aged $370,667 367
Blind/Disabled $917,628 673
Child $18,932,809 88,224
Adult $1,373,429 11,379

TOTAL OTHER EXPENDITURES/RECIPIENTS* $76,325,989 96,297

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arkansas-2
C. ADMINISTRATION
Department of Human Services, Division of Medical
Services, Pharmacy Program.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered
with restrictions: prescribed insulin; disposable
needles and syringe combinations used for insulin.
Products not covered: blood glucose test strips; urine
ketone test strips; total parenteral nutrition,
interdialytic parenteral nutrition; cosmetics; fertility
drugs; experimental drugs; and vitamins (other than
prenatal vitamins for pregnant women). Prior
authorization required for: nitroglycerin patches;
agents for impotence; Synagis; Respigam; Xenical-
hyper lipidemia; Remicade; Regranex; Kineret;
Enbrel; Xolair; and Humira.
Over-the-Counter Product Coverage: Products
covered: digestive products (H2 antagonist). Limited
coverage for: allergy, asthma and sinus products;
analgesics; cough and cold preparations (under 21
years and long-term care limited needs); digestive
products (non-H2 antagonist); feminine products;
and topical products. Products not covered: smoking
deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; sympathominetics
(adrenergic); and thyroid agents. Prior authorization
required for: analgesics, antipyretics, NSAIDs;
antihistamine drugs; misc. GI drugs; prescribed
smoking deterrents. Therapeutic categories not
covered: anorectics.
Coverage of Injectables: Injectable medicines are
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians offices.
Vaccines: Vaccines reimbursable as part of the
Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization
Formulary: State covers outpatient drugs whose
manufacturers have signed a rebate agreement with
CMS. General exclusions include:
1. Agents used for hair growth.
2. Vitamin products except prescription prenatal
vitamins.
3. Drugs determined by the FDA to be ineffective
(DESI drugs).
4. Sedatives and hypnotics in the benzodiazepine
category (partial coverage).
5. Compounded prescriptions (mixtures of two or
more ingredients). States are not allowed to
have state codes such as 99999-9999-99. All
drugs reimbursed by the State must be traced by
NDC code and appear on the utilization report.
Prior Authorization: State currently has a prior
authorization procedure. Beneficiaries have a right to
appeal prior authorization decisions. Physician must
submit letter explaining medical necessity leading to
the request for the medication.
Prescribing or Dispensing Limitations
Prescription Refill Limit: 5 refills within 6 months
are allowed. New Rx required every 6 months.
Monthly Quantity Limit: 31-day supply.
Monthly Prescription Limit: Three prescriptions per
month per recipient, except unlimited for certified
LTC recipients and recipients under 21 years old.
Others can receive extension of three more per
month.
Drug Utilization Review
PRODUR system implemented in March 1997. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $5.51 effective 7/1/99. Effective
3/1/02, non-MAC generics receive an additional
$2.00 dispensing fee.
Ingredient Reimbursement Basis: EAC = AWP-14%
(Brand), AWP-20% (Generic).
Prescription Charge Formula: Legend drugs: lower
of the EAC plus a dispensing fee or CFA/state upper
National Pharmaceutical Council Pharmaceutical Benefits 2003
Arkansas-3
limit plus a dispensing fee. Total charge may not
exceed provider’s charge to the self-paying public.
Maximum Allowable Costs: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. State-specific MAC list contains 800
drugs (see www.medicaid.ar.us). Override requires
physician documentation on MedWatch form as to
why the generic cannot be dispensed.
Incentive Fee: $2.00 additional dispensing fee on
non-MAC generics.
Patient Cost Sharing: Effective 9/1/92, for each
prescription reimbursed, the Medicaid recipient is
responsible for paying a copayment based on the
following:
State Payment Copay
$10.00 or less $0.50
$10.01 to $25.00 $1.00
$25.01 to $50.00 $2.00
$50.01 or more
ArKids
$3.00
$5.00
Services to individuals under 18, pregnant women,
nursing home residents, emergency services, family
planning services, and services provided by an HMO
to its enrollees are excluded from the Medicaid copay
policy.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
An estimated 275,000 Medicaid recipients are
enrolled with Primary Care Physicians and
approximately 70,000 children are enrolled in
ArKids. Pharmaceutical benefits are provided
through the State.








F. STATE CONTACTS
Medicaid Drug Program Administrator
Suzette Bridges, P.D., Administrator
Pharmacy Program
Division of Medical Services
Dept. of Human Services
P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
T: 501/683-4120
F: 501/683-4124
E-mail: suzette.bridges@medicaid.state.ar.us
Prior Authorization Contact
Suzette Bridges, P.D.
501/683-4120
DUR Contact
Pamela Ford, P.D.
Pharmacist II
Division of Medical Services
Dept. of Human Services
P.O. Box 1437, Slot S 415
Little Rock, AR 72203-1437
T: 501/683-4120
F: 501/683-4124
E-mail: pamela.ford@medicaid.state.ar.us
DUR Board
Steve Bryant, P.D.
Jason B. Hawkins, P.D.
Benji Post, P.D.
Debbie Hayes
Ann Blaylock, A.P.N.
Thomas Lewellen, D.O.
Michael N. Moody, M.D.
Laurence Miller, M.D.

New Brand Name Products Contact
Suzette Bridges, P.D.
501/683-4120
Prescription Price Updating
First DataBank
1111 Bay Hill Drive
San Bruno, CA 94066
T: 650/588-5454
F: 650/588-4003





National Pharmaceutical Council Pharmaceutical Benefits 2003
Arkansas-4
Medicaid Drug Rebate Contacts
Audits: Suzette Bridges, P.D., 501/683-4120

Dispute Resolution: Dana Boyer
Rebate Analyst
EDS
500 President Clinton Ave, Suite 400
Little Rock, AR 72201
T: 501/374-6608
F: 501/372-2971
E-mail: dana.boyer@mediciad.state.ar.us

Claims Submission Contact
John Herzog, Account Manager
EDS
500 President Clinton Ave, Suite 400
Little Rock, AR 72201
T: 501/374-6608
F: 501/372-2971
E-mail: john.herzog@medicaid.state.ar.us
Medicaid Managed Care Contact
Kellie Phillips
Program Administrator
Medical Assistance
Division of Medicaid Services
Dept. of Human Services
P.O. Box 1437, Slot 410
Little Rock, AR 72203
T: 501/682-8306
F: 501/682-1197
E-mail: kellie.phillips@medicaid.state.ar.us
Mail Order Pharmacy Benefit
None
Department of Human Services Officials
Kurt Knickrehm, Director
Department of Human Services
P.O. Box 1437, Slot 201
Little Rock, AR 72203-1437
T: 501/682-8650
F: 501/682-6836
E-mail: kurt.knickrehm@state.ar.us
Internet Address: www.accessarkansas.org/dhs

Roy Jeffus, Director
Division of Medical Services
P.O. Box 1437, Slot 1100
Little Rock, AR 72203-1437
T: 501/682-1671
F: 501/682-1197
E-mail: roy.jeffus@medicaid.state.ar.us
Executive Officers of State Medical and
Pharmaceutical Societies
Arkansas Hospital Association
James R. Teeter
President/CEO
419 Natural Resources Drive
Little Rock, AR 72205
T: 501/224-7878
F: 501/224-0519
E-mail: aha@arkhospital.org
Internet Address: www.arkhospitals.org


Arkansas Pharmacists Association
Mark Riley
Executive Director
417 S. Victory Street
Little Rock, AR 72201-2932
T: 501/372-5250
F: 501/372-0546
E-mail: mriley@arpharmacists.org
Internet address: www.arpharmacists.org

Arkansas State Board of Pharmacy
Charles S. Campbell
Executive Director
101 E. Capitol, Suite 218
Little Rock, AR 72201
T: 501/682-0190
F: 501/682-0195
E-mail: charlie.campbell@mail.state.ar.us
Internet address: www.state.ar.us/asbp

Arkansas Osteopathic Medical Association
Ed Bullington
Executive Director
412 Union Station
1400 West Markham
Little Rock, AR 72201
T: 501/374-8900
F: 501/374-8959
E-mail: osteomed@ipa.net
Internet address: www.arkosteomed.org

Arkansas Medical Society
Ken LaMastus
Executive Vice President
P.O. Box 55088
Little Rock, AR 72215
T: 501/224-8967
F: 501/224-6489
E-mail: klamastus@arkmed.org
Internet address: www.arkmed.org




National Pharmaceutical Council Pharmaceutical Benefits 2003
California-1
CALIFORNIA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $2,808,298,437 2,486,910 $3,591,537,830

RECEIVING ASSISTANCE, TOTAL
$2,143,413,178 1,334,480
Aged $479,791,420 266,911
Blind/Disabled $1,547,024,854 579,572
Children $39,100,804 299,830
Adult $77,496,100 188,167

MEDICALLY NEEDY, TOTAL $423,154,155 279,326
Aged $198,544,758 120,346
Blind/Disabled $198,371,267 53,459
Children $11,503,750 68,297
Adults $14,734,380 37,224

POVERTY RELATED, TOTAL $54,387,618 103,247
Aged $14,257,426 11,923
Disabled $32,358,484 10,485
Children $5,572,729 51,243
Adults $2,198,979 29,596

TOTAL OTHER EXPENDITURES/RECIPIENTS* $187,343,486 769,857

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

Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
California-2
C. ADMINISTRATION
Under the Health and Human Services Agency with
direct administration by the Department of Health
Services.
The Department of Health Services Pharmaceutical
Unit of the Medi-Cal Policy Division monitors the
full scope and quality of pharmaceutical benefits
covered under the provisions of the California
Medical Assistance Program.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: The Medi-Cal
pharmacy benefit covers practically all FDA-
approved drugs, including both legend and over-the-
counter products. There are very few drugs or
classes of drugs that are non-benefits. Non-benefits
include common household remedies; non-legend
analgesics and cough/cold medications, except when
specifically listed; multivitamin preparations, except
certain pre-natal and pediatric products; cosmetics;
fertility drugs; and experimental drugs. Most other
products are potential benefits.
In general, products that are listed on the Medi-Cal
List of Contract Drugs do not require prior
authorization. Those not on the List of Contract
Drugs do require prior authorization.
Physician-administered drugs: The Medi-Cal List of
Contract Drugs applies to drugs dispensed from
pharmacies to patients. Drugs administered directly
in a physician's, dentist's, or podiatrist's office are not
bound by the List of Contract Drugs.
Coverage of Injectables: Injectable medicines are
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities and through physician payment when used
in physician offices.
Vaccines: Vaccines are reimbursable by schedule as
part of the Vaccines for Children Program. Vaccines
for adults are covered through the prescription drug
program or as administered in a physician's office.
Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization
Formulary: The Medi-Cal List of Contract Drugs is a
preferred drug list. It contains over 600 drugs, in
differing strengths and dosage forms, listed
generically. Patients can get prior authorization for
unlisted drugs or for listed drugs that are restricted to
specific use(s), if medically justified. Manufacturers
frequently petition Medi-Cal to add drugs to the List
of Contract Drugs. Based on Medi-Cal’s five criteria
(safety, efficacy, misuse potential, essential need, and
cost), a drug may be added to the list by contractual
agreement with the manufacturer to provide the State
a negotiated rebate. The Medi-Cal website at:
http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
tml/faqpage.htm has details of how the drug
contracting process works.
Examples of general limitations and exclusions
(other uses require prior authorization):
1. CNS stimulants, e.g., amphetamines and
methylphenidate, are restricted to attention
deficit disorder in individuals between 4 and 16
years of age.
2. Diazepam is restricted to use in cerebral palsy,
athetoid states, and spinal cord degeneration.
3. Most non-steroidal anti-inflammatory agents are
restricted to use for arthritis.
4. Some antibiotics have diagnostic and/or age
restrictions.
5. Acyclovir capsules are restricted to herpes
genitalis, immunocompromised, and herpes
zoster (shingles) patients.
6. Codeine Combinations: payment to a pharmacy
for ASA or APAP with codeine 30 mg is limited
to a maximum dispensing quantity of 45 tablets
or capsules and a maximum of 3 claims for the
same beneficiary in any 75-day period.
7. Enteral nutritional supplements or replacements
are covered, subject to prior authorization, if
used as a therapeutic regimen to prevent serious
disability or death in patients with medically
diagnosed conditions that preclude the full use of
regular foodstuffs.
8. Cancer, AIDS, and DESI Drugs: Any
antineoplastic drug approved by FDA for the
treatment of cancer and any drug approved by
FDA for the treatment of AIDS or AIDS-related
condition is covered through the Medi-Cal List
of Contract Drugs; most DESI drugs rated less-
than-effective by FDA are not covered.

National Pharmaceutical Council Pharmaceutical Benefits 2003
California-3
Prior Authorization: State currently has a formal
prior authorization procedure.
The patient’s physician or pharmacist may request
prior authorization from the field office Medi-Cal
consultant for approval of unlisted drugs or for listed
drugs that are restricted to specific use(s). This is
done by completing a Treatment Authorization
Request (TAR) form. Providers may appeal prior
authorization decisions within 60 days of notification
to the local field office and then to field services
headquarters if necessary. Beneficiaries also have the
ability to request a hearing to review the denial and
must do so within 90 days of notification.
TARs may be approved for: covered items or
services not included on the Medi-Cal List of
Contract Drugs (including special circumstance such
as the need to override multiple source drug price
ceilings or minimum quantity/ frequency of billing
limitations); and for patients exceeding the 6 Rx per
month limit. Statewide mail and fax requests are
accepted in the Stockton and Los Angeles Medi-Cal
Field Offices. Requests must include adequate
information and justification. Authorization may
only be given for the lowest cost item or service that
meets the patient’s medical needs.
Beneficiary or Prescriber Prior Authorization: On a
case by case basis, the Dept. of Health Services
restricts, through the requirements of prior
authorization, the availability of designated
prescription drugs to certain beneficiaries or
prescribers found by the Department to abuse those
benefits.
Prescribing or Dispensing Limitations
Prescription Refill Limit: A prescription refill can be
dispensed as authorized by prescriber. An exception
is allowed for refill of a reasonable quantity when
prescriber is unavailable (pursuant to California law).
Fee is to be pro-rated so that total fee (for partial
quantity and balance of the prescription after
prescriber is contacted) does not exceed the fee for
the same prescription when refilled as a routine
service.
Monthly Quantity Limit: This is flexible, but should
be consistent with the medical needs of the patient.
Limited to 100 days’ supply on most drugs. Many
maintenance drugs are subject to minimum quantity
or maximum frequency of billing controls.
Monthly Prescription Limit: Limited to 6 per month
without prior authorization. The limit does not apply
to family planning drugs, patients in nursing
facilities, or to AIDS or cancer drugs.
Hospital Discharge Medications: Quantities
furnished as discharge medications are limited to no
more than a 10-day supply. Charges are incorporated
in the hospital’s claims for inpatient services.
Drug Utilization Review
Prospective DUR system implemented in August
1995. State currently has a DUR Board with a
quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.05, effective 8/85.
Ingredient Reimbursement Basis: EAC = AWP-10%
Prescription Charge Formula: Reimbursement is
based on the lowest of:
1. Estimated Acquisition Cost (EAC) + dispensing
fee, less $0.50 for most patients, or less $0.10 for
nursing home patients.
2. Federal Upper Limit (FUL) + dispensing fee,
less $0.50 for most patients, or less $0.10 for
nursing home patients.
3. State Maximum Allowable Ingredient Cost
(MAIC) + dispensing fee, less $0.50 for most
patients, or less $0.10 for nursing home patients.
4. Pharmacy’s usual price to general public, less
$0.50 for most patients, or less $0.10 for nursing
home patients.

Maximum Allowable Cost: State Maximum
Allowable Ingredient Costs (MAICs) are established
for about 50 multi-source items. Override requires
“Medically Necessary” or unavailability of drug
products at or below MAC. List is periodically
revised and price limits changed to reflect current
market conditions.
Incentive Fee: None.
Patient Cost Sharing: $1.00 copayment for branded
and generic products.
Cognitive Services: Does not pay for cognitive
services, but this is under consideration.
National Pharmaceutical Council Pharmaceutical Benefits 2003
California-4
E. USE OF MANAGED CARE
Approximately 3,300,000 Medicaid recipients were
enrolled in MCOs in FY 2001. Recipients receive
pharmaceutical benefits through the State and
managed care plans. Certain psychiatric drugs
(antipsychotics, lithium, MAO inhibitors) and some
anti-parkinson drugs are carved out of managed care.
Most AIDS drugs are no longer carved out of
managed care.

Access Dental Plan, Inc.
555 University Ave, Suite 182
Sacramento, CA 95825

AIDS Healthcare Foundation
6255 W. Sunset Blvd., 16th Floor
Los Angeles, CA 90028-7403

Alameda Alliance for Health
1240 South Loop Road
Alameda, CA 94502

Altamed Health Services Corp.
512 South Indiana Street
Los Angeles, CA 90063

American Health Guard
30 East Santa Clara, Suite D
Arcadia, CA 91006

Blue Cross of California
5151-A Camino Ruiz
Camarillo, CA 93012

Center for Elders Independence
1955 San Pablo Ave
Oakland, CA 94612

Community Health Group
740 Bay Blvd.
Chula Vista, CA 91910

County of Contra Costa
Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553

Delta Dental Plan of CA
1115 International Drive, Bldg. C
Rancho Cordova, CA 95670

Health Net Dental, Inc.
125 Technology Drive, Suite 100
Irvine, CA 92618


Health Net of California
3400 Data Drive, 1
st
Floor West
Rancho Cordova, CA 95670

Health Plan of San Joaquin
1550 W. Fremont Street, Suite 200
Stockton, CA 95203-2643

Inland Empire Health Plan
PO Box 19026
San Bernardino, CA 92423-9026

Kern Health Systems
Kern Family Health Care
1600 Norris Road
Bakersfield, CA 93308

Kaiser Foundation Health Plan, Inc.
393 E. Walnut, 5
th
Floor
Pasadena, CA 91188-8324

Kaiser Foundation
Health Plan, Inc.
Northern California Region
1800 Harrison Street, 9th Floor
P.O. Box 12916
Oakland, CA 94612-2998

LA Care Health Plan
555 W. Fifth Street, 19
th
Floor
Los Angeles, CA 90013-3036

Molina Healthcare Inc
A Professional Corporation
One Golden Shore Drive
Long Beach, CA 90802

On Lok Senior Health Services
1333 Bush Street
San Francisco, CA 94109

Orange County Organized Health System
Cal Optima
1120 West La Veta Ave., 5
th
Floor
Orange, CA 92868-4220

San Francisco Health Authority
San Francisco Health Plan
568 Howard Street, Fifth Floor
San Francisco, CA 94105

San Francisco City & County Public Health
Family Mosaic Project
1309 Evans Avenue
San Francisco, CA 94124

National Pharmaceutical Council Pharmaceutical Benefits 2003
California-5
San Mateo Health Commission
Health Plan of San Mateo
701 Gateway Blvd., Suite 400
South San Francisco, CA 94080

Santa Barbara Regional Health Authority
Santa Barbara Health Initiative
110 Castilian Drive
Goleta, CA 93117-3028

Santa Clara Family Health Plan
210 E Hacienda Ave
Campbell, CA 95008-6617

Santa Cruz -Monterey
Managed Care Commission
Central Coast Alliance for Health
375 Encinal Street, Suite A
Santa Cruz, CA 95060

Scan Health Plan
Senior Care Action Network
3780 Kilroy Airport Way, Suite 100
Long Beach, CA 90806-2460

Sharp Health Plan
4305 University Avenue, Suite 200
San Diego, CA 92105

Solano-Napa County Commission on Medical Care
Partnership Health Plan of California
360 Campus Lane, Suite 100
Suisun City, CA 94585

Sutter Senior Care
1234 U Street
Sacramento, CA 95818

UCSD Healthcare
200 West Arbor Dr.
San Diego, CA 92103-8501

Universal Care
1600 E. Hill Street
Signal Hill, CA 90755-3612

Watts Health Foundation, Inc.
United Health Plan
3405 West Imperial Highway, Suite 628
Inglewood, CA 90303

Western Dental Services
530 South Main Street, 6
th
Floor
Orange, CA 92863

Western Health Advantage
1331 Garden Highway Suite 100
Sacramento, CA 95833-97543
F. STATE CONTACTS
State Drug Program Administrator
J. Kevin Gorospe, Pharm.D.
Chief, Medi-Cal Pharmacy Policy Unit
California Department of Health Services
Medi-Cal Policy Division
1501 Capitol Ave.
P.O. Box 997413, MS 4604
Sacramento, CA 95899-7413
T: 916/552-9500
F: 916/552-9563
E-mail: kgorospe@dhs.ca.gov
Internet Address: http://www.dhs.ca.gov
New Brand Name Products Contact
J. Kevin Gorospe, Pharm.D.
916/552-9500
Prior Authorization Contact
J. Kevin Gorospe, Pharm.D.
916/552-9500
DUR Contact
Vic Walker, R.Ph. B.C.P.P
Senior Consulting Pharmacist
Medi-Cal Policy Division
1501 Capitol Ave.
P.O. Box 997413, MS 4604
Sacramento, CA 95899-7413
T: 916/552-9500
F: 916/552-9563
E-mail: vwalker@dhs.ca.gov
Medi-Cal Drug Utilization Review Board (DUR
Board)
Timothy E. Albertson, M.D., Ph.D.
University of California-Davis
Pulmonary/Critical Care Medicine
4301 X Street, Professional Bldg., Room 2120
Sacramento, CA 95817

Craig Jones, M.D.
Director, Division of Allergy/Immunology
Department of Pediatrics
LA County/USC Medical Center
24725 Avenida Asoleada
Calabasas, CA 91302

Janeen G. McBride, R.Ph.
Rx America
1500 South Anaheim Blvd.
Anaheim, CA 92815-0017

National Pharmaceutical Council Pharmaceutical Benefits 2003
California-6
Kenneth Schell, Pharm.D.
Pharmacy Services
Clinical Operations Manager
Kaiser Permanente
10990 San Diego Mission Road
San Diego, CA 92108

Stephen M. Stahl, M.D., Ph.D.
Clinical Neuroscience Research Center
8899 University Center Lane, Ste. 130
San Diego, CA 92122

Andrew L. Wong, M.D.
Chief of Rheumatology
University of California - Los Angeles
14445 Olive View - UCLA Medical Center
Sylmar, CA 91342
Prescription Price Updating
EDS Federal Corp.
P. O. Box 13029
Sacramento, CA 95813-4029
916/636-1000
Medicaid Drug Rebate Contact
Craig Miller
Chief, Medi-Cal Rebate and Vision Section
Medi-Cal Policy Division
1501 Capitol Ave.
P.O. Box 997413, MS 4604
Sacramento, CA 95899-7413
T: 916/552-9500
F: 916/552-9563
E-mail: cmiller2@dhs.ca.gov
Claims Submission Contact
EDS Federal Corp.
P.O. Box 13029
Sacramento, CA 95813-4029
916/636-1000
Internet Address: www.medi-cal.ca.gov
Medicaid Managed Care Contact
Ronald Sanui, Pharm D.
Pharmaceutical Consultant II
Medi-Cal Managed Care Division
1501 Capitol Ave.
P.O. Box 997413, MS 4404
Sacramento, CA 95899-7413
916-449-5138
E-mail: rsanui@dhs.ca.gov

Disease Management Program/Initiative
Contact
Vic Walker, R.Ph., B.C.P.P., 916/552-9500
Mail Order Drug Benefit
State currently has a mail order pharmacy capability
in the Medi-Cal program. All fee-for-service
beneficiaries are entitled to participate.
Health and Welfare Agency Officials
S. Kimberly Belshé
Secretary
California Health and Human Services Agency
1600 9th Street, Suite 460
Sacramento, CA 95814
T: 916/654-3454
F: 916/654-3343
E-mail address: www.chhs.ca.gov

Stan Rosenstein
Deputy Director
Medical Care Services
California Department of Health Services
1501 Capitol Ave., P.O. Box 997413, MS 4000
Sacramento, CA 95899-7413
T: 916/ 440-7800
F: 916/ 440-7805
E-mail: srosenst.dhs.ca.gov
Medi-Cal Contract Drug Advisory Committee
William B. Ness, M.D.
65 North 14th Street
San Jose, CA 95112

Bruce K. Uyeda, Pharm.D.
1076 Mercy Street
Mountain View, CA 94041-1915

Adrian M. Wong, Pharm.D.
17 Warren Drive
San Francisco, CA 94131

Richard H. White, M.D.
U.C. Davis Medical Center
Division of General Medicine
Primary Care Center, Room 3107
2221 Stockton Blvd.
Sacramento, CA 95817

Shirley Ann Floyd
Blue Cross of California
131 Chester Ave., Suite A
Bakersfield, CA 93301
National Pharmaceutical Council Pharmaceutical Benefits 2003
California-7
Executive Officers of State Medical and
Pharmaceutical Associations/Boards
California Medical Association
Jack C. Lewin, M.D.
CEO and Executive Vice-President
1201 J Street
Sacramento, CA 95814
916/444-5532
Internet address: www.cmanet.org

Osteopathic Physicians & Surgeons of California
Kathleen S. Creason
Executive Director
1900 Point West Way, Suite 188
Sacramento, CA 95815-4703
T: 916/561-0724
F: 916/561-0728
E-mail: 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 Pharmaceutical Benefits 2003
California-8




National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-1
COLORADO
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)

Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult

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


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients
TOTAL $177,115,553 143,169 $189,717,036

RECEIVING CASH ASSISTANCE, TOTAL $117,978,722 76,243
Aged $38,858,494 18,832
Blind/Disabled $71,297,760 26,703
Child $2,406,437 15,586
Adult $5,416,031 15,092

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $20,438,343 41,156
Aged $101,358 129
Blind/Disabled $15,354,288 3,802
Child $3,695,461 27,041
Adult $1,287,236 10,184

TOTAL OTHER EXPENDITURES/RECIPIENTS* $38,698,488 25,770
*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-2
C. ADMINISTRATION
Colorado Department of Health Care Policy and
Financing administers the drug program. Eligibility
is determined by 63 County Departments of Social
Services, and the Department.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered with restriction:
total parenteral nutrition (prior authorization).
Products not covered: cosmetics; DESI drugs;
fertility drugs; prescribed vitamins (except prenatal);
interdialytic parental nutrition products; and
experimental drugs. Disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips are considered
DME and do not fall under the State’s drug benefit.
Over-the-Counter Product Coverage: Products
covered with restriction (i.e., must be deemed
medically necessary): allergy, asthma, and sinus
products; analgesics; cough and cold preparations;
digestive products; feminine products; topical
products; and smoking deterrent products (prior
authorization).
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antilipemic agents; antihistamines; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents (given in home);
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; and thyroid agents.
Prior authorization required for: anabolic steroids;
analgesics, antipyretics, NSAIDs; anti-psychotics
(prior authorization required for clozoril); prescribed
cough and cold medications; growth hormones; misc.
GI drugs; sympathominetics (adrenergic); vitamins;
acne products; leukocyte stimulants; LHRH/GnRH;
injectables; plasma products; Epoetin; fluoride
preparations; antisera; Oxycontin; erectile
dysfunction; sympathominetics (adrenergie); and
prescribed smoking deterrents. Products not
covered: anoretics.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physician offices. Prior authorization is required
for self-administration at home.
Vaccines: Vaccines reimbursable as part of the
EPSDT Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.
Prior Authorization: State currently has a formal
prior authorization procedure. There is an appeal
process and re-review when appealing coverage of an
excluded product and prior authorization decisions.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: New prescriptions for
chronic or acute conditions are prescribed at the
discretion of the physician. Normal quantity limit is
a 30-day supply. However, reasonable amounts for
more than a 30-day supply for chronic conditions are
recommended. Maximum supply is 100 days for
maintenance medication.
Other Limits: Stadol: limit of 4 bottles per month.
Oxycontin: 2 tablet (any strength) per day limit
without prior authorization.
Drug Utilization Review
PRODUR system implemented in December 1998.
DUR Board meets semiannually.
Lock-In Review Procedures: The Department
receives computer processed printouts designed to
discover over-utilization of drugs prescribed by
physicians, dispensed by vendors, and received by
eligible recipients.
Pharmacy Payment and Patient Cost Sharing
Dispensing fee: $4.00 as of July 1, 2001.
Institutional pharmacies receive a dispensing fee
equal to $1.89. Dispensing physicians shall not
receive a dispensing fee unless their offices or sites
of practice are located more than 25 miles from the
nearest participating pharmacy. In the latter case,
physicians receive a fee equal to $1.89.
Ingredient Reimbursement Basis: EAC = AWP-
13.5% or WAC (wholesaler acquisition cost) + 18%.
AWP-35% for generics. Other: FUL, State Mac,
usual and customary.
Prescription Charge Formula: Benefit drugs shall be
reimbursed at the lesser of the Medicaid allowable
National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-3
reimbursement charge, or the provider’s usual and
customary charge or whatever is accepted from any
third party, discounts, rebates, etc.
The Medicaid allowable reimbursement charge is the
sum of the ingredient cost of the drug dispensed and
the provider’s dispensing fee.
Ingredient cost for retail pharmacies (estimated
acquisition cost) is the price of the drug actually
dispensed as defined below or the MAC or the high
volume EAC, whichever is less.
The ingredient cost for institutional and government
pharmacies is defined as the actual cost of acquisition
for the drug dispensed or the MAC, or the high
volume EAC, whichever is less.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires prior authorization
with explanation of medical necessity (Med Watch
form).
The State MAC is the maximum ingredient cost
allowed by the Department for certain multiple-
source drugs. The establishment of a MAC is
subject, but not limited to, the following
considerations:
(1) Multiple manufacturers;
(2) Broad wholesale price span;
(3) Availability of drugs to retailers at the selected
cost;
(4) High volume of Medicaid recipient utilization;
(5) Bioequivalence or interchangeability.
When Federal MAC limits for multiple source drugs
are announced, they will be adopted if they are less
than State MACs or if no State MACs exist.
The ingredient cost of any drug subject to MAC shall
be limited to MAC or wholesale price as determined
by the Department, whichever is less. Exceptions
that will allow reimbursement greater than MAC for
a drug entity are obtained through a prior
authorization mechanism. An exception will be
granted if the patient’s response to the generic drug is
not therapeutic, an allergic reaction is involved, or
any similar situation exists.
If a recipient requests a brand name for a prescription
that is subject to MAC, then he/she may pay the
ingredient cost difference between the MAC and
brand name drug. The recipient must sign the
prescription stating that he/she is willing to pay the
difference in ingredient cost to the pharmacy. The
pharmacy will be paid MAC plus a dispensing fee or
reimbursement charges, whichever is lower.
High volume Estimated Acquisition Cost (EAC):
Reimbursement for single source drugs or certain
multiple source drugs which are most frequently
prescribed will be based upon average wholesale
prices (AWP) minus 13.5%, or direct manufacturers’
prices for package sizes containing quantities greater
than 100 dosage units or less if not available in
100’s.
Basis for inclusion in the high volume estimated
acquisition cost list includes but is not limited to:
(1) Single source manufacturers;
(2) High volume Medicaid recipient utilization;
(3) Interchangeability problems with multiple source
drugs;
(4) Package sizes in excess of 100.
Drug Pricing: The Department will maintain a drug-
pricing file that will be updated at least monthly. The
average wholesale price of a drug as determined by
the Department, MAC, and high volume EAC, will
be the basis for setting the prices in the drug pricing
file.
The Department will determine the average
wholesale price that will be placed in the drug-
pricing file as follows:
(1) The average wholesale price as it appears in the
Red Book, its supplements, and Medi-Span will be
the first source. However, if there is a difference
between the two published average wholesale prices,
the Department will set the price as the published
amount which is the closest to the lowest average
price charged by two drug wholesalers doing
business in Colorado.
(2) If there is a price change which does not appear
immediately in the Red Book, its supplements, or in
Medi-Span, then the Department will set the average
wholesale price by averaging the wholesale prices of
three drug wholesalers doing business in Colorado,
until the price is published in the Red Book, its
supplements, or in Medi-Span.
(3) If the prices or changes do not appear in the
publications or the wholesalers’ records, then the
distributors’ or manufacturers’ prices will be adjusted
to the wholesale pricing level and used in the drug
pricing file as the price of the drug.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-4
If the difference between the pharmacist’s invoice
purchase price and the average wholesale price which
appears in the Red Book, its supplements, or Medi-
Span exceeds 18%, then the Department may adopt a
lower price after a survey is conducted to determine
the validity of the published prices. The price from
the distributor or manufacturer will be adjusted the
same as in 3 above.
Special Note: The Maximum Allowable Cost shall be
determined by the Division of Medical Assistance,
based upon professional determination of a quality
product available at the least expense possible.
Exceptions to the above are:
- Shelf package size oral liquid medications, in pint
size only, or smaller package size when not packaged
in pint size.
- Shelf package size oral tablet and capsule
medications in quantities of 100 only or smaller
when not available in package size of 100.
- Prescriptions for less than minimum amounts will
be denied reimbursement of the professional fee
unless the physician notified the Department in
writing of the medical need for amounts less than a
30-day supply. Medical consultation determines the
decision.
Incentive Fee: None.
Patient Cost Sharing: $3.00
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Over 260,000 Medicaid recipients were enrolled in
managed care in FY 2001. Recipients receive
pharmaceutical benefits through the Managed Care
Organization.
Managed Care Organizations
Total Long-Term Care
303 East 17
th
Avenue, Suite 650
Denver, CO 80203
303/896-4664

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

Rocky Mountain HMO
2775 Crossroads Boulevard
Grand Junction, CO 81506
800/843-0719
Colorado Access
600 South Cherry Street, Suite 800
Denver, CO 80222
303/355-6707

Community Health Plan of the Rockies
400 South Colorado Boulevard, Suite 300
Denver, CO 80222
303/355-3220

United Healthcare
6251 Greenwood Plaza Boulevard, Suite 200
Englewood, CO 80111-4910
303/267/3594
F. STATE CONTACTS
Medicaid Drug Program Administrator
Martha Warner
Pharmacy Supervisor
Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203
T: 303/866-3176
F: 303/866-2573
E-mail: martha.warner@state.co.us
DUR Contact
Catherine Travgott
Pharmacist
Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203
T: 303/866-2468
F: 303/866-2578
E-mail: Catherine.travgott@state.co.us
New Brand Names Products Contact
Catherine Travgott
303/866-2468
Prescription Price Updating
Martha Warner
303/866-3176
National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-5
Medicaid Drug Rebate Contacts
Vince Sherry
Drug Rebate Manager
Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203
T: 303/866-5408
F: 303/866-2573
E-mail: vince.sherry@state.co.us
Claims Submission Contact
ACS, Inc.
600 17
th
Street
Suite 600 North
Denver, CO 80202
T: 800/237-0757
F: 303/534-0439
Medicaid Managed Care Contact
Katie Brookler
Managed Care Manager
Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203
T: 303/866-2416
F: 303/866-2573
E-mail: katie.brookler@state.co.us
Disease Management/Patient Education
Programs
Disease/Medical State: Schizophrenia
Program Name: Schizophrenia with Co-Morbid
Conditions Pilot Program
Program Manager: Gloria Johnson
Sponsor: Eli Lilly and Company

Disease/Medical State: Diabetes
Program Name: Diabetes Disease Management Pilot
Program
Program Manager: Gloria Johnson
Sponsor: Eli Lilly and Company
Disease Management/Patient Education
Contact
Katie Brookler, 303/866-2416
Mail Order Pharmacy Program
None

Health Care Policy & Financing Department
Officials
Karen K. Reinertson
Executive Director
Department of Health Care Policy and Financing
1570 Grant Street
Denver, CO 80203-1818
T: 303/866-2993
F: 303/866-4411
E-mail: Karen.reinertson@state.co.us
Internet Address: www.chcpf.state.co.us

Vivianne M. Chavmont, Director
Medical Assistance Office
Department of Healthcare Policy and Financing
1570 Grant Street
Denver, CO 80203
303/866-3058
Medical Services Board
Michael Oliva, President
Julie Reiskin, Vice President
Mary Ellen Faules
Joan M. Johnson
Wendal Phillips
Joe Rall
Maguerite Salazar
Steve Tool
Mathew Dunn, M.D.
Jeremy Schupbach, Coordinator
Medical Advisory Council
Donald W. Schiff, M.D.
600 Front Range Road
Littleton, CO 80120
303/837-2745

Molly A. Markert
11060 E. Wesley Pl.
Aurora, CO 80014
303/756-7234

Mary Jo Jacobs, M.D.
7425 E. Kenyon Ave.
Denver, CO 80237
303/694-2878

Walter Daniels, D.D.S.
1633 Filmore Street
Denver, CO 80206
303/388-0989

Rodney Fair, O.D.
105 Bridge Street
Brighton, CO 80601
303/659-3036
Douglas Clinkscales
National Pharmaceutical Council Pharmaceutical Benefits 2003
Colorado-6
Denver Health and Hospitals
777 Bannock Street
Denver, CO 80204
303/426-7253

Cathy Corcoran
15920 W. 66th Place
Golden, CO 80403
303/861-6256

Ernestine Kotthoff-Burrell
6098 S. Iola Ct.
Englewood, CO 80111
303/270-8974

Carol Bartley
Denver VNA
3801 E. Florida Ave., Suite 800
Denver, CO 80201
303/753-7312

Mary Ellen Kuhlman, MSW
St. Mary’s Hospital & Medical Center
P.O. Box 1628
Grand Junction, CO 81502
970/244-2273

Dan Stenerson
Shalom Park
14800 E. Belleview
Aurora, CO 80015
303/680-5000

Mark Kunart, D.O.
17200 E. Iliff Avenue
Aurora, CO 80013
303/755-4111

Robert Slay
Jefferson Co. CCB
7456 W. 5th Avenue
Lakewood, CO 80226
303/233-3363 x366
Executive Officers of State Medical and
Pharmaceutical Societies
Colorado Medical Society
Sandra L. Maloney
Executive Director
7351 Lowry Boulevard
Denver, CO 80230
T: 720/859-1001
F: 303/771-8659
E-mail: sandi_maloney@cms.org
Internet address: www.cms.org

Colorado Pharmacists Society
Val Kalnins, R.Ph., Executive Director
6825 E. Tennessee Avenue, Suite 440
Denver, CO 80224-1662
T: 303/756-3069
F: 303/756-3649
E-mail: val@copharm.org
Internet address: www.copharm.org

Colorado Society of Osteopathic Medicine
Marie Kowalsky
Executive Director
650 South Cherry Street, Suite 440
Denver, CO 80246
T: 303/322-1752
F: 303/332-1956
E-mail: coloradodo@aol.com
Internet address: www.coloradodo.org

Colorado State Board of Pharmacy
Susan L. Warren
Program Administration
1560 Broadway, Suite 1310
Denver, CO 80202-5146
T: 303/894-7750
F: 303/894-7764
E-mail: pharmacy@dora.state.co.us
Internet address: www.dora.state.co.us/pharmacy

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









National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-1
CONNECTICUT
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)

Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray
Service

Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001 2002*
Expenditures Recipients Expenditures Recipients
TOTAL $304,470,534 116,755 $357,919,257

RECEIVING CASH ASSISTANCE, TOTAL $85,509,574 29,004
Aged $14,661,696 6,146
Blind/Disabled $70,113,706 17,814
Child $176,052 2,598
Adult $558,120 2,446

MEDICALLY NEEDY, TOTAL $89,643,018 29,417
Aged $21,970,885 10,353
Blind/Disabled $67,436,637 18,548
Child $91,458 283
Adult $144,038 233

POVERTY RELATED, TOTAL $3,750,393 5,721
Aged $644,493 700
Blind/Disabled $2,152,958 1,089
Child $877,998 2,974
Adult $74,944 958

TOTAL OTHER EXPENDITURES/RECIPIENTS* $125,567,549 52,613

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-2
C. ADMINISTRATION
State of Connecticut Department of Social Services
through three regional offices and twelve sub-offices.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin, disposable needles and syringe
combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition
(except in NH); and interdialytic parenteral nutrition
(except in NH). Products not covered: cosmetics;
fertility drugs; experimental drugs; and weight loss
products.
Over-the-Counter Product Coverage: Products
covered: cough and cold preparations (children < 19
years) and topical products. Products covered with
restrictions: digestive products (non H2 antagonists)
– liquid generics only; and digestive products (H2
antagonists) – legend drugs not covered; birth control
products; antihistamines; and decongestants.
Products not covered: smoking deterrent products;
allergy, asthma and sinus products; analgesics;
feminine products; iron; calcium; and some trace
elements. For nursing home patients, the department
will not pay for OTC drugs used in nursing facilities
(such drugs are covered in the per diem rate). Some
drugs require diagnosis for reimbursement such as
CNS stimulants for ADD and narcolepsy.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; ENT anti-inflammatory
agents; estrogens; hypotensive agents; misc. GI
drugs; sympathominetics (adrenergic); thyroid
agents; and growth hormones. Therapeutic
categories not covered: anorectics and prescribed
smoking deterrents.
Coverage of Injectables: Injectable medicines
reimbursable through physician payment when used in
home health care, extended care facilities, and in
physicians offices.
Vaccines: Vaccines reimbursable as part of the
Children Health Insurance Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary, however, the following
products are excluded from Medicaid prescription
coverage: experimental drugs, cosmetics, fertility
drugs; smoking cessation products; DESI drugs, and
drugs available free from the Department of Health
Services.
Prior Authorization: State does not currently have a
prior authorization procedure.
Prescribing or Dispensing Limitations
Prescription Refill Limit: 5 refills per prescription
except for oral contraceptives, which have a 12-
month limit.

Monthly Quantity Limit: Maximum 240 tablets or
capsules/30 day supply. Oral contraceptives: 3
months supply may be dispensed at one time.
Physicians are encouraged to prescribe drugs
generically, when possible.
Drug Utilization Review
Pro-DUR system implemented September 1996.
Retro-DUR since September 1991; the State
currently has a 9 member DUR Board with a
quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.30, effective 10/1/03.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Special rules for Factor VIII (AAC + 8%), OTCs
(AWP x # units x 1.15), and neutral and parenteral
nutritionals (AWP x # units x 1.15).
Prescription Charge Formula: Federal MAC or EAC
plus dispensing fee; or usual and customary if lower.
Special rules for blood factor VIII and
enteral/parenteral nutrition products.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Effective 1/1/2003,
the Department implemented a state MAC to include
additional multi-source generic products that are not
on the FUL list. The State MAC reimbursement is
AWP-40%.
Patient Cost Sharing: None.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-3
E. USE OF MANAGED CARE
Connecticut has approximately 290,000 Medicaid
recipients enrolled in managed care. Pharmaceutical
benefits received through the managed care plan.
Managed Care Organizations
Anthem Blue Cross/Blue Shield of CT
Blue Care Family Plan
Paula Smyth, Director
Medicaid Managed Care
370 Bassett Road
North Haven, CT 06473-4201
T: 203/654-3506
F: 203/234-5310

Community Health Network of CT
Sylvia Kelly, CEO
290 Pratt - 2nd Floor
Meriden, CT 06450
T: 203/237-4000
F: 203/634-8411

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

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


F. STATE CONTACTS
Medicaid Drug Program Administrator
Evelyn A. Dudley
Pharmacy Program Manager
Department of Social Services
Medical Operations Unit #4
25 Sigourney Street
Hartford, CT 06106
T: 860/424-5654
F: 860/424-5206
E-mail: evelyn.dudley@po.state.ct.us
Internet address: www.ctmedicalprogram.com




Department of Social Services
Administrative Officials
Patricia A. Wilson-Coker
Commissioner
Department of Social Services
25 Sigourney Street
Hartford, CT 06016-5033
T: 860/424-5008
F: 860/566-2022
E-mail: pat.wilson-coker@po.state.ct.us

Claudette Beaulieu, Deputy Commissioner
860/424-5010

Michael Starkowski, Deputy Commissioner
860/424-5053

David Parrella, Director
Medical Care Administration
860/424-5177

Rose Ciarcia, Director
25 Sigourney Street
Hartford, CT 06106
860-424-5139
E-mail: rose.ciarcia@po.state.ct.us

Michelle Parsons, Manager
Alternate Care Unit
860/424-5177

Marcia Mains, Director
Medical Operations
860/424-5219

Evelyn Dudley
Pharmacy Program Manager
860/424-5654
DUR Contact
James Zakszewski, R.Ph.
Pharmacy Consultant
Department of Social Services
25 Sigourney Street
Hartford, CT 06106
T: 860/424-5150
F: 860/424-5206
E-mail: james.zakszewski@po.state.ct.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-4
Connecticut DUR Board
Kenneth Fisher, R.Ph.
Brooks Pharmacy

Arturo Morales, M.D.
St. Francis Hospital

Lori Jane Duntz Lord, R.Ph.
Greenville Drug

Dennis J. Chapron, R.Ph.
Pharmokinetics Lab

Keith Lyke, R.Ph.
Pelton’s Pharmacy

Frederick N. Rowland, M.D.
St. Francis Hospital and Medical Center

Richard Gannon, Pharm.D.
Hartford Hospital

Kathryn Mashey, DPM
Community Health Services

Michael Moore, R.Ph.
Hebrew Home Hospital
Prescription Price Updating
Ellen Arce, R.Ph.
Pharmacy Manager
Electronic Data Systems
100 Stanley Street
New Britain, CT 06053
860/832-5885
Medicaid Drug Rebate Contacts
Mark Heuschkel
Lead Planning Analyst - Pharmacy
Department of Social Services
Medical Operations Unit #4
25 Sigourney Street
Hartford, CT 06106
T: 860/424-5347
F: 860/424-5206
E-mail: mark.heuschkel@po.state.ct.us

Ellen Arce, R.Ph. (Rebates & Disputes)
860/832-5885
Claims Submission Contact
Ellen Arce, R.Ph.
860/832-5858
Medicaid Managed Care Contact
Rose Ciarcia
860/424-5139
Mail Order Pharmacy Program
None
Elderly Drug Coverage Program Contact
Evelyn Dudley
860/424-5654
Physician-Administered Drug Program
Contact
Timothy Bowles, Medical Policy
25 Sigourney Street
Hartford, CT 06106
860/424-4984
State Pharmacy Commission
William Summa, P.D., Chairman
Executive Officers of State Medical and
Pharmaceutical Societies
State Medical Society
Timothy B. Norbeck, Executive Director
160 St. Ronan Street
New Haven, CT 06511-2390
T: 203/865-0587
F: 203/865-4997
E-mail: tnorbeck@csms.org
Internet address: www.csms.org

Connecticut Pharmacists Association
Margherita R. Guiliano, R.Ph. Executive V.P.
35 Cold Spring Road, Suite 124
Rocky Hill, CT 06067-3161
T: 860/563-4619
F: 860/257-8241
E-mail: mguiliano@ctpharmacists.org
Internet address: www.ctpharmacists.org

Connecticut Osteopathic Medical Society
Donald Halpin, Executive Director
P.O. Box 487
Winchester, MA 01800-0487
T: 781/721-9900
F: 781/721-4400
E-mail: don@northeastosteo.org
Internet address: www.northeastosteo.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-5
Pharmacy Commission & Drug Control Division
Michelle Sylvestre, R.Ph.
Board Administrator
State Office Building
165 Capitol Avenue, Room 147
Hartford, CT 06106
T: 860/713-6070
F: 860/713-7242
E-mail: michelle.sylvestre@po.state.ct.us
Internet address:
www.ctdrugcontrol.com/rxcommission.htm

Connecticut Hospital Association, Inc.
Jennifer Jackson
President and CEO
110 Barnes Road
P.O. Box 90
Wallingford, CT 06492-0090
T: 203/265-7611
F: 203/284-9318
Internet address: www.chime.org






























































































National Pharmaceutical Council Pharmaceutical Benefits 2003
Connecticut-6





































































































National Pharmaceutical Council Pharmaceutical Benefits 2003
Delaware-1
DELAWARE
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients
TOTAL $81,623,058 85,351 $97,750,161

RECEIVING CASH ASSISTANCE, TOTAL $52,023,939 62,035
Aged $5,833,794 2,470
Blind/Disabled $27,480,662 9,724
Child $7,259,311 31,503
Adult $11,450,172 18,338

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $1,423,154 3,654
Aged $145,083 132
Blind/Disabled $533,696 282
Child $718,597 3,103
Adults $25,778 137

TOTAL OTHER EXPENDITURES/RECIPIENTS* $28,175,965 19,662

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Delaware-2
C. ADMINISTRATION
Division of Social Services, Department of Health
and Social Services, through three county offices of
the State agency.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; urine ketone test strips; and total parenteral
nutrition. Products covered with restrictions:
interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; and experimental
drugs.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive
products; and topical products. Products covered
with restrictions: smoking deterrent products (prior
authorization and quantity limits). Products not
covered: feminine products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: analgesics,
antipyretics, and NSAIDs; anoretics; antibiotics; anti-
psychotics; growth hormones; prescribed smoking
deterrents; Regranex; Zyvox; Soma Accutane Cipro;
Cholinesterase inhibitors; Modafanil; and Epoetin.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians’ offices.
Vaccines: Vaccines reimbursable under the Vaccines
for Children program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.
Prior Authorization: State currently has a formal
prior authorization procedure. Standard procedures
for clients to request a fair hearing to appeal prior
authorization decisions.
Prescribing or Dispensing Limitations
Prescription Refills: Prescription blank has space for
physician to authorize renewals.
Monthly Quantity Limit: Greater of 34-day supply or
100 dosing units.
Monthly Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in August 1994. State
has a DUR Board that meets bimonthly.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.65.
Ingredient Reimbursement Basis: EAC = AWP-
14.0%. (AWP-16% for LTC)
Prescription Charge Formula: Payment is based on
AWP-14.0% or maximum allowable cost (MAC)
plus a dispensing fee, or the usual and customary cost
to the general public, whichever is lower.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires completion of an
FDA MedWatch form.
Incentive Fee: None.
Patient Cost Sharing: None.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Delaware-3
E. USE OF MANAGED CARE
Approximately 90,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through the State.
Managed Care Organizations
DelawareCare
2751 Centerville Road, Suite 400
Wilmington, DE 19808
215/937-8285

First State Health Plan
1801 Rockland Road, Suite 300
Wilmington, DE 19803
302/576-7603
F. STATE CONTACTS
State Drug Program Administrator
Cynthia R. Denemark, R.Ph.
Director of Pharmacy Services
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
E-mail: cynthia.denemark@eds.com
Internet address: www.dmap.state.de.us
Prior Authorization Contact
Cynthia R. Denemark, R.Ph.
302/453-8453
DUR Contact
Cynthia R. Denemark, R.Ph.
302/453-8453
DUR Board
Calvin Freedman, R.Ph.
Marvin H. Dorph, M.D.
Richard Steele, R.Ph.
Sharon Wisneski, R.N., M.S.
Mark Borer, M.D.
Nadia Zalusky, R.Ph.
Chris Sual, R.Ph.
Frank Falco, M.D.
New Brand Name Products
Cynthia R. Denemark, R.Ph.
302/453-8453
Prescription Price Updating
Dan Cohn
DSS/EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
Medicaid Drug Rebate Contacts
Frank Long
Contracts Manager
DSS
Herman Holloway Campus
Lewis Building
1901 North DuPont Highway
New Castle, DE 19720
T: 302/255-9624
F: 302/255-4425
Medicaid Drug Rebate Contact
Audits:
Frank Long
302/255-9624

Disputes:
Lynessa Tejeda
Rebate Analyst
EDS
248 Chapman Road, Suite 100
Newark, DE 19702
T: 302/456-8453
F: 302/454-0224
Claims Submission Contact
Jose Tieso
System Manager
EDS
248 Chapman Rd, Suite 100
Newark, DE 19702
T: 302/453-8453
F: 302/454-0224
Medicaid Managed Care Contact
Glynne Williams
Health Care Cost Containment Specialist
DSS
Herman Holloway Campus
Lewis Building
1901 North DuPont Highway
New Castle, DE 19720
T: 302/255-9628
F: 302/255-4425
National Pharmaceutical Council Pharmaceutical Benefits 2003
Delaware-4
Mail Order Pharmacy Benefit
None
Health and Social Services Department
Officials
Vincent P. Meconi
Secretary
Dept. of Health & Social Services
1901 North DuPont Highway
New Castle, DE 19720
T: 302/255-9040
F: 302/255-4429
E-mail: vmeconi@state.de.us

Philip P. Soulé
Deputy Director
Medicaid Division
Dept. of Health & Social Services
1901 North DuPont Highway
New Castle, DE 19720
T: 302/255-9501
F: 302/255-4425
E-mail: psoule@state.de.us
Medical Advisory Committee Members
Susan Ebner
Anne Aldridge, M.D.
Caroline Vecchiolla
Neil McLaughlin
Richard Cherrin
Kevin Sheahan
Bob Welch
John A. Forrest, Jr., M.D.
Mark Meister
Olga Ramirez
Penny D. Chelucci
Joseph Letnaunchyn
Al Pilong
George English
Michael Glacken, M.D.
Daniese McMullin-Powell
Leonard Nitowski, M.D.
Julia M. Pillsbury, D.O.
Ulder Jane Tillman, M.D.
Yrene E. Waldron
Anne M. Allen
Theodore Gregory
Ellen M. Steele
Kim L. Carpenter, M.D.
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
Patricia Carroll-Grant, R.Ph., CDE
Executive Director
P.O. Box 454
Smyrna, DE 19977-0454
T: 302/659-3088
F: 302/659-3089
E-mail: questions@depharmacy.net
Internet address: www.depharmacy.net

Osteopathic Medical Society
Edward Sobel, D.O.
Executive Director
P.O. Box 8177
Talleyville, DE 19803-8177
T: 302/764-1198
F: 302/764-1322
E-mail: info@deosteopathic.org
Internet address: www.deosteopathic.org

State Board of Pharmacy
David W. Dryden, R.Ph., J.D.
Executive Secretary
P.O. Box 637
Dover, DE 19903
T: 302/744-4547
F: 302/739-3071
E-mail: david.dryden@state.de.us
Internet address:
www.professionallicensing.state.de.us

Delaware Healthcare Association
Joseph M. Letnaunchyn
President & CEO
1280 South Governors Avenue
Dover, DE 19904-4802
T: 302/674-2853
F: 302/734-2731
E-mail: joelet@deha.org
Internet address: www.deha.org


National Pharmaceutical Council Pharmaceutical Benefits 2003
District of Columbia-1
DISTRICT OF COLUMBIA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disable
d
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

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

TOTAL $62,292,004 35,324 $66,129,208

RECEIVING CASH ASSISTANCE TOTAL $42,750,082 22,033
Aged $3,745,744 2,262
Blind/Disabled $37,256,814 14,440
Child $358,540 2,063
Adult $1,388,984 3,268

MEDICALLY NEEDY, TOTAL $7,930,965 4,980
Aged $1,637,536 819
Blind/Disabled $5,639,520 2,399
Child $128,355 853
Adult $525,554 909

POVERTY RELATED, TOTAL $8,495,578 5,135
Aged $2,772,481 1,513
Blind/Disabled $5,511,608 1,858
Child $195,736 1,575
Adult $15,753 189

TOTAL OTHER EXPENDITURE/RECIPIENTS $3,115,379 3,176

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

Source: CMS, MSIS Report, FY 2000 and CMS-64 Report, FY 2002.






National Pharmaceutical Council Pharmaceutical Benefits 2003
District of Columbia-2
C. ADMINISTRATION
The District of Columbia Department of Health
(DOH), Medical Assistance Administration.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; and ferrous sulfate.
Products covered with restrictions: (e.g., long-term
care only): total parenteral nutrition; (greater flow)
Prior authorization required for: cosmetics (25 years
of age); injectable drugs administered on an
outpatient basis; anorexic drugs for treatment of
narcolepsy and minimal brain dysfunction in
children; acute anti-ulcer drugs, and brand NSAIDs.
Products not covered: anesthetics; infant formulas;
cold tar preparations; ostomy products; diagnostic
products; reusable needles/syringes (non-insulin);
and all other non-legend items.
Over-the-Counter Product Coverage: Products
covered with restrictions: oral analgesics; oral
antacids; contraceptive foams and jellies; prenatal,
pediatric and geriatric vitamins; and bowel
preparation kits. Products not covered: allergy,
asthma, and sinus products; cough and cold
preparations; digestive products (H2 antagonists);
feminine products; topical products; and smoking
deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamines; antilipemic agents; anti-psychotics;
anxiolytics; sedatives; and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; prescribed smoking
deterrents; and thyroid agents. Prior authorization
required for: analgesics, antipyretics, and NSAIDs;
anoretics; growth hormones; misc. GI drugs;
sympathominetics (adrenergic); erectile dysfunction
products; multisource brands; Medicare-covered
drugs; Levocamitine; Hepatitis C; and Synagis.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians offices’.

Vaccines: Vaccines reimbursable at cost as part of
the EPSDT service.
Unit Dose: Unit dose packaging not reimbursable
Formulary/Prior Authorization
Formulary: Open formulary with restrictions on use,
prior authorization, and therapeutic substitution.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: In general, amounts
dispensed are to be limited to quantities sufficient to
treat an episode of illness. Maintenance drugs such
as thyroid, digitalis, etc. may be dispensed in
amounts up to a 30-day supply with 3 refills that
must be dispensed within 4 months. Antibiotic
medications used in treatment of acute infections are
not to be dispensed in excess of a 10-day supply.
Birth control tablets may be dispensed in 3-cycle
units with a maximum of 3 refills within one year.
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.
Provider/subscriber may appeal denials by writing to
the District of Columbia Medicaid Program.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.50.
Ingredient Reimbursement Basis: AWP-10%.
Prescription Charge Formula: The lesser of: FUL or
the AWP-10% plus the dispensing fee or usual and
customary to the public.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” plus prior
authorization.
Incentive Fee: None.
Patient Cost Sharing: $1.00 copay by recipient.
Does not apply to recipients under 18, prescriptions
for family planning, nursing home patients, or
pregnancy related.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
District of Columbia-3
E. USE OF MANAGED CARE
Approximately 80,000 Medicaid recipients were
enrolled in managed care in 2002. Recipients
enrolled in managed care receive pharmaceutical
benefits through managed care plans.
Managed Care Organizations
Advantage Health Plan, Inc.
P.O. Box 9596
Washington, DC 20016
202/686-8555

American Preferred Provider Plan Mid-Atlantic, Inc.
1501 M Street, NW, Suite 500
Washington, DC 20002
202/408-0460

D.C. Chartered Health Plan
820 First Street, NE, Suite LL100
Washington, DC 20002
202/408-4710

Capitol Community Health Plan
750 First Street, NE, Suite 1120
Washington, DC 20002
202/408-0460

George Washington University Health Plan
4550 Montgomery Avenue
Bethesda, MD 20814
301/941-2044

Health Right, Inc.
3020 14
th
Street, NW
Washington, DC 20009
202/518-2370

Prudential Health Care Plan
2800 N. Charles Street
Baltimore, MD 21218
410/554-7224
F. STATE CONTACTS
State Drug Program Administrator
Donna Bovell, R.Ph.
Pharmacist Consultant
Medical Assistance Administration
Department of Health
825 North Capitol Street, NE
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: donna.bovell@dcgov.org
DUR Contact
Donna Bovell, R.Ph.
202/442-5988
District of Columbia DUR Board
Christopher Keeyes, Pharm.D. (Chair)
President, Clinical Pharmacy Associates
11710 Beltsville Drive, Suite 510
Calverton, MD 20705
301/572-1616

Martin Dillard, M.D. (Vice Chair)
Assistant Dean for Clinical Affairs
Chief, Division of Nephrology
Howard University Hospital
2041 Georgia Avenue, NW, Suite 5C02
Washington, DC 20060
202/865-1191

Howard Robinson, R.Ph.
Manager, Central Pharmacy
Greater Community Hospital
1310 Southern Avenue, SE
Washington, DC 20032

Dr. Kim Bullock
Providence Hospital
Emergency Room
1150 Varnum St., NE
Washington, DC 20017
202/269-7863
Prior Authorization Contacts
Donna Bovell, R.Ph.
202/442-5988
Medicaid Drug Rebate Contacts
Technical: Ken Boni
202/965-7400

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

DUR: Donna Bovell, R.Ph.
202/442-5988
New Brand Name Products Contact
Donna Bovell, R.Ph.
202/442-5988



National Pharmaceutical Council Pharmaceutical Benefits 2003
District of Columbia-4
Prescription Price Updating Contact
Glenn Sharp
Clinical Account Manager
First Health Service Corporation
4300 Cox Road
Glen Allen, VA 23060
T: 804/965-7447
F: 804/273-6961
E-mail: sharpgl@fhsc.com
Claims Submission Contact
Anita Martin
Manager-Plan Administration
First Health Service Corporation
4300 Cox Road
Glen Allen, VA 23060
T: 804/965-7425
F: 804/273-6961
E-mail: camartin@fhsc.com
Medicaid Managed Care Contact
Donna Bovell, R.Ph.
202/442-5988
Mail Order Pharmacy Program
None
Department of Human Services Officials
James A. Buford
Director
Department of Health
825 North Capitol Street, NE
Fourth Floor
Washington, DC 20002
T: 202/442-5999
F: 202/442-4788
E-mail: james.buford@dc.gov

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



Executive Officers of District Medical and
Pharmaceutical Societies
Medical Society of the District of Columbia
K. Edward Shanbacker
2175 K Street, NW, Suite 200
Washington, DC 20037
T: 202/466-1800
F: 202/452-1542
E-mail: shanbacker@msdc.org
Internet address: www.msdc.org

Washington D.C. Pharmacy Association
Herbert Kwash, R.Ph., President
908 Caddington Avenue
Silver Spring, MD 20901-1109
T: 301/539-3292
F: 301/539-7215
E-mail: mldpharm@aol.com

Osteopathic Association of the District of Columbia
K. Joseph Heaton, D.O., President
2517 North Glebe Road
Arlington, VA 22207
T: 703/522-8404
F: 703/522-2692

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

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










National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-1
FLORIDA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


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

TOTAL $1,487,935,645 1,159,155 $1,714,883,612 1,179,944

RECEIVING CASH ASSISTANCE TOTAL $893,222,135 552,401 $1,026,862,696 576,092
Aged $152,426,910 78,408 $170,850,446 79,748
Blind/Disabled $661,129,209 231,074 $750,274,442 235,685
Child $34,626,972 154,340 $46,013,540 170,004
Adult $45,039,044 88,579 $59,724,268 90,655

MEDICALLY NEEDY, TOTAL $62,753,603 24,089 $118,805,473 33,216
Aged $3,522 5 $31,545 21
Blind/Disabled $50,596,537 8,873 $120,427,359 16,970
Child $2,620,115 3,179 $2,360,440 2,997
Adult $9,533,429 12,032 $15,986,129 13,228

POVERTY RELATED, TOTAL $312,171,444 350,262 $336,992,042 397,152
Aged $116,037,164 63,790 $100,463,428 56,777
Blind/Disabled $143,969,419 43,100 $145,453,276 41,099
Child $48,125,864 217,570 $60,847,477 230,119
Adult $4,038,997 25,802 $10,227,861 69,157

TOTAL OTHER EXPENDITURE/RECIPIENTS $219,788,463 232,403 $232,223,401 173,484

*Total other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the Florida Agency for Health Care Administration.
Source: CMS, MSIS Report, FY 2001 and Florida Medicaid Statistical Information System, FY 2002.

National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-2
C. ADMINISTRATION
Agency for Health Care Administration. Claims
processing and payment by contract with fiscal agent.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; total parenteral nutrition; and urine ketone test
strips (children under age 21only). Prior
authorization required for: Cytogam; Proleukin;
Serostim; Albumin; Neutrexin; Provigil; Zoloft
50mg; Paxil 10mg; Panretin gel; Regranex (long term
care); Botox; and nutritional supplements and non-
preferred items. Products not covered: cosmetics;
fertility drugs; experimental drugs; and interdialytic
parenteral nutrition.
Over-the-Counter Product Coverage: Products
covered with restrictions: allergy, asthma, and sinus
products (select products); analgesics (Tylenol);
cough and cold preparations (select products);
digestive products (H2 anatgonists-Prilosec OTC
only); topical products (select products); and
feminine products. Products not covered: digestive
products (non-H2 antagonists) and smoking deterrent
products.
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, NSAIDs;
antibiotics; anticoagulants; anticonvulsants; anti-
depressants; antidiabetic agents; antihistamines;
antilipemic agents; antipsychotics; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; growth hormones;
hypotensive agents; misc. GI drugs; prescribed
smoking deterrents; sympathominetics (adrenergic);
and thyroid agents. Partial coverage for: anoretics;
prescribed cold medications. Prior authorization
required for: anabolic steroids; drugs not included on
the Medicaid preferred drug list; and brand name
prescriptions beyond the four brand cap unless
exempted. Therapeutic categories not covered:
anoretics.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through both the Prescription Drug
Program and physician payment when used in
physicians’ offices.
Vaccines: Vaccines reimbursable as part of the
Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Preferred Drug List (PDL) with
mandatory limits and exclusions. All covered drugs
are available through the preferred drug process.
General exclusions include excluding products based
on contracting issues, restrictions on use, prior
authorization and physician profiling. Specific limits
and exclusions include:
1. Vitamins and phosphate binders only for dialysis
patients.
2. Prostheses; appliances; devices; and personal
care items.
3. Non-legend drugs (except for prescribed insulin,
pancreatic enzymes, buffered and enteric coated
aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
4. Anorexants unless the drug is prescribed for an
indication other than obesity (i.e., narcolepsy,
hyperkinesis).
5. Drugs with questionable efficacy as rated by
FDA (DESI).
6. Investigational and experimental items.
7. Oral vitamins with exception of fluorinated
pediatric vitamins prescribed for pediatric
patients, vitamins for dialysis patients, prenatal
vitamins.
8. Nursing home floor stock drugs.
Prior Authorization: State currently has a formal
prior authorization procedure. Direct appeal to
AHCA and/or formal request for administrative
hearing required to appeal prior authorization
decisions.
Prescribing or Dispensing Limitations
Prescription Refill Limit:
1. Limited to four brand name RX’s per month with
exceptions for specific therapeutic groups.
Exemptions are: Anti-Retrovirals for HIV, Anti-
Psychotics, Depressants and Convulsants,
Family Planning, and Diabetic supplies and
insulin, unlimited generic prescriptions.
2. Drugs not included in the Preferred Drug list
(PDL) require PA. Anti-retrovirals and mental
health are exempted.
3. Maintenance medication should be dispensed
and billed for at least a one-month supply.

National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-3
4. Refills must be authorized by the prescriber
andcan be made for up to one year, except that
controlled substances can be refilled only in
accordance with Federal and State regulations.
5. Nutritional supplements are covered with prior
authorization when the patient is otherwise at
risk of hospitalization.
6. Other third parties, including Medicare, must be
billed first.
Drug Utilization Review
PRODUR system implemented in July 1993. State
currently has a DUR board with a quarterly review.
Retrospective Drug Utilization Review has been in
place since 1982. The State Medicaid agency and the
Florida Pharmacy Association, which performs the
reviews, share the administration of the program.
Heritage information systems contracts to provide
DUR and prescriber pattern profiling and clinical
review assistance.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.23, effective 3/11/86.
Nursing Home Fee $4.73, effective 7/1/01
Ingredient Reimbursement Basis: AWP-13.25 % or
WAC + 7%.
Prescription Charge Formula: Lower of:
1. FUL (Federal Upper Limits or State MAC) plus
dispensing fee.
2. EAC plus dispensing fee.
3. Usual and customary charge.
4. In-house unit dose diff. + 0.015/dose.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. MAC override by physicians requires
completed MedWatch form and prior authorization.
Incentive Fee: No incentive fee.
Patient Cost Sharing: No copayment
Cognitive Services: States pay for DUR and disease
management counseling for HIV, mental health,
diabetes, and hypertension services.


E. USE OF MANAGED CARE
Approximately 600,000 Medicaid recipients (30% of
all recipients) received pharmaceutical benefits
through managed care plans (inclusion of such
benefits is mandated under State law) in 2002.
Managed Care Organizations
Amerigroup Florida, Inc.
(FKA Physicians Health Care Plans, Inc.)
4200 W. Cypress Street, Suite 900
Tampa, Fl 33607-4173
800/600-4441

Buena Vista Medicaid
Vista Health Plan, Inc.
(FKA Beacon and Discovery)
300 South Park Road
Hollywood, FL 33021
866/441-5501

Healthease of Florida, Inc.
6800 N. Dale Mabry Hwy., Suite 168
Tampa, FL 33614-3988
800/278-0656

Humana Family
c/o Humana Medical Plan, Inc.
3501 SW 160
th
Street
Miramar, FL 33027
800/533-5001

Jackson Memorial Health Plan
1801 NW 9
th
Ave., Suite 700
Miami, FL 33136
800/721-2993

Neighborhood Health Partnership, Inc.
7600 Corporate Center Dr., 2
nd
Floor
Miami, Fl 33126-1216
800/354-0222

Personal Health Plan
324 Datura Street, Suite 401
West Palm Beach, FL 33401
561/659-1270

Preferred Medical Plan, Inc.
4950 SW 8
th
Street
Coral Gables, FL 33134
305/447-8373

StayWell Health Plan of Florida, Inc.
6800 N. Dale Mabry Hwy., Suite 168
Tampa, FL 33614
813/935-5227
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-4
United Healthcare of Florida, Inc.
13621 N.W. 12
th
Street
Sunrise, FL 33323
800/910-3224

Vista South Florida
(FKA Foundation Health Plan)
300 South Park Road
Hollywood, FL 33021
800/441-5501

F. STATE CONTACTS
State Drug Program Administrator
Jerry F. Wells
Pharmacy Program Manager
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Tallahassee, FL 32308
T: 850/487-4441
F: 850/922-0685
E-mail: wellsj@fdhc.state.fl.us
Internet address: www.fdhc.state.fl.us
Agency for Health Care Administration
Officials
Vacant
Secretary
Agency for Health Care Administration
2727 Mahan Drive, MS 1
Tallahassee, FL 32308
T: 850/922-3809
F: 850/488-0043
E-mail: AHCAcontact@fdhc.state.fl.us

Bob Sharpe
Deputy Secretary
Agency for Health Care Administration
2727 Mahan Drive, MS 8
Tallahassee, FL 32308
T: 850/488-3560
F: 850/488-2520
E-mail: AHCAcontact@fdhc.state.fl.us
Prior Authorization Contact
Bruce McCall, Pharm.D.
Pharmacy Program Manager
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Tallahassee, FL 32308
T: 850/487-4441
F: 850/922-0685
E-mail: mccallb@fdhc.state.fl.us
DUR Contact
Linda G. Barnes
Senior Pharmacist
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Tallahassee, FL 32308
T: 850/487-4441
F: 850/922-0685
E-mail: barnesl@fdhc.state.fl.us
Medicaid DUR Board
Arijit Aichbhaumik
Plant City, FL

Lois Adams, R.Ph.
Orlando, FL

Bryan Bognar, M.D.
Lutz, FL

Leanne Lai, Ph.D.
Ft. Lauderdale, FL

David Levine, DPM, D.O.
Ft. Lauderdale, FL

Earlene Lipowski, Ph.D., R.Ph.
Gainesville, FL

Larry Mattingly, D.O.
Orange Park, FL

Jeane McCarthy, M.D., Ph.D.
St. Petersburg, FL

Richard Roberts, Pharm.D.
Jacksonville, FL

Robert Taymans, R.Ph.
Safety Harbor, FL
Pharmaceutical and Therapeutics Committee
Robert Blackburn, D.O. (Chair)
Spring Hill, FL

James Brookins, M.D.
Tampa, FL

Leanne Lai, Ph.D.
Ft. Lauderdale, FL

Jeane McCarthy, M.D., Ph.D.
St. Petersburg, FL


National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-5
Lorianne McElheney, R.Ph.
Palmetto, FL

Douglas Nee, Pharm.D.
Fort Meyers, FL

Dorinda Segovia, Pharm.D.
Hialeah, FL

Jerry Jean Stambaugh, Pharm.D.
Lantana, FL

Craig A. Trigueiro, M.D.
Bradenton, FL
New Brand Name Products Contact
Jerry F. Wells
850/487-4441
Prescription Price Updating
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Jason Ottinger
Rebate Coordinator
Agency for Health Care Administration
2727 Mahan Drive, MS 38
Tallahassee, FL 32308
T: 850/922-7794
F: 850/922-0685
E-mail: ottingej@fdhc.state.fl.us
Claims Submission Contact
Kevin Whittington
Clinical Program Coordinator
ACS
9040 Roswell Road
Roswell, GA
850/201-1418
Medicaid Managed Care Contact
Christina Lopez
Manager, Health Systems Development
Agency for Health Care Administration
2727 Mahan Drive, MS 8
Tallahassee, FL 32308
850/487-2355
E-mail: lopezc@fdhc.state.fl.us
Mail Order Pharmacy Program
State has a mail order pharmacy benefit under its
diabetes demonstration waiver.
Disease Management Program/Initiative
Contact
Melanie Brown-Woofter
Program Administrator
Agency for Health Care Administration
2727 Mahan Drive, MS 50
Tallahassee,FL 32308
T: 850/487-2355
F: 850/410-1676
E-mail: brownme@fdhc.state.fl.us
Disease Management /Patient Education
AIDS:
Peter D. Reis
Director of Business Development
AIDS Healthcare Foundation
6255 West Sunset Blvd, 16
th
Fl.
Los Angeles, CA 90028
T: 213/860-5200
F: 213/860-5235
E-mail: pdreisjr@aol.com
Executive Officers of State Medical and
Pharmaceutical Societies
Florida Medical Association, Inc.
Sandra B. Mortham
CEO
113 East College Avenue
Tallahassee, FL 32301
T: 850/224-6496
F: 850/222-8030
E-mail: smortham@medone.org
Internet address: www.fmaonline.org

Florida Pharmacy Association
Michael Jackson, R.Ph.
Executive Director
610 North Adams Street
Tallahassee, FL 32301-1114
T: 850/222-2400
F: 850/561-6758
E-mail: fpa@pharmview.com
Internet address: www.pharmview.com







Florida Osteopathic Medical Association
National Pharmaceutical Council Pharmaceutical Benefits 2003
Florida-6
Stephen R. Winn
Executive Director
The Hull Building
2007 Apalachee Parkway
Tallahassee, FL 32301
T: 850/878-7364
F: 850/942-7538
E-mail: admin@foma.org
Internet address: www.foma.org

State Board of Pharmacy
John D. Taylor
Executive Director
4052 Bald Cypress Way, Bin C04
Tallahassee, FL 32399-3254
T: 850/487-1257
F: 850/413-6982
E-mail: mqa_pharmacy@doh.state.fl.us
Internet address: www.doh.state.fl.us/mga

Florida Hospital Association
Wayne N. Smith
President
306 East College Avenue
Tallahassee, FL 32301-1522
T: 850/222-9800
F: 850/561-6230
E-mail: wayne@fha.org
Internet address: www.fha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-1
GEORGIA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients
TOTAL $655,515,772 856,797 $873,703,133

RECEIVING CASH ASSISTANCE, TOTAL $422,797,389 368,161
Aged $49,961,732 31,775
Blind/Disabled $323,103,058 156,568
Child $22,633,229 112,507
Adults $27,099,370 67,311

MEDICALLY NEEDY, TOTAL $15,484,179 8,446
Aged $5,802,403 3,606
Blind/Disabled $9,681,639 4,837
Child $137 3
Adults $0 -

POVERTY RELATED, TOTAL $63,048,028 309,147
Aged $3,524,685 2,335
Blind/Disabled $3,102,251 2,047
Child $44,949,926 230,198
Adults $11,471,166 74,567

TOTAL OTHER EXPENDITURES/RECIPIENTS* $154,186,176 171,043

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-2
C. ADMINISTRATION
Department of Community Health, Division of
Medicaid
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin and disposable needles and syringe
combinations used for insulin. Products covered with
restrictions: blood glucose test strips (Roche products
only); urine ketone test strips (total parenteral
nutrition (21 and younger) and interdialytic
parenteral nutrition (21 and younger). Products
requiring prior authorization: Marinol; Betaseron,
Avonex, Rebif, Leukine, Crinone 8%, Forteo, growth
hormone, immune globulin, Fuzeon, Penlac, Epoetin;
interferons; lactulose; Neupogen; top.vit.A
derivatives; Toradol; Regranex; Viagra; Cialis,
Levitra, Oral Diflucan 50mg, 100mg & 200mg ,
Panretin Gel,, Vfend, Zetia, topical testosterone,
Insulin Pen Delivery Systems and Cartridges for
adults, PPIs; Oral Lamisil; ESRD drugs; Oral
Sporanox; Botox; Oxycontin; brand-names and
multi-source. Products not covered: cosmetics;
fertility drugs; experimental drugs; prescription
vitamins and minerals (except for prenatal and
fluorides not in combination with other vitamins);
barbituates (except Seconal & Mebaral ); DESI
drugs; and Miralax;( covered for 21 and younger)
and smoking cessation products.
Over-the-Counter Product Coverage: Products
covered: analgesics (Ibuprofen suspension) covered
with restriction for ages less than 21; cough and cold
preparations; topical products; PIN-X; NIX; Lice-B-
Gone OTC iron and multivitamins; klout; and
meclizine. Products not covered: allergy, asthma,
and sinus products; digestive products; feminine
products; and smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antihistamines; antilipemic agents; antipsychotics;
cardiac drugs; chemotherapy agents; prescribed cold
medications (partial coverage); contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; sympathominetics
(andrenergic); and thyroid agents. Prior
authorization required for: anabolic steroids;
analgesics, antipyretics, NSAIDS for single source;
anxiolytics, sedatives, and hypnotics; growth
hormones; and immunoglobulins. Therapeutic
categories not covered: anoretics and prescribed
smoking deterrents.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT service and as part of the Vaccines for
Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Closed formulary with restrictions on use
(quantity level limits), PA, preferred products, and
physician profiling.
Prior Authorization: State currently has a formal
prior authorization procedure
Prescribing or Dispensing Limitations:
Prescription Refill Limit: Maximum of five refills for
adults, six for children. May be overridden at POS by
the pharmacist for certain maintenance drugs.
Monthly Quantity Limit: Physicians are encouraged
to prescribe a 31-day supply. Some exceptions exist.
Monthly Dollar Limit: $2,999.99 requires an
override; >$9,999.99 requires paper claim and a copy
of the prescription.
Drug Utilization Review
On-line PRODUR system implemented in October
2000. State has a 20 member DUR Board (4
meetings per year).
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.63, effective 7/1/98
Ingredient Reimbursement Basis: EAC = AWP -
10% or MFN price.
Prescription Charge Formula: Lower of average
wholesale price (AWP) minus 10% plus dispensing
fee, MAC plus fee, or usual and customary.
Maximum Allowable Cost: State imposes a
combination of Federal Upper Limits as well as
State- Specific Limits on generic drugs. Override
requires Prior Approval. Approximately 800 drugs
on the State-specific MAC list.
Incentive Fee: $0.50 for generic drug.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-3
Patient Cost Sharing: $0.50 per prescription for
generics or preferred drugs. $0.50 - $3.00 for non-
preferred and brand drugs, dependent on the cost of
the drug.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Does not use MCOs to deliver services to Medicaid
recipients.
F. STATE CONTACTS
State Drug Program Administrator
Jerry Dubberly, RPh
Director, Pharmacy Services
Department of Community Health-Medicaid Division
2 Peachtree Street, NW, 37
th
Floor
Atlanta, GA 30303-3159
T: 404/656-4044
F: 404/656-8366
E-mail: jdubberly@dch.state.ga.us
Internet address: www.dch.state.ga.us
Department of Community Health
Tim Burgess, Commissioner
Department of Community Health
2 Peachtree Street, NW, Suite 4043
Atlanta, GA 30303-3159
T: 404/656-4507
F: 404/651-6880
E-mail: tburgess@dch.state.ga.us

Mark Trail, Medicaid Director
Department of Community Health
2 Peachtree Street, NW, Suite 4043
Atlanta, GA 30303-3159
T: 404/656-4496
F: 404/651-6880
E-mail: mtrail@dma.state.ga.us
Prior Authorization Contact
Patricia Zeigler Jeter, M.P.A., R.Ph.
Pharmacist
Pharmacy Services Unit, Program Policy Section
Division of Medical Assistance
2 Peachtree Street, NW 37
th
Floor
Atlanta, GA 30303
T: 404/657-9181
F: 404/656-8366
E-mail: pjeter@dch.state.ga.us
DUR Contact
Pat Zeigler-Jeter, M.P.A., R.Ph.
404-657-9181
Medicaid DUR Board
John Stephen Antalis, M.D.
Dalton Family Practice, P.C.
1114 Professional Blvd.
Dalton, GA 30720

Frank W. Brown, M.D., M.B.A.
Wesley Woods Center
1841 Clifton Road, NE
Atlanta, GA 30329

Catherine E. Burley, M.D.
7365 Old National Hwy, Suite A
Riverdale, GA 30296

J. Russell May, Pharm.D. , Chairperson
Director of Pharmacy Services
Department of Pharmacy
Medical College of Georgia
Hospital and Clinics
1120 15th Street
Augusta, GA 30912-5600

Harry Strothers III, M.D., M.M.M.
Professor, Family Medicine
Morehouse School of Medicine
Department of Family Medicine
505 Fairburn Rd. S.W.
Atlanta, GA 30331

L. Dianne Bradford, Ph.D.
Morehouse School of Medicine
Departments of Psychiatry and Medicine
720 Westview Drive, SW
Atlanta, GA 30310-1495

Daniel Gallina, M.D.
Emory University School of Medicine
Grady Health System
Diabetes Unit
69 Butler Street
Atlanta, GA 30303-3033

Phyllis A. Johnson, R.N., Ph.D.
1010 Forest Overlook Trail, SW
Atlanta, GA 30331

Robyn Anderson Lorys, Pharm.D.
2430 Laurelwood Road
Atlanta, GA 30360


National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-4
Calvin W. McLarin, M.D.
Metropolitan Atlanta Cardiology Consultants
999 Peachtree Street, NE
Suite 850
Atlanta, GA 30309

Mathew Perri III, R.Ph., Ph.D.
Department of Clinical and Administrative Sciences
University of Georgia College of Pharmacy
DW Brooks Drive, Room 250G
Athens, GA 30602

Cynthia O’Steen-Piela, R.Ph.
District Manager
Wal-Mart Pharmacy
1350 Arborwood Ridge
Bishop, GA 30621

Kimberly Rogan, R.Ph.
District Manager, South Region
Ekcerd Drugs
3549 Chamblee Tucker Road
Tucker, GA 30341

Joseph Rosenfeld, M.D.
Snapfinger Woods Pediatric
5008 Snapfinger Woods Drive
Decatur, GA 30035

William Dennis Taylor, M.D.
Green Acres Nursing Home
313 Allen Memorial Drive
Milledgeville, GA 31061

Cynthia Wainscott
2274 Camden Drive
Marietta, GA 30064

Andrew D. Weinberg, M.D., FACP
1647 Brookhaven Close, NE
Atlanta, GA 30319
New Brand Name Products Contact
Etta L. Hawkins, R. Ph.
404/656-4044
Prescription Price Updating
Andrew Shim, Pharm.D.
Clinical Program Manager
Express Scripts, Inc.
6625 W. 78
th
Street, BL-0420
Bloomington, MN 55439
T: 952/837-5326
F: 952/837-7184
E-mail: andrew.shim@express-scripts.com

Medicaid Drug Rebate Contact
Pat Zeigler-Jeter, M.P.A., R.Ph.
404-657-9181
Claims Submission Contact
Scott Percival
Account Manager
Express Scripts, Inc.
6625 W. 78
th
St., BL-0420
Bloomington, MN 55439
T: 952/837-7744
F: 952/837-7741
E-mail: scott.percival@express-scripts.com
Medicaid Managed Care Contact
Kathy Driggers
Director, Managed Care
Department of Community Health
2 Peachtree Street, NW
Atlanta, GA 30303
T: 404/657-7793
F: 404/656-8366
E-mail: kdriggers@dch.state.ga.us
Disease Management Program/Initiative
Contact
Charmaine Heard, M.D.
Medical Director
Department of Community Health
2 Peachtree Street, NW, 37
th
Floor
Atlanta, GA 30303
T: 404/463-7638
F: 404/656-8366
E-mail: cheard@dch.state.ga.us
Mail Order Pharmacy Benefits
None
Medical Assistance Advisory Committee
Representatives from each of the following groups:
Medical Association of Georgia
Georgia Pharmaceutical Association
Atlanta Medical Association
Georgia Health Care Association
Georgia Hospital Association
Georgia Dental Association
Georgia Osteopathic Medical Association
National Pharmaceutical Association
National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-5
Pharmacy Advisory Committee
Ifeanyi J. Anikpe, Pharm.D.
Washington Road Pharmacy
3518 Washington Road
East Point, GA 30344

Anthony Compton, Pharm.D.
Pharmacy Manager
Saint Joseph’s Hospital of Atlanta
2783 Harvest Drive
Conyers, GA 30013

Amanda R. Gaddy, R.Ph.
Kroger
131 Windsong Drive
Stockbridge, GA 30281

Ted M. Hunt, R.Ph.
General Manger
PharMerica
1100 Wilson Way, Suite 500
Smyrna, GA 30082

Leslie M. Litton
Executive Director
Kaiser Permanente
9 Piedmont Center
3495 Piedmont Rd. NE
Atlanta, GA 30082

Scott Moody, Pharm.D.
Regional Manager, Pro
Glaxo Wellcome, Inc.
9306 Fall Court West
Brentwood, TN 37027

Malcolm “Mickey” Tatum, R.Ph.
Dinglewood Pharmacy
1819 Wynnton Road
Columbus, GA 31902

Homer L. Whelchel, R.Ph.
President, CEO
Berrien Health Center
P.O. Box 866
Nashville, GA 31639-0866
Julie M. Wickman, Pharm.D.
Mercer University
593 Cantebury Lane
Winder, GA 30680

Ellen Whipple Guthrie, Pharm.D.
Pharmacy Manager
The Shepard Center
2020 Peachtree Rd., NW
Atlanta, GA 30309

Timara Faulkner Rembert, Pharm.D.
87 Buckeye Loop
Midland, GA 31820
Executive Officers of State Medical and
Pharmaceutical Societies
Medical Association of Georgia
David Cook, Executive Director
1330 W. Peachtree Street, NW, Suite 500
Atlant, GA 30309
T: 404/876-7535
F: 404/881-5021
E-mail: dcook@mag.org
Internet address: www.mag.org

Georgia Pharmacy Association
Oren “Buddy” Harden, Jr.
Chief Executive Officer
50 Lenox Pointe, NE
Atlanta, GA 30324-3170
T: 404/231-5074
F: 404/237-8435
E-mail: bharden@gpha.org
Internet address: www.gpha.org

Osteopathic Medical Association
Sheila J. Smith, D.O.
President
2037 Grayson Highway, Suite 200
Grayson, GA 30017
T: 770/493-9278
F: 770/908-3210
E-mail: exdir@goma.org
Internet address: www.goma.org

State Board of Pharmacy
Sandy Bond
Executive Director
237 Coliseum Drive
Macon, GA 31217-3858
T: 478/207-1686
F: 404/656-0513
E-mail: sosweb@sos.state.ga.us
Internet address: www.sos.state.ga.us/plb/pharmacy/

Georgia State Medical Association
Katherine Daniels
Executive Director
Morehouse School of Medicine
720 Westview Drive, SW
Atlanta, GA 30310-1495
T: 404/752-1564
F: 404/752-1024
Internet address: www.gastatemedicalassoc.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Georgia-6
Georgia Hospital Association
Joseph A. Parker
President
1675 Terrell Mill Road
Marietta, GA 30067
T: 770/249-4522
F: 770/955-5801
E-mail: jparker@gha.org
Internet address: www.gha.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Hawaii-1
HAWAII
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


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

TOTAL $74,869,859 $88,256,904

RECEIVING CASH ASSISTANCE TOTAL
Aged
Blind/Disabled
Child
Adult

MEDICALLY NEEDY, TOTAL
Aged
Blind/Disabled
Child
Adult

POVERTY RELATED, TOTAL
Aged
Blind/Disabled
Child
Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS*

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

Source: CMS, CMS-64 Report, FY 2001 and FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Hawaii-2
C. ADMINISTRATION
Hawaii Department of Human Services through its
Med-Quest Division and four county branch offices.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered as DME:
disposable needles and syringe combinations used for
insulin; blood glucose test strips; and urine ketone
test strips. Products requiring prior authorization:
total parenteral nutrition (for home infusion);
interdialytic parenteral nutrition (for home infusion);
Clorazil; Procardia XL; Norvasc; brand products on
FUL price list; Betaseron; and Oxycontin. Products
not covered: cosmetics; fertility drugs; and
experimental drugs.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics; and digestive products (non-H2
antagonists). Products covered with restrictions;
cough and cold preparations (select products, others
require prior authorization); digestive products (H2
antagonists-cimatidine and ranitidine, others require
prior authorization); topical products (for non-
cosmetic purposes only); and smoking deterrent
products (Xyban only, others require prior
authorization).
Therapeutic Category Coverage: Products covered:
analgesics, antipyretics, and NSAIDs; antibiotics;
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antilipemic agents; anxiolytics;
sedatives; and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; estrogens;
hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents
Prior authorization required for: anabolic steroids;
anorectics; non-sedating antihistamine drugs; atypical
anti-psychotics; prescribed cold medications; proton
pump inhibitors; growth hormones; and prescribed
smoking deterrents.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through both the Prescription Drug
Program and physician payment when used in
physicians’ offices.
Vaccines: Vaccines reimbursable as part of EPSDT
service, CHIP, and the Vaccines for Children
Program.
Unit Dose: Unit dose packaging reimbursable
Formulary/Prior Authorization
Formulary: Open formulary managed through prior
authorization. Preferred drug list to be implemented
in 2004.
Prior Authorization: State currently has a formal
prior authorization procedure. A fair hearing may be
requested for appeal of prior authorization decisions.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: Physicians are encouraged
to prescribe a 30-day supply or 100 units. State has
implemented maximum doses for certain drugs,
including Epogen, Liptor, Zofran, and Zomig.
Drug Utilization Review
PRODUR system implemented in September 1997.
State currently has a DUR board with a quarterly
review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.67, effective May 9, 1990.
Ingredient Reimbursement Basis: EAC = AWP-
10.5%.
Prescription Charge Formula: Payment for
prescription and OTC drugs listed in the formulary is
limited to the State or Federally established MAC
price, or Estimated Acquisition Cost (EAC) or AWP-
10.5% when equal to average selling price plus
dispensing fee, or billed amount, whichever is
lowest.
Maximum Allowable Cost: State imposed Federal
Upper Limits and State-specific limits on generic
drugs. Override requires prior authorization.
Incentive Fee: None.
Patient Cost Sharing: No copayment.
Cognitive Services: Does not pay for cognitive
services.



National Pharmaceutical Council Pharmaceutical Benefits 2003
Hawaii-3
E. USE OF MANAGED CARE
Approximately 135,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
most of their pharmaceutical benefits through
managed care plans. State has specific guidelines for
the pharmacy benefit for Medicaid recipients enrolled
in managed care plans. Drugs prescribed by dentists
are “carved out” of managed care and provided
through the State.
Managed Care Organizations
AlohaCare, Inc.
Mr. John McComas
1357 Kapiolani Blvd., Suite 1250
Honolulu, HI 96814
808/973-1650

Hawaii Medical Service Association (HMSA)
QUEST Administration
818 Keeaumoku Street
Honolulu, HI 96808
808/948-5250

Kaiser Foundation Health Plan, Inc.
Ms. Virginia Vierra
1441 Kapiolani Blvd, Suite 1600
Honolulu, HI 96814
808/944-0261

Behavioral Health Services
Andreas Carvalho
Community Care Services (CCS)
810 N. Vineyard Blvd.
Honolulu, HI 96817
808/948-5250
F. STATE CONTACTS
Medicaid Drug Program Administrator
Lynn S. Donovan, R.Ph.
Pharmacy Consultant
Department of Human Services
Med-Quest Division
601 Kanokila Boulevard, Suite 506B
Kapolei, HI 96707
T: 808/692-8116
F: 808/692-8131
Internet address: www.med-quest.us
Prior Authorization Contact
Lynn S. Donovan, R.Ph.
808/692-8116

DUR Contact
Kathleen Kang-Kaulupali
Pharmacy Consultant
Department of Human Services
Med-Quest Division
601 Kanokila Blvd., Room 506-B
Kapolei, HI 96707
T: 808/692-8065
F: 808/692-8131
Medicaid DUR Board
Myron Shirasu, M.D. (Internal Medicine)
321 North Kuakini Street, Suite 200
Honolulu, HI 96817
808/523-8611
Gregory E.M. Yuen, M.D. (Psychiatry)
1188 Bishop Street, Suite 806
Honolulu, HI 96813
808/599-5050
Linda Tom MD (Geriatric Medicine), Vice-Chair
347 N. Kuakini Street, HPM-9
Honolulu, HI 96817
808/523-8461
James Lumeng, M.D. (Medicine/Pathology)
850 West Hind Drive, #114
Honolulu, HI 96821
808/377-5485
Brian Matsuura (Medical Services Rep.)
DHS/MQD/MSB
P.O. Box 700190
Kapolei, HI 96709-0190
808/692-8065
Joy Higa, R.Ph. (Long Term Care), Chair
DHS/MQD/MSB
P.O. Box 700190
Kapolei, HI 96709-0190
808/692-8065
Jerry Smead, R.Ph. (Ambulatory Care)
Kaiser Parmanente Hawaii Region
201 Hamakua Drive, Building B
Kailua, HI 96734
808/432-3454
Kerry Kitsu, R.Ph. (Community, chain)
DHS/MQD/MSB
P.O. Box 700190
Kapolei, HI 96709-0190
808/692-8065
Carl Mudrick, R.Ph. (Community, independent)
750 Palani Avenue
Honolulu, HI 96816
808/739-1188
National Pharmaceutical Council Pharmaceutical Benefits 2003
Hawaii-4
New Brand Name Products Contact
Lynn S. Donovan, R.Ph.
808/692-8116
Prescription Price Updating
First Data Bank
111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
Medicaid Drug Rebate Contacts
Policy: Lynn S. Donovan, R.Ph.
808/692-8116

Audits: Martha Kessinich
Drug Rebate Manager
ACS State Healthcare
365 Northridge Road, Suite 400
Atlanta, GA 30350
800/358-2381
Claims Submission Contact
Heather Bodiford
Account Manager
ACS State Healthcare
365 Northridge Road, Suite 400
Attn: Hawaii Medicaid
T: 800/358-2381
F: 770/730-5198
E-mail: heather.bodiford@acs-inc.com
Disease Management/Patient Education
Contact
Lynn S. Donovan, R.Ph.
808/692-8116
Mail Order Pharmacy Benefit
None
Department of Human Services Officials
Lillian Koller
Director
Department of Human Services
1390 Miller Street, Room 209
Honolulu, HI 96813
T: 808/586-4997
F: 808/586-4890
E-mail: lillian.b.koller@hawaii.gov




Aileen Hiramatsu
Administrator, Med-Quest Division
Department of Human Services
P.O. Box 399
Kapolei, HI 96809-0339
T: 808/692-8050
F: 808/586-4890
E-mail: 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 200
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

State Board of Pharmacy
Lee Ann Teshima
Executive Officer
P.O. Box 3469
Honolulu, HI 96801
T: 808/586-2694
F: 808/586-2689
E-mail: pharmacy@dcca.state.hi.us
Internet address: www.state.hi.us/dcca/pvl

Healthcare Association of Hawaii
Richard E. Meiers
President/CEO
932 Ward Avenue, Suite 430
Honolulu, HI 96814-2126
T: 808/521-8961
F: 808/599-2879
E-mail: postmaster@hah.org
Internet address: www.hah.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Idaho-1
IDAHO
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $105,473,425 112,357 $119,177,013

RECEIVING CASH ASSISTANCE, TOTAL $64,871,126 22,489
Aged $4,947,969 2,016
Blind/Disabled $59,411,640 19,271
Child $280,234 963
Adult $231,283 239

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $10,152,018 55,312
Aged $139,939 93
Blind/Disabled $160,823 132
Child $8,806,102 48,702
Adult $1,045,154 6,385

TOTAL OTHER EXPENDITURES/RECIPIENTS* $30,450,281 34,556

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Idaho-2
C. ADMINISTRATION
Division of Medicaid
Idaho Department of Health & Welfare
By the State Department of Health and Welfare
through seven regional offices, each serves five or
more of the State’s 44 counties.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations for insulin and total parenteral
nutrition. Products not covered: cosmetics; fertility
drugs; experimental drugs; and interdialytic
parenteral nutrition. Note: blood glucose test strips
and urine ketone test strips are DME items and do
not fall under the pharmacy program.
OTC Coverage: Products covered: permethrin; oral
iron salts; insulin and insulin syringes. Products not
covered: allergy, asthma, and sinus; analgesics,
cough and cold preparations; digestive products;
feminine products; topical products; and smoking
deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antilipemic agents; anti-psychotics; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive
agents;sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: anabolic
steroids; analgesics; antipyretics, and NSAIDs;
antihistamines; prescribed cold medications; growth
hormones misc. GI drugs; amphetamines; Provigil;
Aldara; Synagis; Regranex; Retinoids; Androgel;
Prolastin; Klonopin Wafer; Zetia; Xanax XR; and
brand names of FUL and SMAC drugs. Therapeutic
categories not covered: anorectics and prescribed
smoking deterrents.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used
in physicians offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT service, The Children’s Health Insurance
Program, the Vaccines for Children Program, and the
State Vaccine Program.
Unit Dose: Unit dose packaging reimbursable when
used in unit dose systems.
Formulary Authorization
Formulary: Open formulary. Pharmacy program is
managed through an enhanced prior authorization
program, therapeutic substitution, preferred products,
physician profiling, and generic substitution for
multi-source products.
Prior Authorization: State currently has a formal
prior authorization procedure and a prior
authorization committee. Informal reconsideration of
denied prior authorization requests followed by a
formal appeal process Written “notice of appeal”
required for fair hearing.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: Prescription drugs are
limited to a 34-day supply. Limits on the number of
refills per script and early refills. The following drugs
are limited to a 100-day supply: Digoxin, thyroids,
prenatal vitamins, nitroglycerin, fluoride, fluoride
and vitamin combinations, non-legend oral iron salts
and 3 cycles of birth control.
Drug Utilization Review
Contracted DUR through Idaho State University.
PRODUR system implemented January 1998. State
currently has a DUR board with a quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.94 ($5.54 for unit dose),
effective March 1999.

Ingredient Reimbursement Basis: EAC = AWP-12%
as determined by First DataBank Data File Service or
manufacturer direct price for selected manufacturers.

Prescription Charge Formula: Lower of FUL,
SMAC or EAC plus a dispensing fee or provider’s
usual and customary price to the general public.

Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires failure of two
generic formulations and submission of a MedWatch
form.

Incentive Fee: None.

Patient Cost Sharing: No copayment.

National Pharmaceutical Council Pharmaceutical Benefits 2003
Idaho-3
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Does not use MCOs to deliver services to Medicaid
recipients. Some Medicaid recipients are enrolled in
primary care case management and receive their
benefits from the state.
F. STATE CONTACTS
Medicaid Drug Program Administrator
Shawna L. Kittridge, R.Ph., M.H.S.
Pharmacy Services Supervisor
Department of Health and Welfare
Division of Medicaid
3232 Elder
Boise, ID 83705
T: 208/364-1956
F: 208/364-1864
E-mail: kttrids@idhw.state.id.us
Internet address: www.idahohealth.org
Prior Authorization Contact
Shawna L. Kittridge, R.Ph., M.H.S.
208/364-1956
DUR Contact
Tamara Eide, Pharm.D., BCPS, FASHP
Pharmacy Service Specialist
Department of Health and Welfare
Division of Medicaid
3232 Elder
Boise, ID 83705
T: 208/364-1821
F: 208/364-1864
E-mail: eidet@idhw.state.id.us
Medicaid DUR Board
Board Members:
Gary Wilburn, R.Ph.
Don Smith, R.Ph.
Kent Jensen, R.Ph.
Joseph Steiner, Pharm. D.
Nancy Mann, M.D.
E. Gregory Thompson, M.D.
Robert Ting, M.D.

Staff:
Tamara Eide, Pharm. D., Dept. Contact
Vaughn Culbertson, Pharm.D. Project Dir.
New Brand Name Products Contact
Shawna Kittridge, R.Ph., M.H.S.
208/364-1956
Prescription Price Updating
Katie Ayad
Technical Records II
Department of Health and Welfare
Division of Medicaid
3232 Elder
Boise, ID 83705
T: 208/364-1970
F: 208/364-1864
E-mail: ayadk@idhw.state.id.us
Medicaid Drug Rebate Contact
Mary Wheatly
Pharmacy Services Specialist
Department of Health and Welfare
Division of Medicaid
3232 Elder
Boise, ID 83705
T: 208/364-1832
F: 208/364-1864
E-mail: wheatlem@idhw.state.id.us
Claims Submission Contact
EDS
P.O. Box 23
Boise, ID 83707
T: 208/395-2000
F: 208/395-2030
Medicaid Managed Care Contact
Shawna Kittridge, R.Ph., M.H.S.
208/364-1956
Mail Order Pharmacy Program
State currently has a mail order pharmacy program.
Pharmacy must be a registered Idaho Medicaid
provider.
Health and Welfare Department Officials
Karl Kurtz, Director
Dept. of Health & Welfare
450 West State Street
PO Box 83720
Boise, ID 83720-0036
T: 208/334-5500
F: 208/334-6558
E-mail: dhwinfo@idhw.state.id.us

National Pharmaceutical Council Pharmaceutical Benefits 2003
Idaho-4
Joe Brunson, Administrator
Department of Health and Welfare
Division of Medicaid
Americana Building
P.O. Box 83720
Boise, ID 83720-0036
T: 208/364-5747
F: 208/334-1811
E-mail: allynkp@mmis.state.id.us
Title XIX Medical Care Advisory Committee
JoAn Condie
Idaho State Pharmacy Association

Greg Dickerson
Mental Health Providers Association

Bill Foxcroft
Idaho Primary Care Association

Bonnie Haines
Idaho Hospital Association

Linda Johnson
(Individual)

Deedra Kucera
(Aged Community)

Mark Leeper
(Disabled Community)

Marla Lewis
Kootenai County Welfare Department

Randy Robinson
Legal Aid-Lewiston

Robert VandeMerwe
Idaho HealthCare Association

Bob Seehusen
Idaho Medical Association

Mitzi Smith
St. Luke’s Hospital

Gene Wiggers (Chairperson)
AARP








Executive Officers of State Medical and
Pharmaceutical Societies
Idaho Medical Association
Robert Seehusen, CEO
P.O. Box 2668
305 West Jefferson
Boise, ID 83701
T: 208/344-7888
F: 208/344-7903
E-mail: mail@idmed.org
Internet address: www.idmed.org

Idaho State Pharmacy Association
JoAn Condie
Executive Director
P.O. Box 140117
Boise, ID 83714-0117
T: 208/424-1107
F: 208/376-3131
E-mail: condie@velocitus.net
Internet address: www.idahopharmacy.org

State Board of Pharmacy
Richard K. Markuson
Executive Director
P.O. Box 83720
Boise, ID 83720-0067
T: 208/334-2356
F: 208/334-3536
E-mail: rmarkuson@bop.state.id.us
Internet address: www.state.id.us.bop

Idaho Hospital Association
Steven A. Millard
President
615 North Seventh Street
P.O. Box 1278
Boise, ID 83701
T: 208/338-5100
F: 208/338-7800
E-mail: info@teamiha.org
Internet address: www.teamiha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-1
ILLINOIS
1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult

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

B. EXPENDITURES FOR DRUGS
2001 2002**

Expenditures Recipients Expenditures Recipients

TOTAL $934,241,252 1,068,535 $1,293,435,797

RECEIVING CASH ASSISTANCE TOTAL $330,543,572 241,552
Aged $39,704,574 19,211
Blind/Disabled $270,163,357 120,773
Child $9,670,272 71,473
Adult $11,005,369 30,095

MEDICALLY NEEDY, TOTAL $458,879,265 294,472
Aged $128,710,263 61,247
Blind/Disabled $271,010,968 93,079
Child $620,940 784
Adult $58,537,094 139,362

POVERTY RELATED, TOTAL $84,314,675 456,821
Aged $3,621,119 2,432
Blind/Disabled $9,302,549 3,668
Child $64,771,300 404,568
Adult $6,619,707 46,153

OTHER EXPENDITURES/RECIPIENTS* $60,503,740 75,690

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

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-2
C. ADMINISTRATION
Illinois Department of Public Aid, Division of
Medical Assistance.

D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Prior
authorization required: syringe combinations used for
insulin. Products covered with restrictions: total
parenteral nutrition and interdialytic parenteral
nutrition. Products not covered: cosmetics; DESI-
ineffectives; fertility drugs; and experimental drugs.
OTC Coverage: Products covered: analgesics and
smoking deterrent products. Products requiring prior
authorization: allergy, asthma, and sinus products;
digestive products (non-H2 antagonist); and topical
products. Products not covered: cough and cold
preparations; digestive products (H2 antagonists) and
feminine products.
Therapeutic Category Coverage: Categories
covered: analgesics, antipyretics, and NSAIDs;
antibiotics; anticogulants; anticonvulsants; anti-
depressants; antidiabetic agents; antilipemic agents;
anti-psychotics; cardiac drugs; chemotherapy agents;
contraceptives; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; sympathominetics
(adrenergic); and thyroid agents. Partial coverage:
antihistamines; anxiolytics, sedatives, and hypnotics;
and estrogens. Prior authorization required: ENT
anti-inflammatory agents; growth hormones; and Cox
II’s. Products not covered: anoretics and prescribed
cold medications.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities and through both the Prescription Drug
Program and physician payment when used in
physician offices.
Vaccines: Vaccines are reimbursable as part of the
Vaccines for Children Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.
Prior Authorization: State currently has a formal
prior authorization procedure and a Committee on
Drugs and Therapeutics. Recipient must file an
appeal with their local office in order to appeal prior
authorization decisions. To appeal the coverage of an
excluded product, the recipient can request the
opportunity to appear before the Committee on Drugs
and Therapeutics.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Maximum of eleven refills.
Monthly Quantity Limit: As medically appropriate.
Also edit for maximum daily quantities.
Drug Utilization Review
PRODUR system implemented in January 1993.
State currently has a DUR board which meets as
needed.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.00 for branded drugs; $5.10 for
generics. Effective 7/1/00.
Ingredient Reimbursement Basis: EAC = B: AWP-
11%; G: AWP-20%.
Prescription Charge Formula: Lowest of 1) usual
and customary, 2) Department's MAC plus fee.
Professional fee: $3.58 up to EAC of $35.80; above
EAC of $35.80, fee is 10% of EAC.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Generics priced at the lower of the
NDC, FUL, state MAC, or AWP-20%. Override
requires prior authorization.
Incentive Fee: None.
Patient Cost Sharing: $1.00 for both branded drugs
and generics.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 140,000 Medicaid recipients were
voluntarily enrolled in MCOs in 2003. Recipients
receive pharmaceutical benefits through managed
care plans.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-3
Managed Care Organizations
Amerigroup Illinois
211 Wacker Drive
Suite 1350
Chicago, IL 60606-3101

United Health Care of IL
233 N. Michigan Ave. 8
th
Fl-12
th
Fl.
Chicago, IL 60601

Harmony Health Plan of Illinois
125 South Wacker Drive
Suite 2600
Chicago, IL 60606-4402

Harmony Health Plan
23 Public Square, Suite 340
Belleville, IL 62220

Humana Health Plan
30 South Wacker Drive
Suite 3100
Chicago, IL 60606

Family Health Network
910 West Van Buren
6th Floor
Chicago, IL 60607-3523

F. STATE CONTACTS
State Drug Program Administrator
Marvin L. Hazelwood, Manager
Pharmacy and Ancillary Services Programs
Illinois Department of Public Aid
Division of Medical Assistance
1001 N. Walnut St.
Springfield, IL 62702
T: 217/524-5565
F: 217/524-7194
E-mail: 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
New Brand Name Products Contact
Marvin L. Hazelwood
217/524-5565
Prescription Price Updating
First DataBank
111 Bayhill Dr.
San Bruno, CA 94066
650/588-5454
Medicaid Drug Rebate Contact
Brandley Wallner, Manager
Illinois Department of Public Aid
2200 Churchill Road
Springfield, IL 62704
217/785-6114
E-mail: cpa_webmaster@state.il.us
Medicaid Managed Care Contact
Bureau of Managed Care
Illinois Department of Public Aid
201 S. Grand Avenue East
Springfield, IL 62763
T: 217/524-7478
F: 217/524-7535
E-mail: dpa_webmaster@state.il.us
Mail Order Pharmacy Benefit
None
Elderly Expanded Drug Coverage Program
Susan Coombe, Supervisor, Circuit Breaker Program
Illinois Department of Revenue
101 W. Jefferson, Level 3 - 250
Springfield, IL 62794
217/785-2097
Physician-Administered Drug Program
Contact
Cheryl Bechner
217/782-5565
Illinois Medicaid Agency Officials
Barry Maram, Director
Illinois Department of Public Aid
201 South Grand Avenue, East, Third Floor
Springfield, IL 62794
T: 217/782-1200
F: 217/524-7120
E-mail: directordpa@mail.idpa.state.il.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-4
A. George Hovanec, Administrator
Division of Medicaid Programs
Illinois Department of Public Aid
201 South Grand Avenue, East, Third Floor
Springfield, IL 62763-0001
T: 217/782-1200
F: 217/524-7979
Title XIX Medical Care Advisory Committees
State Medical Advisory Committee
Arthur Traugott, M.D.
32207 Weisiger Way
Urbana, IL 61801

Committee on Drugs and Therapeutics
Marshall Blankenship, M.D., Chairman
1555 Astor Avenue
Chicago, IL 60610
708/636-3757

Nicholas C. Bellios, M.D.
2504 Washington
Waukegan, IL 60085
708/249-3660

Armand Littman, M.D.
Medical Services
Hines VA Hospital
Hines, IL 60141
708/216-2006

Vincent A. Costanzo, Jr., M.D.
7501 South Stony Island Avenue
Chicago, IL 60649
312/995-1075

Theodore M. Kanellakes, M.D.
229 N. Hammes Avenue
Joliet, IL 60435
815/744-2300

Patrick R. Staunton, M.D.
156 N. Oak Park Avenue
Oak Park, IL 60301
708/696-5887

Board of Trustees
Phillip D. Boren, M.D.
Doctor's Clinic
S. Plum Street
Carmi, IL 62821
618/382-4193





Joan E. Cummings, M.D.
Extended Care
181 Hines VA Hospital
Building 1, Room C-124D
Hines, IL 60141
708/343-7200 ext. 5057

David B. Littman, M.D.
1030 Old Elm Road
Highland Park, IL 60035
708/433-3900

Richard P. Snodgrass, M.D.
550 30th Avenue
Moline, IL 61265
309/764-1910

IDPA Representative
Marvin Hazelwood
Illinois Department of Public Aid
1001 N. Walnut Street
Springfield, IL 62702
217/524-7112

Illinois State Medical Society
Kenneth E. Ryan
Director, Department of Economics
20 N. Michigan Avenue, Suite 700
Chicago, IL 60602
312/782-1654

IDPH Representative:
Ron Gottrich, R.Ph
Illinois Department of Public Health
525 W. Jefferson
Springfield, IL 62761
217/782-7532
Executive Officers of State Medical and
Pharmaceutical Societies
Illinois State Medical Society
William E. Kobler, M.D.
President
20 N. Michigan Avenue, Suite 700
Chicago, IL 60602
T: 312/782-1654
F: 312/782-2023
E-mail: info@isms.org
Internet address: www.isms.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-5
Illinois Pharmacists Association
Terri McEntaffer, R.Ph., CAE
Executive Director
204 West Cook Street
Springfield, IL 62704-2526
T: 217/522-7300
F: 217/522-7349
E-mail: terrim@ipha.org
Internet address: www.ipha.org

Illinois Osteopathic Medical Society
Gary Knepp
President
142 East Ontario Avenue, Suite 1023
Chicago, IL 60611-2854
T: 312/202-8174
F: 312/202-8224
E-mail: 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
E-mail: krobbins@ihha.org
Internet address: www.ihatoday.org










































































National Pharmaceutical Council Pharmaceutical Benefits 2003
Illinois-6



National Pharmaceutical Council Pharmaceutical Benefits 2003
Indiana-1
INDIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients
TOTAL $562,120,344 464,879 $636,346,098 490,260

RECEIVING CASH ASSISTANCE, TOTAL $277,174,243 188,399 $315,484,522 200,489
Aged $47,951,486 16,531 $52,184,587 16,691
Blind/Disabled $190,763,506 56,296 $217,167,920 59,727
Child $15,067,039 69,054 $17,736,334 70,416
Adult $23,392,212 46,518 $28,395,681 53,655

MEDICALLY NEEDY, TOTAL $0 - $0 -
Aged $0 - $0 -
Blind/Disabled $0 - $0 -
Child $0 - $0 -
Adult $0 - $0 -

POVERTY RELATED, TOTAL $48,080,747 146,488 $55,897,050 155,896
Aged $304,966 378 $400,906 482
Blind/Disabled $535,916 566 $1,018,867 777
Child $46,038,486 136,278 $53,085,594 145,439
Adult $1,201,379 9,266 $1,391,683 9,198

TOTAL OTHER EXPENDITURES/RECIPENTS* $236,865,354 129,992 $264,964,526 133,875


*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the Indiana Medicaid Program’s Office of Medicaid Policy and Planning.

Source: CMS, MSIS Report, FY 2001 and Indiana Medicaid Statistical Information System, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Indiana-2
C. ADMINISTRATION
Office of Medicaid Policy and Planning

*NOTE WELL—All requests for information by,
or on behalf of, drug manufacturers must
be made ONLY to: PDL@FSSA.state.in.us
Phone requests will not be accepted.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
All FDA-approved legend drugs from rebating
labelers, excluding those products specifically non-
covered by State law (e.g., cosmetics; enhancement
drugs; and experimental drugs).
Over-the-Counter Product Coverage: Indiana has a
Medicaid OTC drug formulary. Listed drugs are
reimbursed based on State MAC.
Therapeutic Category Coverage: All coverage in
accordance with OBRA ’90 & ’93.
Coverage of Injectables: Covered.
Vaccines: Covered.
Unit Dose: In accordance with OBRA 1990
Requirements. MCFA policy only.
Formulary/Prior Authorization
Formulary: Preferred Drug List
Prior Authorization: State has a prior authorization
program with formal appeal process.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: None.
Drug Utilization Review
PRODUR system implemented in March 1996. State
currently has a DUR Board with a monthly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.90, effective 05/30/02.
Ingredient Reimbursement Basis:
EAC = Brand: AWP-13.5%
Generic: AWP-20%
Legend Drug Reimbursement Methodology:
Lower/Lowest of:
1. Federal MAC, if applicable, plus a dispensing
fee.
2. State MAC, if applicable, plus a dispensing fee.
3. EAC plus a dispensing fee.
4. Pharmacy’s usual and customary charge to the
general public.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. “Brand Medically Necessary” requires
prior authorization as of September 2001.
Incentive Fee: None.
Patient Cost Sharing: Copayment varies from $0.50
to $3.00 for branded drugs and is $0.50 for generic
drugs.
Cognitive Services: None.
E. USE OF MANAGED CARE
Approximately 105,000 Medicaid recipients were
enrolled in MCOs in FY 2001. Recipients receive
pharmaceutical benefits through managed care plans.
Managed Care Organizations
Harmony Health Management, Inc.
504 Broadway, Suite 200
Gary, IN 46404-4300

Managed Health Services
1099 N. Meridian Street, Suite 400
Indianapolis, IN 46204

MDwise
1099 N. Meridian Street, Suite 320
Indianapolis, IN 46204

AmeriChoice
333 N. Alabama
Suite 350
Indianapolis, IN 46204







National Pharmaceutical Council Pharmaceutical Benefits 2003
Indiana-3
F. STATE CONTACTS
State Drug Program*
Marc Shirley, R.Ph.
Pharmacy Program Director
Office of Medicaid Policy and Planning
Room W382
Indiana State Government Center South
402 W. Washington Street
Indianapolis, IN 46204-2739
T: 317/232-4307
F: 317/232-7382
E-mail: mshirley@fssa.state.in.us

*NOTE WELL—All requests for information by,
or on behalf of, drug manufacturers must
be made ONLY to: PDL@FSSA.state.in.us
Phone requests will not be accepted.
DUR Contact
Karen Clifton
DUR Board Secretary
Office of Medicaid Policy & Planning
Room W382, Indiana Sate Government Center
South, 402 West Washington Street
Indianapolis, IN 46204
T: 317/232-4307
F: 317/232-7382
E-mail: kclifton@fssa.state.in.us
Medicaid DUR Board
Physicians
Neil Irick, M.D.
Patricia Treadwell, M.D.
John J. Wernert, M.D.
Philip N. Eskew, Jr., M.D.

Pharmacists
Paula Ceh, Pharm.D.
Brian Musial, R.Ph.
Thomas A. Smith, P.D., M.S.
G. Thomas Wilson, B.S. Pharm., J.D.

Health Care Economist
Marko Mychaskiw, R.Ph., Ph.D.

Pharmacologist
Terry Lindstrom, Ph.D.

Representative from HMO
Vicki Perry


Prescription Pricing Updating
First DataBank
1111 Bay Hill Drive
San Bruno, CA 94066
650/588-5454
Medicaid Drug Rebate Contact
Martha Kessenich
Rebate Accounting Manager
365 Northridge Road, Suite 400
Atlanta, GA 30350
T: 770/730-3292
F: 866/759-4100
E-mail: martha.kessenich@acs-inc.com
Claims Submission Contact
Ulka Pandya
365 Northridge Road, Suite 400
Atlanta, GA 30350
T: 866-322-5960 x4032
F: 866/759-4100
E-mail: ulka.pandya@acs-inc.com
Medicaid Managed Care Contact
John Barth
Managed Care Director
Office of Medicaid Policy and Planning
402 W. Washington Street
Room W382, MS07
Indianapolis, IN 46204
T: 317/233-0237
F: 317/232-7382
E-mail: jbarth@fssa.state.in.us
Mail Order Pharmacy Program
None
Administration Officials
Melanie Bella
Assistant Secretary
Medicaid Policy & Planning
Indiana Family & Social Services Administration
402 W. Washington Street, Room W382
Indianapolis, IN 46204
T: 317/234-2407
F: 317/232-7382

John Barth
Managed Care Director
317/233-4697


Pat Nolting, Director
National Pharmaceutical Council Pharmaceutical Benefits 2003
Indiana-4
Medicaid Program Operations – Acute Care
317/232-4318
Medicaid Advisory Committee
Indiana Council of Community Mental Health
Centers
James F. Jones

Indiana Hospital Association
L. Richard Gohman

Indiana Dental Association
Ed Popcheff

Indiana State Osteopathic Association
Edward A. White, D.O.

Indiana State Nurses Association
Ernest C. Klein

Indiana State Podiatry Association
Kirk S. Holston, D.P.M.

Indiana Optometric Association
Marjorie Knotts, O.D.

Indiana Pharmaceutical Association
Monica Foye

Indiana Psychological Association
Paul Schneider, Ph.D.

Indiana State Chiropractic Association
Michael Gallagher

Indiana Association for Home Care
Todd Stallings

Indiana Academy of Ophthalmology
Kim Williams

Indiana Speech and Hearing Association
Susan Holbert

Business and Industrial Interests
Lula E. Baxter

Labor Interests
Donald Mulligan, Sr.







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: jbolin@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
E-mail: kstella@inhha.org
Internet address: www.inha.org





National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-1
IOWA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $230,430,967 221,691 $285,467,642

RECEIVING CASH ASSISTANCE TOTAL $114,379,584 106,099
Aged $14,750,173 6,734
Blind/Disabled $81,135,611 32,484
Child $7,586,771 39,126
Adult $10,907,029 27,755

MEDICALLY NEEDY, TOTAL $13,202,042 6,191
Aged $3,922,542 2,287
Blind/Disabled $7,976,548 2,034
Child $154,791 278
Adult $1,148,161 1,592

POVERTY RELATED, TOTAL $8,996,176 46,728
Aged $513,385 843
Blind/Disabled $740,862 756
Child $6,629,188 37,819
Adult $1,112,741 7,310

TOTAL OTHER EXPENDITURES/RECIPIENTS* $93,853,165 62,673

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

Source: CMS, MSIS Report, FY 2001 and Iowa Medicaid Statistical Information System, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-2
C. ADMINISTRATION
State Department of Human Services, Bureau of
Long Term Care.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered requiring prior
authorization: PPIs; dipyridamole; epoetin;
filgrastim; vitamins and minerals; ergotamine
derivatives; narcotic agonist-antagonist nasal sprays;
isotretinoin; oral antifungals; non-parenteral
vasopressin derivatives; and Serotonin 5-HT1
receptor agonists. Products not covered: fertility
drugs; experimental drugs; cosmetics; disposable
needles and syringe combinations for insulin; blood
glucose test strips; urine ketone test strips; total
parenteral nutrition; and interdialytic parenteral
nutrition.
Over-the-Counter Product Coverage: Products
covered with restriction (selected products): allergy,
asthma and sinus products; analgesics; cough and
cold preparations; and topical products. Products not
covered: digestive products (non-H2 antagonists and
H2 antagonists); feminine products; and smoking
deterrent products.
The Iowa Department of Human Services adopted an
administrative rule that permits coverage for these
non-prescription drugs:
− Aspirin: 325/650 mg Tabs; 81mg Chewable;
Aspirin Enteric Coated: 325/650mg Tabs; 81mg
Chewable; Aspirin Tablets Buffered, 325 mg
− Acetaminophen: 325/500mg Tablets; 120mg/5ml
and 160mg/5mL Elixir; 100 mg/ml Solution;
120mg Suppositories
− Bacitracin Ointment 500 units/gm
− Benzoyl Peroxide 5% and 10%, Cleanser, Lotion,
Cream, Gel
− Chlorpheniramine Maleate Tablets 4 mg
− Diphenhydramine Hydrochloride: 25 mg
Capsules; 6.25mg/5mL and 12.5mg/5ml Liquid
− Ferrous Sulfate: 300/325mg Tablets; 220mg/5ml
Elixir; 75 mg/0.6 ml Drops
− Ferrous Gluconate: 300/325mg Tablets;
300mg/5ml Elixir
− Ferrous Fumarate Tablets 300 mg, 325 mg
− Guafenesin 100 mg/5 ml with Dextromethorphan
10 mg/5 ml liquid
− Meclizine Hydrochloride Tablets 15.5 mg, 25 mg
− Miconazole Nitrate: Topical and Vaginal Cream
2%, Vaginal Suppositories, 100mg
− Nicotinic Acid (Niacin) Tablets:
25/50/100/250/500 mg
− Pediatric Oral Electrolyte Solutions
− Permethrin Liquid 1%
− Pseudoephedrine Hydrochloride: 30/60 mg
Tablets; 30mg/5mg Liquid
− Salicylic Acid Liquid 17%
− Senokot: 326 mg/tsp Granules for children aged
20 and under; 187 mg Tablets for children aged
20 and under
− Sodium Chloride Solution 0.9% for inhalation,
with metered dispensing valve 90 ml, 240 ml
− Tolnaftate 1% Cream, Solution, Powder
− Nonprescription multiple vitamin and mineral
products specifically formulated and
recommended for use as a dietary supplement
during pregnancy and lactation
− With prior authorization, nonprescription multiple
vitamins and minerals under the conditions
specified in subparagraph 78.1(2) “a” (3)
− Insulin
− Oral solid forms of the above-covered items shall
be prescribed and dispensed in a minimum
quantity of 100 units per prescription or the
currently available consumer package size except
when dispensed via a unit dose system. When
used for maintenance therapy, all of the above-
listed items may be prescribed and dispensed in
90-day quantities
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold
medications; contraceptives; ENT anti-inflammatory
agents; estrogens; hypotensive agents;
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: analgesics,
antipyretics, NSAIDs; amphetamines; antihistamine
drugs; growth hormones; and misc. GI drugs.
Therapeutic categories not covered: anorectics;
prescribed smoking deterrents; drugs for strictly
cosmetic purposes and hair growth; fertility drugs;
and drugs without signed Medicaid rebate
agreements.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
and physician payment when used in physicians
offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT service and the Vaccines for Children
Program.
Unit Dose: Unit dose packaging reimbursable.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-3
Formulary/Prior Authorization
Formulary: No formulary.

Prior Authorization: State currently has a formal
prior authorization procedure. State appeals and a
fair hearing procedure required for appeal of prior
authorization decisions and coverage of an excluded
product.
Prescribing and Dispensing Limitations:
Prescribing or Dispensing Limitations: Maximum 30
day supply except select maintenance drugs (90 days)
including oral contraceptives, cardiac drugs,
hypotensive agents, antidiabetic agents, diuretics,
anticonvulsants and thyroid/antithyroid agents.
Drug Utilization Review
PRODUR system implemented in July 1997. State
currently has a DUR Board with a monthly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.26, effective 7/1/03.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Prescription Charge Formula: Payment will be
based on the pharmacist's usual, customary and
reasonable charge, but payment may not exceed EAC
plus a dispensing fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Necessary,” completion of a MedWatch form, and
prior authorization.
Incentive Fee: None.
Patient Cost Sharing: Copayment of $0.50-$3.00 for
brand products, depending on the cost of the drug.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 285,000 Medicaid beneficiaries were
enrolled in managed care organizations in 2002.
Iowa Medicaid recipients enrolled in managed care
receive pharmaceutical benefits through the State.
Managed Care Organizations
John Deere Health Care, Inc.
Kristine Klaver
1300 River Drive, Suite 200
Moline, IL 61265-1368
309/765-1482

Timothy J. Gibson
Area Manager, Central Iowa
4201 Westown Parkway, Suite 325
West DesMoines, IA 50266-6270
515/327-2004

Coventry Health Care of Iowa
Jennifer Goodell
Account Manager
4600 Westown Parkway, Suite 301
Des Moines, IA 50266
515/225-1234
Iowa Health Solutions
Bob Wilcox
Vice President
2550 Middle Road, Suite 405
Bettendorf, IA 52722
319/359-8999
F. STATE CONTACTS
State Drug Program Administrator
Susan L. Parker, Pharm.D.
Pharmacy Consultant
Division of Medical Services
Bureau of Long Term Care
Hoover State Office Bldg.
Des Moines, IA 50319
T: 515/281-3002
F: 515/281-8512
E-mail: sparker2@dhs.state.ia.us
Prior Authorization Contact
Sandy Pranger, R.Ph.
ACS
P.O. Box 14422
Des Moines, IA 50306-3422
T: 515/327-0950 ext. 1329
F: 515/327-0945
National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-4
DUR Contact
Julie Kuhle, R.Ph.
DUR Coordinator
Iowa Pharmacy Association
8515 Douglas Ave, Suite 16
Des Moines, IA 50322
T: 515/270-0713
F: 515/270-2979

Medicaid DUR Board
Richard Rinehart, M.D.
Connie Connolly, R.Ph.
Ronald Miller, M.D., M.B.A.
Bruce Alexander, R.Ph., Pharm. D.
Sandi Birchem, D.O.
George Kappos, M.D.
Dan Murphy, R.Ph.
Julie Kuhle, R.Ph., Project Coordinator
Cheryl Clark, R.Ph.
Janalyn Phillips, R.Ph.
Susan Parker, Pharm.D.
New Brand Name Products Contact
Susan L. Parker, Pharm.D.
515/281-3002
Prescription Price Updating
Sherry Swanson
Deputy Account Manager
ACS
P.O. Box 14422
Des Moines, IA 50306-3422
T: 515/327-0950 ext. 1107
F: 515/327-0945
Medicaid Drug Rebate Contacts
Technical: Rocco Russo, 515/327-0950 ext. 1114
Audits: Rocco Russo, 515/327-0950 ext. 1114
DUR: Julie Kuhle 515/270-0713
PA: Sandy Pranger, 515/327-0950 ext. 1329
Claims Submission Contact
Mindy Ruby
Claims Manager
ACS
P.O. Box 14422
Des Moines, IA 50306-3422
T: 515/327-0950 ext. 1108
F: 515/327-0945
Medicaid Managed Care Contact
Dennis Janssen
MHC Program Manager
Bureau of Managed Care and Clinical Services
Hoover Building, 5
th
Floor
T: 515/281-8747
F: 515/281-8512
E-mail: djansse@dhs.state.ia.us
Mail Order Pharmacy Program
State currently has a mail order pharmacy program.
Participating pharmacies must be enrolled as an Iowa
Medicaid provider.
Iowa Pharmacy Association Medicaid
Pharmacy Advisory Committee
Tim Becker (Chair)
Mason City, IA
641/422-6100

David Brotherson (Vice Chair)
Davenport, IA
563/388-1887

Hal Jackson
Winterset, IA
515/462-2479

Russ Wiesley
Waukee, IA
515/987-8111

Matthew Shivers
Burlington, IA
319/753-0112

Jerry Hartleip
Waterloo, IA
319/234-1589

Mary Tasler
LaPorte City, IA
319/272-5700

Joe Mahrenholz
Panora, IA
641/755-3052

Marilyn Aldrich
DSM
515/255-8642

Larry Costello
Mason City, IA
641/424-1343
National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-5
Wally Tschopp
Hartley, IA
712/728-2165

Joe Cunningham
Waukon, IA
563/568-6315

Robert Dean
Sioux City, IA
712/252-2761

Sue Testroet
Bettendorf, IA
563/324-5004

Sally Horst
Maquoketa, IA
563/652-5611

Dennis Killion
Red Oak, IA
712/623-3370

Steve Firman
Cedar Falls, IA
319/352-4440

Leman Olson
Mason City, IA
641/422-7917

David Gavin
Indianola, IA
515/961-2191

Alan Shepley
Mount Vernon, IA
319/895-6248

Matt Osterhaus
Maquoketa, IA
563/652-5611

Gene Lutz
Altoona, IA
515/967-4213

Cora Lynn Becker
West Des Moines, IA
515/360-0065

Jim Wallace
Davenport, IA


Iowa Human Services Department Officials
Kevin W. Concannon, Director
Dept. of Human Services
Hoover State Office Bldg., 5
th
Floor
Des Moines, IA 50319-0014
T: 515/281-5452
F: 515/281-7791
E-mail: kconcan@dhs.state.ia.us

Eugene Gessow
Medicaid Director
Department of Human Services
Hoover State Office Building, 5th Floor
Des Moines, IA 50319-6242
T: 515/281-6249
F: 515/281-8512
E-mail: egessow@dhs.state.ia.us
Title XIX Medical Assistance Advisory
Council
College of Medicine
Stacey T. Cyphert, Ph.D.
Assistant Vice President-Statewide Health Services
Senior Assistant Director of University Hospitals and
Clinics
The University of Iowa
Iowa City, IA 52242-1009

House of Representatives
Andra Attenberry
1034 Sherman Avenue
Manchester, IA 52057

Brad Hansen
1015 Shoal Pointe Dr.
Carter Lake, IA 51510

Iowa Nurses Association
Linda Goeldner
1501 42nd Street, Suite 471
West Des Moines, IA 50266

Iowa Medical Society
Angela Dorsey
Manager of Legislative Affairs
1001 Grand Avenue
West Des Moines, IA 50265

Opticians Assn. of Iowa
Vacant

Iowa Senate
Sen. Maggie Tinsman
3541 E. Kimberly Road
Davenport, IA 52807

National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-6

Senator Jack Holveck
2007 47
th
Street
Des Moines, IA 50310

Iowa Dept. of Public Health
Anne Kinzel
State Planning Grant Project Director
Lucas State Office Bldg., 5
th
Floor
DesMoines, IA 50319-0075

Public Representatives
Vacant

Mary Ann Weber
565 Greenwood Court
Dubuque, IA 52001

Orvil Nelson
1534 Second Street
Boone, IA 50036

Jodi Tomlonovic
Executive Director
Family Planning Council of Iowa
108 Third Street, Suite 220
Des Moines, IA 50309

Iowa Speech & Hearing Association
Barbara Vogen
Central Rehabilitation, Ltd.
950 Office Park Road, Suite 100
West Des Moines, IA 50265

Iowa Hospital Association
Tracy Warner
100 E. Grand Avenue, Suite 100
Des Moines, IA 50309-1835

Iowa Health Care Association
Steve Ackerson
Executive Director
6750 Westown Parkway, Suite 100
West Des Moines, IA 50266-7726

Iowa Assn. for Home Care
Larry L. Breeding
Executive Director
1520 High Street, Suite 203-B
Des Moines, IA 50309

Iowa Chiropractic Society
Dr. Terry Burk
P.O. Box 370
Huxley, IA 50124


Iowa Pharmacy Association
Jerry Karbeling
8515 Douglas, Suite 16
Des Moines, IA 50322

Iowa Assn. of Homes and Services for the Aging
Dana Petrowsky
President
1701 48
th
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 5
th
Avenue, Suite 333
Des Moines, IA 50309

Iowa Council of Health Care Centers
George W. Appleby
Carney, Appleby, Neilson and Skinner PLC
303 Locust Street, 400 Homestead Building
Des Moines, IA 50309

Iowa Osteopathic Medical Association
Leah McWilliams
Executive Director
950 12
th
Street
Des Moines, IA 50309-1001

Iowa Optometric Association
Gary Ellis
1454 30th Street, Suite 204
West Des Moines, IA 50266-1312

Iowa Podiatric Medical Association
Dr. Richard Spencer
Spencer Foot & Ankle Clinics
110 East McLane
Osceola, IA 50213

Iowa Psychological Society
Mark Peltan, Ph.D.
Mercy Medical Center-North Iowa
1000 4
th
Street, SW
Mason City, IA 50401-2921

Iowa Association of Hearing Health Professionals
Bev Thomas, Executive Director
1001 Office Park Road, Suite 105
West DesMoines, IA 50265
National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-7

Alliance for the Mentally Ill of Iowa
Margaret Stout
5911 Meredith Drive, Suite E
Urbandale, IA 50322

Iowa Psychiatric Society
Karen Loihl
2643 Beaver, Suite 338
Des Moines, IA 50310

Iowa Governor’s Developmental Disabilities Council
Rick Shannon
617 E. 2nd Street
Des Moines, IA 50309

Iowa Academy of Family Physicians
Dr. Dave Carlyle
1215 Duff Avenue
Ames, IA 50010

Iowa Physical Therapy Association
Michael Mandel
1228 8
th
Street, Suite 106
West Des Moines, IA 50265-2624

Iowa Physician Assistant Society
Michael Farley
4524 Boulevard Pl.
Des Moines, IA 50311

Iowa Association of Nurse Practitioners
Wanda Marshall
Children’s Health Center
1212 Pleasant Avenue, Suite 300
Des Moines, IA 50309

Iowa Association of Rural Health Clinics
Ed Friedmann
1013 1
st
Street, Box C
Redfield, IA 50233

Iowa Occupational Therapy Association
Angela Hansen-Abbas
161 315
th
Street
Perry, IA 50220

The ARC of Iowa
Vacant

Des Moines University-Osteopathic Medical Center
Howard S. Teitelbaum, D.O., Ph.D., M.P.H.
Dean of OMS
3200 Grand Avenue
Des Moines, IA 50312




Iowa Chapter-Nat’l. Association of Social Workers
Jay J. Cayner, A.C.S.W., L.I.S.W.
Assistant Hospital Director and Director, Social,
Patient, and Family Services
University of Iowa Hospitals and Clinics
200 Hawkins Drive
Iowa City, IA 52242

Iowa Chapter-Am. Academy of Pediatrics
Rizwan Z. Shah, M.D.
Children’s Health Center
1212 Pleasant Street
Des Moines, IA 50309
Executive Officers of State Medical and
Pharmaceutical Societies
Iowa Medical Society
Michael Abrams
Executive Vice President
1000 Grand Avenue West
Des Moines, IA 50265
T: 515/223-1401
F: 515/223-0590
E-mail: mambrams@iowamedical.org
Internet address: www.iowamedical.org

Iowa Pharmacy Association
Thomas R. Temple, R.Ph., M.S.
Executive Vice President & CEO
8515 Douglas, Suite 16
Des Moines, IA 50322-2927
T: 515/270-0713
F: 515/270-2979
E-mail: ipa@iarx.org
Internet address: www.iarx.org

Iowa Osteopathic Medical Association
Leah McWilliams
Executive Director
950 12
th
Street
Des Moines, IA 50309-1001
T: 515/283-0002
F: 515/283-0355
E-mail: leah@ioma.org
Internet address: www.ioma.org

State Board of Pharmacy Examiners
Lloyd K. Jessen
Executive Secretary/Director
400 SW 8
th
Street, Suite E
Des Moines, IA 50309-4688
T: 515/281-5944
F: 515/281-4609
E-mail: debbie.jorgenson@ibpe.state.ia.us
Internet address: www.state.ia.us/ibpe

National Pharmaceutical Council Pharmaceutical Benefits 2003
Iowa-8

The Association of Iowa Hospitals and Health
Systems
J. Kirk Norris
President
100 East Grand Avenue, Suite 100
Des Moines, IA 50309-1835
T: 515/288-1955
F: 515/283-9366
E-mail: norrisk@ihaonline.org
Internet address: www.ihaonline.org



































































National Pharmaceutical Council Pharmaceutical Benefits 2003
Kansas-1
KANSAS
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult

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

B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $189,290,260 158,515 $213,145,382 156,832

RECEIVING CASH ASSISTANCE TOTAL $85,089,631 58,792 $91,842,893 34,917
Aged $8,618,107 4,187 $14,301,443 6,006
Blind/Disabled $70,087,687 29,828 $68,219,151 22,560
Child $2,774,647 14,115 $9,322,299 6,405
Adult $3,609,190 10,662 $0 -

MEDICALLY NEEDY, TOTAL $11,665,933 8,314 $94,149,457 30,715
Aged $2,421,349 1,362 $56,071,896 19,501
Blind/Disabled $8,335,032 2,898 $37,779,501 9,870
Child $331,900 1,946 $146,766 829
Adult $577,652 2,108 $151,294 515

POVERTY RELATED, TOTAL $10,333,897 49,242 $9,970,767 77,451
Aged $484,846 470 $248 1
Blind/Disabled $1,460,600 867 $0 -
Child $7,711,591 41,266 $9,415,709 72,996
Adult $676,860 6,639 $554,810 4,454

TOTAL OTHER EXPENDITURES/RECIPIENTS* $82,200,799 42,167 $17,182,265 13,695

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients and unknown.
**2002 data provided by the Health Care Policy Division, Kansas Department of Social and Rehabilitation Services.

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

Note: Kansas estimates 2003 drug expenditures to be approximately $237 million and the number of Medicaid drug recipients to
be 200,000.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kansas-2
C. ADMINISTRATION
State Department of Social and Rehabilitation
Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin: Products covered under DME:
disposable needles and syringe combinations used for
insulin; blood glucose test strips; urine ketone test
strips; and total parenteral nutrition. Products covered
with restriction: interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs;
experimental drugs; DESI drugs; and drugs not
rebated by the manufacturer.
Over-the-Counter Product Coverage: Products
covered: analgesics (for adults); digestive products
(H2 antagonist); and antifungals. Products covered
with restrictions: cough and cold preparations (for
children), smoking deterrent products (patches
covered for limited time period); and topical products
Products not covered: allergy, asthma and sinus
products; digestive products (non-H2 antagonists);
feminine products; and nutritional supplements.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics (for
children), antipyretics (for children), NSAIDs;
antibiotics; anticoagulants; anticonvulsants;
antidepressants; antidiabetic agents; antihistamine
drugs; anti-psychotics antilipemic agents; cardiac
drugs; chemotherapy agents; contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; sympathominetics
(adrenergic); and thyroid agents. Partial coverage for:
prescribed cold medications; prescribed smoking
deterrents. Prior authorization required for:
anxiolytics, sedatives, and hypnotics; anorectics;
growth hormones; triptans; nasal steroids; PPIs,
statins; H2 antagonists; and non-preferred drugs.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment program
when used in physician offices.
Vaccines: Vaccines reimbursed as part of the
Children Health Insurance Program and the Vaccines
for Children Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: State currently maintains a formulary
along with a Preferred Drug List (PDL). (See
www.srskansas.org/hcp/medicalpolicy/pharma for a
listing of PDL categories.) Prior authorization
required for non-PDL products.
Prior Authorization: State currently has a formal
prior authorization procedure. The individual
appealing may request an administrative hearing to
appeal a prior authorization hearing by sending a
request in writing to:
Administrative Hearing Office
610 S.W. 10
th
Ave, 2
nd
Floor
Topeka, KS 66612-1616
Prescribing or Dispensing Limitations
Monthly Prescription Limit: 5 single source
scripts/month.
Prescription Refill Limit: As authorized by the
prescriber and allowed by statute up to a one-year
period from the date of issuance of the prescription
for non-controlled drugs. No early refills (<75% Rx
utilized).
Monthly Quantity Limit: 31-day supply.
Other: Narcotics, Viagra, Cialis, Levitra, Ketorolac,
Toradol and Relenza have other specific limits.
Drug Utilization Review
PRODUR system implemented in November 1996.
State currently has a DUR Board that meets every
two months.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.40, effective 7/1/02.
Ingredient Reimbursement Basis: EAC Brand, =
AWP - 13%. Generics, AWP-27%. IV fluids, AWP-
50%. Blood fraction products, AWP-30%.

Prescription Charge Formula: Pharmacies are
reimbursed the lesser of usual and customary, MAC,
FUL, or acquisition cost (EAC) plus a dispensing
fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kansas-3
allowable cost (MAC) limits on generic drugs.
Override requires “Dispense as Written.”
Incentive Fee: None.
Patient Cost Sharing: A recipient copay charge of
$3.00 (effective 7/02) applies to each new and refill
prescription not specifically exempted under Federal
regulations.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 45,000 Medicaid Recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through both the State and
managed care plans. Hemophilia drugs and certain
other specific compounds are carved out of managed
care.
Managed Care Organizations
First Guard
3801 Blue Pkwy
Kansas City, MO 64130
F. STATE CONTACTS
State Drug Program Administrator
Mary H. Obley, Pharmacist
Pharmacy Program Manager
Health Care Policy Division
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-8406
F: 785/296-4813
E-mail: mho@srskansas.org
Internet address: www.srskansas.eds.com
New Brand Name Products Contact
Mary H. Obley, Pharmacist
785/296-8406
Prior Authorization Contact
Mary H. Obley, Pharmacist
785/296-8406
DUR Contact
Vicki L. Schmidt, Pharmacist
Health Care Policy Division
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/274-4287
F: 785/296-4813
E-mail: vixs@srskansas.org
DUR Board
Michael Burke, M.D., Ph.D.
Barry Sarvis, R.Ph.
Kevin Waite. Pharm.D.
John Lowdermilk, R.Ph.
R. Kevin Bryant, M.D., C.M.D
Brenda Shewe, M.D.
John Whitehead, D.O.
Linda Kroeger, ARNP, FNP
Prescription Price Updating
Mary H.Obley, Pharmacist
785/296-8406
Medicaid Drug Rebate Contacts
Policy: Mary H. Obley, Pharmacist
Pharmacy Program Manager
785/296-8406
Technical: Cindy LaClair
Drug Rebate Specialist, EDS
3600 SW Topeka Boulevard, Suite 204
Topeka, KS 66611
785/274-5987
E-mail: cindy.laclair@ksxix.hcg.eds.com
Claims Submission Contact
EDS
3600 SW Topeka Boulevard, Suite 204
Topeka, KS 66611
785/274-4200
Medicaid Managed Care Contact
Debra Bachmann, R.N. IV
Manager, Health Wave XIX
Health Care Policy Division, Kansas Dept. of SRS
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-3667
F: 785/296-4813
E-mail: djzb@srskansas.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kansas-4
Mail Order Pharmacy Program
None
Social and Rehabilitation Services
Department Officials
Janet Schalansky, Secretary
Department of Social and Rehabilitation Services
Docking State Office Bldg.
915 SW Harrison
Topeka, KS 66612-1570
T: 785/296-3271
F: 785/296-2173
E-mail: JKS@srskansas.org

Robert Day, Ph.D., Director
Adult and Medical Services
Department of Social and Rehabilitation Services
915 SW Harrison
Topeka, KS 66612-1570
T: 785/296-3981
F: 785/296-4813
E-mail: rmd@srskansas.org
Medical Care Advisory Committee Contact
Nialson Lee, B.S.N., M.H.A
Administrator, Health Care Systems and Policy/
Medical
Department of Social and Rehabilitation Services
915 SW Harrison, Rm. 651-S
Topeka, KS 66612-1570
T: 785/296-4753
F: 785/2964813
E-mail: nxl@srskansas.org
Executive Officers of State Medical and
Pharmaceutical Societies
Kansas Medical Society
Dan Suiter, President
623 SW 10
th
Avenue
Topeka, KS 66612
T: 785/235-2383
F: 785/235-5114
E-mail: apeterson@kmsonline.org
Internet address: www.kmsonline.org

Kansas Pharmacists Association
Sherry Denton, Interim Executive Director
1020 SW Fairlawn Road
Topeka, KS 66604-2275
T: 785/228-2327
F: 785/228-9147
E-mail: info@kansaspharmacy.org
Internet address: www.kansaspharmacy.org


Kansas Association of Osteopathic Medicine
Charles Wheeler, Executive Director
1260 SW Topeka Boulevard
Topeka, KS 66612
T: 785/234-5563
F: 785/234-5564
E-mail: kansasdo@aol.com

State Board of Pharmacy
Debra Billingsley, Secretary
Landon State Office Building
900 Jackson, Room 560
Topeka, KS 66612-1231
T: 785/296-4056
F: 785/296-8420
E-mail: pharmacy@ink.org
Internet address: www.accesskansas.org

Kansas Hospital Association
Don Wilson
President
215 Southeast Eighth Street
Topeka, KS 66603
T: 785/233-7436
F: 785/233-6955
E-mail: cyelkin@kha-net.org
Internet address: www.kha-net.org


National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-1
KENTUCKY
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $598,093,343 475,365 $652,904,065

RECEIVING CASH ASSISTANCE, TOTAL $424,804,782 235,058
Aged $37,547,483 16,692
Blind / Disabled $355,245,438 137,989
Child $12,748,175 51,834
Adult $19,263,686 28,543

MEDICALLY NEEDY, TOTAL $19,756,137 24,343
Aged $4,859,165 2,018
Blind / Disabled $3,736,659 1,645
Child $3,032,751 11,256
Adult $8,127,562 9,424

POVERTY RELATED, TOTAL $40,038,880 160,513
Aged $557,666 595
Blind / Disabled $1,299,771 941
Child $35,140,791 140,715
Adult $3,040,652 18,262

TOTAL OTHER EXPENDITURES/RECIPIENTS* $113,493,544 55,451

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-2
C. ADMINISTRATION
Department for Medicaid Services, within the
Cabinet for Health Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; syringe combinations used for
insulin. Products covered with restrictions (i.e.,
require prior authorization): total parenteral nutrition;
and interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; experimental
drugs; disposable needles used for insulin; blood
glucose test strips; and urine ketone test strips.
Over-the-Counter Product Coverage: Products
covered with restrictions (i.e., require prior
authorization): allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive
products (H2 and non-H2 antagonists); feminine
products and topical products. Products not covered:
smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; and thyroid agents.
Prior authorization required for: anabolic steroids;
analgesics, antipyretics, NSAIDs; anoretics;
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; prescribed cold medications; growth
hormones; hypotensive agents; misc. GI drugs;
topical steroids; erectile dysfunction products;
Leukotriene inhibitors; Synagis; Respigam; Zetia;
CNS stimulants for ADHD and other disorders;
Avodart; Proscar; anti-fungals for nails; Serotonin
5HT1 Receptor Agonosts; GCSF products;
Recombinant Human Erythropoietin agents; and
Xolair. Therapeutic categories not covered:
prescribed smoking deterrents; agents for cosmetic
purposes or hair growth and agents to promote
fertility.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through both the Prescription Drug
Program and physician payment when used in
physician offices. Reimbursement is limited to
antineoplastic drugs with “J” codes in physician
offices, several antibiotics, Depo-Provera for birth
control.
Vaccines: Vaccines reimbursable in the cost of the
physician visit as part of EPSDT service, Children’s
Health Insurance Program, Vaccines for Children
Program and through the Pharmacy Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Closed Formulary. The Kentucky
Medicaid Program maintains a closed formulary and
covers all rebated products. The State manages the
formulary through a variety of techniques including
the exclusion of products based on contracting issues,
restrictions on use, prior authorization, algorithms,
and preferred products. Prior authorization required
for many brand name products with generic
equivalents.
Prior Authorization: State currently has a prior
authorization procedure. A formal appeals process is
available if a request is denied.
Prescribing or Dispensing Limitations
Prescription Refill Limit: (1) No prescriptions may be
refilled more than 5 times or more than 6 months
after the prescription is written. (2) After initial
filling, one dispensing fee per 30-day period for
designated maintenance drugs.
Monthly Quantity Limit: For designated classes of
maintenance drugs, refills of the original prescription
and subsequent prescriptions for these drugs must be
prescribed and dispensed in quantities of not less
than a 30 day supply unless the prescriber requests an
exception to his policy.
Drug Utilization Review
PRODUR system implemented in 1987. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.51, effective 1/16/01.
Ingredient Reimbursement Basis: EAC = AWP-12%.
Prescription Charge Formula: Reimbursement
consists of the lowest of: (1) the usual and customary
charge; (2) the FMAC, if any, plus a dispensing fee;
or (3) the EAC plus a dispensing fee, or (4), SMAC
if any, plus a dispensing fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Necessary,”
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-3
“Brand Medically Necessary,” or Prior
Authorization.
Incentive Fee: None.
Patient Cost Sharing: $1.00
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 153,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through both the State and
managed care plans. Medications prescribed by a
board certified psychiatrist are carved out of
managed care.
Managed Care Organization
Passport Health Plan
Joyce Schifano, Executive Director
F. STATE CONTACTS
Medicaid Drug Program Administrator
Dan Yeager, R.Ph.
Interim Pharmacy Director
Department for Medicaid Services
CHR Building, 6 W-A
275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: dan.yeager@ky.gov
Internet address: www.chs.ky.us/dms
Prior Authorization Contact
Dan Yeager, R.Ph.
502/564-7940
Pharmacy and Therapeutics Advisory
Committee
Robert C. Hughes, M.D. (Chair)
Truman Perry, M.D.
Dale E. Toney, M.D.
Christopher A. Cunha, M.D.
Carol Lee Steltenkamp, M.D., M.B.A.
Connie Gayle White, M.D. (Vice-Chair)
Naren N. James, M.D.
Carmel Wallace, M.D.
Andrew T. Cooley, M.D.
Janet Poe Wright, Pharm.D.
R. Michael Cayce, R.Ph.
Garry A. Hamm. R.Ph.
Dan Yeager, R.Ph. (non-voting)
DUR Contact
Debra Bahr, R.Ph.
Pharmacy Services Program Manager
Department for Medicaid Services
CHR Building, 6 W-A
275 East Main Street
Frankfort, KY 40621
T: 502/564-7940
F: 502/564-0509
E-mail: Debra.Bahr@ky.gov
Drug Management Review Advisory Board
Richard Arnold, M.D. (Chair)
Phillip Bressoud, M.D.
Phillip Baier, O.D.
Patricia Freeman, R.Ph., Ph.D.
James S. Davis, M.D.
Karen Barnes, M.D.
Janice Sullivan, M.D.
Madonna H. Ringswald, D.O.
John Spencer, Pharm.D.
Sandra Thornbury
Jacob Hutti, Pharm.D.
Misha Glendening, A.R.N.P.
Pam Koob, Ph.D. A.R.N.P.
Scott Moody, Pharm.D. (non-voting)
New Brand Name Products Contact
Debra Bahr, R.Ph.
502/564-7940
Prescription Price Updating
UNYSIS Provider Services
P.O. Box 2106
Frankfort, KY 40602
T: 502/226-1140
F: 502/226-1860
Medicaid Drug Rebate Contact
Betsy Scott
Department for Medicaid Services
CHR Building, 6 E-B
275 East Main Street
Frankfort, KY 40621
T: 502/564-5472
F: 502/564-3232
E-mail: Betsy.Scott@ky.gov
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-4
Claims Submission Contact
Unisys Provider Services
P.O. Box 2106
Frankfort, KY 40602
T: 502/226-1140
F: 502/226-1860
Medicaid Managed Care Contact
Lorraine Dumas
Department of Medicaid Services
CHR Building, 6 E-C
275 E. Main St
Frankfort, KY 40621
T: 502/564-4923
F: 502/564-0223
E-mail: Lorraine.Dumas@ky.gov
Mail Order Pharmacy Program
Sate currently has a mail order pharmacy program.
Mail order pharmacy program is open to all Medicaid
recipients. Must use a pharmacy that participates in
the Kentucky Medicaid Program.
Department for Medicaid Services Officials
James W. Holsinger, Jr., M.D., Secretary
Cabinet for Health and Family Services
CHR Building, 5 W-A
275 East Main Street
Frankfort, KY 40621
T: 502/564-6786
F: 502/564-0274

Mike Robinson, Commissioner
Department for Medicaid Services
Sixth Floor
275 East Main Street
Frankfort, KY 40621
T: 502/564-4321
F: 502/564-0509
State Advisory Council on Medical
Assistance
Frank Butler
Elvin E. Dodson
Bob Gray
William P. Mattingly
Marsha Mercer
Marcia Morgan
Chester A. Nava Jr., D.P.M. (chair)
Kristin V. Paul, R.N.
Vickie L. Prichard
William K. Rich, D.M.D
Leslie Rogers
Nancy Steele
Suzanne Watkins, O.D.
William T. Watkins, M.D.
Bettie Speicher Weyler
Donnie Wilhite
John Withrow
Executive Officers of State Medical and
Pharmaceutical Societies
Kentucky Medical Association
William T. Applegate
4965 U.S. Highway 42, Suite 2000
Louisville, KY 40222-6301
T: 502/426-6200
F: 502/426-6877
E-mail: member@kyma.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
E-mail: kyphassoc@aol.com
Internet address: www.kphanet.org

State Board of Pharmacy
Michael A. Mone
Executive Director
23 Millcreek Park
Frankfort, KY 40601-9230
T: 502/573-1580
F: 502/573-1582
E-mail: pharmacy.board@mail.state.ky.us
Internet address: www.state.ky.us/boards/pharmacy

Kentucky Society of Health-System Pharmacists
Dwaine K. Green
Executive Vice President
One Quality Street
Lexington, KY 40507-1428
T: 859/433-3641
F: 859/257-7297
E-mail: 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
E-mail: tunderwood@koma.org
Internet address: www.koma.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-5
Kentucky Hospital Association
Michael T. Rust
President
2501 Nelson Miller Parkway
Louisville, KY 40223
T: 502/426-6220
F: 502/426-6226
Internet address: www.kyha.com

Kentucky Association of Health Care Facilities
Rich Miller, President
9403 Mill Brook Road
Louisville, KY 40223
T: 502/425-5000
F: 502/425-3431
E-mail: rmiller@kahcf.org
Internet address: www.kahcf.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Kentucky-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-1
LOUISIANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult

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


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $554,670,701 628,571 $714,107,841

RECEIVING CASH ASSISTANCE, TOTAL $351,387,693 259,405
Aged $91,902,271 41,683
Blind/Disabled $227,169,789 114,935
Child $15,071,139 64,596
Adult $17,244,494 38,191

MEDICALLY NEEDY, TOTAL $7,085,668 5,470
Aged $2,977,860 1,238
Blind/Disabled $2,574,449 1,411
Child $61,884 215
Adult $1,471,475 2,606

POVERTY RELATED, TOTAL $67,020,934 260,160
Aged $1,987,183 1,371
Blind/Disabled $1,481,920 1,336
Child $59,094,838 228,683
Adult $4,456,993 28,770

TOTAL OTHER EXPENDITURES/RECIPIENTS* $129,176,406 103,536

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-2
C. ADMINISTRATION
Department of Health and Hospitals.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered
as DME: total parenteral nutrition and interdialytic
parenteral nutrition. Products not covered:
cosmetics; DESI drugs; fertility drugs; experimental
drugs; and cough and cold preparation.
Over-the-Counter Product Coverage: Products not
covered (with limited exceptions): allergy, asthma,
and sinus products; analgesics; cough and cold
preparations; digestive products; feminine products;
topical products; and smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories/ products covered: all except cosmetics,
cough and cold preparations, DESI drugs and
experimental drugs. Prior authorization required for:
analgesics, antipyretics, and NSAIDs; antibiotics;
anticoagulants; anti-depressants; antidiabetic agents;
antihistamines; antilipemic agents; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents;
misc. GI drugs; and sympathominetics (adrenergic).
Partial coverage for: anoretics.
Coverage of Injectables: Injectable medicines
reimbursable under the Prescription Drug Program
and through physician payment when used in
physician offices.
Vaccines: Vaccines reimbursable at cost as part of
EPSDT service and Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. General management
techniques include restrictions on use, prior
authorization, preferred products, and physician
profiling.
Prior Authorization: State currently has a formal
prior authorization procedure but no method of
appealing a prior authorization decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Permitted as indicated by
physician within 6 months and not to exceed 5 refills.
Monthly Quantity Limit: New prescription must be
issued for drugs given on a continuing basis, after 5
refills or after 6 months. Maximum quantity for
prescriptions shall be either 30-day supply or 100
unit doses, whichever is greater. Monthly limit of 8
prescriptions per recipient.
Other: Viagra and other drugs to treat impotence are
limited to a quantity of 6 pills per month.
Drug Utilization Review
PRODUR system implemented in April 1996. State
has a DUR Board that meets quarterly.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.45 on average to $5.77
maximum, effective 7/1/94.
Ingredient Reimbursement Basis: EAC = AWP-
13.5% for Independent Pharmacies. AWP - 15% for
chain pharmacies. (Chain pharmacies are defined as
ownership of more than fifteen (15) Medicaid
enrolled pharmacies under common ownership.)
Prescription Charge Formula: Medicaid
reimbursement for pharmacy services will be based
on the lower of:
1. AWP minus 13.5% for independent pharmacies
and AWP minus 15% for chain pharmacies plus
a dispensing fee for single source products or
multiple source products with no maximum
allowable cost limitations or when physician
authorizes “Brand Medically Necessary” for a
brand name product which has a State MAC or
FUL.
2. Louisiana Maximum Allowable Costs (LMAC)
or the Federal Upper Limit plus the dispensing
fee.
3. AWP for multi-source drugs when lower than
FUL or LMAC.
4. The provider’s usual and customary charge to
other payors.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Approximately 800 drugs are listed on
the State-specific MAC list. Override requires
“Brand Necessary” or “Brand Medically Necessary.”
National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-3
Incentive Fee: None.
Patient Cost Sharing: $ 0.50 - $3.00 copayment
depending of the cost of the prescription, effective
7/13/95.
Cognitive Services: Does not pay for cognitive
services
E. USE OF MANAGED CARE
Does not use MCOs to deliver services to Medicaid
recipients.
F. STATE CONTACTS
State Drug Program Administrator
Mary J. Terrebonne, P.D.
Pharmacy Director
Department of Health & Hospitals
1201 Capital Access Road, 6
th
Floor
P.O. Box 91030
Baton Rouge, LA 70821
T: 225/342-9768
F: 225/342-1980
E-mail: mterrebo@dhh.la.gov
Internet address: www.lamedicaid.com
Department of Health and Hospital
Administration Officials
Frederick P. Cerise, Secretary
Department of Health and Hospitals
P.O. Box 629, Bin #2
Baton Rouge, LA 70821
T: 225/342-9500
F: 225/342-9508
E-mail: fcerise@dhh.state.la.us
Ben A. Bearden, Director
Bureau of Health Services Financing
Department of Health and Hospitals
P.O. Box 91030
Baton Rouge, LA 70821
T: 225/342-3891
F: 225/342-9508
E-mail: bbearden@dhhmail.dhh-state.la.us
DUR Contact
Mary J. Terrebonne, P.D.
225/342-9768





DUR Board
Edwin Adams
120 Dove Drive
West Monroe, LA 71291
318/343-3562

Ken Ardoin, Senior Manager
State Government Relations
Pfizer, Inc.
7 Village Circle, Suite 400
Westlake, TX 76262
817/491-8410

Brad Belding, P.D.
Director of Pharmacy
Thibodaux Hospital
402 Easy Street
Thibodaux, LA 70301
504/493-4786

Sylvia Heidingsfelder, M.D.
5805 Highland Road
Baton Rouge, LA 70808
225/358-1069

Susan Hinton, Pharm.D.
7680 Dune Drive
New Orleans, LA 70128
504/483-7570

Richard Soileau
401½ St Peters Street
New Iberia, LA 70560
337/365-6721

Paul Staab, M.D.
5216 Lapalco Boulevard
Marrero, LA 70072
504/348-4357

Charmaine Venters, M.D.
Earl K. Long Hospital
5825 Airline Highway
Baton Rouge, LA 70805
225/358-1063
New Brand Name Products Contact
Mary J. Terrebonne, P.D.
225/342-9768





National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-4
Prescription Price Updating
Maggie Vick
Unisys
8591 United Plaza Boulevard, Suite 300
Baton Rouge, LA 70809
T:225/237-3251
F: 225/237-3334
E-mail: margaret.vick@unisys.com
Medicaid Drug Rebate Contacts
Technical: Timothy Williams, 225/342-5194
Policy: Mary J. Terrebonne, 225/342-9768
Disputes: Katie Landry, 225/342-0427
Claims Submission Contact
Doug Hasty
Project Manager
Unisys
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
T: 225/237-3391
F: 225/237-3334
E-mail: doug.hasty@unisys.com
Mail Order Pharmacy Program
State has a voluntary mail order pharmacy program
open to all Medicaid recipients.
Medical Managed Care Contact
Mary J. Terrebonne, P.D.
225/342-9768
Medical Care Advisory Committee
Sandra C. Adams (Chairperson)
Brenda Armstrong
Ralph D. Balentine
Dr. Donnie Batie
Francine Boyles
Dr. Floyd A. Buras
Jennifer Canaday
Marcia Daigle
Sen. John L. “Jay” Dardenne, Jr.
Partricia DeMichele
Daily Dupre, Jr.
Wanda Ellis
Warren Hebert
Paul Hildreth
Robert D. Horneman
Amelia Lafont
Rep. Jerry L. “Luke” LeBlane
Dr. Charles Clinton Lewis
Kay Marcel
Dr. Robert L. Marier
June Peach
Dr. Keith M. Perrin
Ms. Bea Piker
Tawana Pounders
Sean Prados
Willa Rawls
Sen. J. “Tom” Schedler
Greg Scott
Mary Scott
Richard “Andy” Soileau
Mary Tonore
Dr. Leonard Weather, Jr.
Linda Welch
Ms. Ann Williamson
Medicaid Pharmaceutical and Therapeutics
Committee
Mr. Joe Adams
Mandeville, LA

State Representative Rodney Alexander
Jonesboro, LA

Dr. Donnie Batie
Baton Rouge, LA

Mr. Ben Bearden
Baton Rouge, LA

Dr. Vincent Culotta
Metairie, LA

Dr. Richard Doskey
River Ridge, LA

Dr. Blackwell B. Evans, Jr.
New Orleans, LA

Dr. Conchetta Fulton
New Orleans, LA

Mr. David Hood
Baton Rouge, LA

Charles Jastram
New Orleans, LA

Dr. Ernest Kinchen
Lafayette, LA

Dr. Michael Kudla
Lake Charles, LA

Dr. W. Chapman Lee
Baton Rouge, LA

National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-5
James Lowery
Pineville, LA
Dr. Brobson Lutz
New Orleans, LA

Dr. Catherine A. McDonald
Lafayette, LA

Mr. Marty McKay
Alexandria, LA

Dr. Phillip J. Medon
Monroe, LA

Dr. John B. Pope
Shreveport, LA

Ms. Carolyn Tackett
Hammond, LA

Dr. Henderson Tilton
New Orleans, LA

Dr. Leonard Weather
New Orleans, LA

Dr. Lolie C. Yu
New Orleans, LA
Pharmacy Advisory Committee
Ken Ardoin
Michelle Wolf-Selfo
Scott Napoli
William Bouren
Allan Brinkhaus
Clovis Burch
Horace Bynum
Wayne T. Harris
Tim Jacks
Ruth “Cookie” Jean
Ricky Guidry
Carl Aron
Amy Soileau
Marty McKay
Jerry Wallace
Kirt Soileau








Executive Officers of State Medical and
Pharmaceutical Societies

Louisiana State Medical Society
Dave L. Tarver
Executive Vice President
6767 Perkins Road, Suite 100
Baton Rouge, LA 70808
T: 225/763-8500
F: 225/763-6122
E-mail: executive@lsms.org
Internet address: www.lsms.org

Louisiana Osteopathic Medical Association
(Inactive)
Nancy Bellemare, D.O.
President
215 Friedrichs Avenue
Metairie, LA 70005-4516
800/621-1773, ext. 8188
E-mail: info@loma-net.org
Internet address: www.loma-net.org

State Board of Pharmacy
Malcolm J. Broussard
Executive Director
5615 Corporate Boulevard, Suite 8E
Baton Rouge, LA 70808-2537
T: 225/925-6496
F: 225/925-6499
E-mail: labp@labp.com
Internet address: www.labp.com

Louisiana State Pharmacists Association
Doug Cheramie
Executive Director
4744 Jamestown, Suite 101
Building 7-B
Baton Rouge, LA 70808
T: 225/926-2666
F: 225/926-1020
E-mail: lpa2000@tlxnet.net
Internet address: www.louisianapharmacists.org

Louisiana Society of Health-System Pharmacists
David Lofton
President
8550 United Plaza Boulevard, Suite 1001
Baton Rouge, LA 70809
T: 225/922-4520
F: 225/922-4611
E-mail: lshp@pncpa.com
Internet address: www.lshp.org




National Pharmaceutical Council Pharmaceutical Benefits 2003
Louisiana-6
Louisiana Hospital Association
Lynn B. Nicholas
President & CEO
9521 Brookline Avenue
Baton Rouge, LA 70898-0720
T: 504/928-0026
F: 225/923-1004
E-mail: lnicholas@lhaonline.org
Internet address: www.laha.org







National Pharmaceutical Council Pharmaceutical Benefits 2003
Maine-1
MAINE
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients
TOTAL $203,693,259 192,833 $220,420,714

RECEIVING CASH ASSISTANCE, TOTAL $99,156,442 63,650
Aged $9,742,927 4,469
Blind/Disabled $75,144,561 28,041
Child $3,038,840 13,637
Adults $11,230,114 17,503

MEDICALLY NEEDY, TOTAL $3,381,341 1,253
Aged $2,428,720 912
Blind/Disabled $916,215 281
Child $8,041 24
Adults $28,365 36

POVERTY RELATED, TOTAL $42,571,202 49,911
Aged $10,445,319 5,441
Blind/Disabled $22,747,950 7,758
Child $9,021,432 34,767
Adult $356,501 1,945

TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,584,274 78,019

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

Source: CMS, MSIS Report FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maine-2
C. ADMINISTRATION
State Department of Human Services, Bureau of
Medical Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin (not covered for
nursing home patients); blood glucose test strips
(with HbA1e values); urine ketone test strips.
Products not covered: cosmetics; fertility drugs;
experimental drugs; total parenteral nutrition;
interdialytic parenteral nutrition (part of procedure);
vitamin and vitamin preparations (except
pregnancy); and injectables when oral medication is
available for equally effective treatment.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics; digestive products (non H2 antagonists);
topical products; and feminine products. Products
covered with restrictions: H2 antagonists (limited
coverage after 1/1/01); smoking deterrent products
(by Rx only). Products not covered: cough and cold
preparations.
Therapeutic Category Coverage: Therapeutic
categories covered: (prior authorization required):
anabolic steroids; analgesics, antipyretics, and
NSAIDs; anoretics; antibiotics anticoagulants;
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamine drugs; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents;
misc. GI drugs; prescribed smoking deterrents;
sympathominetics (adrenergic); thyroid agents;
injectable arthritis medications; acute migraine
medications; Synvisc; antifungals; EPO; Synagis,
and erectile dysfunction products.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities and in physician offices.
Vaccines: Vaccines reimbursable based on cost as
part of the EPSDT service (admin. fees), as part of
the Children’s Health Insurance Program, and as
part of the Vaccines for Children Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Closed formulary with restrictions on
use, prior authorization, and preferred products.
(The Maine Care Preferred Drug List can be seen at
www.ghsinc.com.)

Prior Authorization: State currently has a formal
prior authorization procedure. Prior authorization
may be obtained in the case of necessary
exceptions. Fair hearing appeal of denials through
the Office of Administrative Hearings. State has no
formal prior authorization committee.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: 34 day for brand-name
drugs and 90 days for generic drugs per month.

Prescription Refill Limit: maximum of 11 refills
per prescription.
Drug Utilization Review
PRODUR system implemented in 1995. State
currently has a DUR Board that meets 12 times per
year.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.35 - $12.50 (Effective
1/20/2004)
Ingredient Reimbursement Basis: EAC = AWP -
15%.
Prescription Charge Formula: Lowest of usual and
customary, FUL, AWP-15%, or Maine MAC.
Maine MAC includes 1,232 drug products in
addition to FUL products.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires prior
authorization.
Incentive Fee: None.
Patient Cost Sharing: $2.50 per script up to a
maximum of $25.00 per month.
Cognitive Services: State does not pay for cognitive
services.
E. USE OF MANAGED CARE
About 110,000 Medicaid recipients are enrolled in
managed care in 2002. Medicaid recipients
enrolled in managed care receive pharmaceutical
benefits through the State.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maine-3
F. STATE CONTACTS
State Drug Program Administrator
Jude Walsh, Director
Health Care Management Division
Department of Human Services
Bureau of Medical Services
11 SHS, 442 Civic Center Drive
Augusta, ME 04333
T: 207/287-1815
F: 207/287-6533
E-mail: jude.c.walsh@maine.gov
Internet address: www.maine.gov/bms
Prior Authorization Contact
Jude Walsh
207/287-1815
Pharmacy Advisory Group
Alroy Chow, M.D.
Tim Clifford, M.D.
Edward Ervin, M.D.
Jabbar Fazeli, M.D.
Thomas Hayward, M.D.
Lawrence Losey, M.D.
James Raczek. M.D.
John Grotton, R.Ph.
Paula Knight, R.Ph.
Dennis Lyons, R.Ph.
Steve McPike, R.Ph.
Gary Roy, R.Ph.
DUR Contact
Jude Walsh
207/287-1815
Maine DUR Board
Timothy Clifford, M.D.
Pharmacy Consultant
P.O. Box 708
Augusta, ME 04332
207/622-7153

William Alto, M.D.
Maine Dartmouth Family Practice
4 Sheridan Drive
Fairfield, ME 04937
207/861-5000

John Grotton, R.Ph.
Goold Health Systems
P.O. Box 708
Augusta, ME 04332
207/622-7153


Cheryl Blaisdell, R.Ph.
94 Marston Road
Waterville, ME 04901

Paula Knight, R.Ph.
31 Birch Circle
Sidney, ME 04330
207/547-3681

Stephen McPike, R.Ph.
15 Wildwood Lane
Gray, ME 04039
207/822-7627

Michael Ouellette, R.
4235 Bassett Road
Winslow, ME 04901
207/281-2727

Robert Weiss, M.D.
2 Great Falls Plaza
Auburn, ME 04210

Jabbar Fazeli, M.D.
100 Campus Avenue
Lewiston, ME 04240

Non-voting:
Joe Bruno (President)
Goold Health Systems
P.O. Box 708
Augusta, ME 04332
207/622-7153

Dennis G. Lyons, R.Ph.
255 Bear Hill Rd., 2
nd
Fl.
Waltham, MA 02451
New Brand Name Products Contact
Jude Walsh
207/287-1815
Prescription Price Updating
Jude Walsh
207/287-1815
Medicaid Drug Rebate Contact
Rossi Rowe
Insurance Recovery/ Drug Rebate Manager
Department of Human Services
Bureau of Medical Services
11 SHS, 442 Civic Center Drive
Augusta, ME 04333
T: 207/287-1838
F: 207/287-1788
E-mail: rossi.rowe@maine.gov

National Pharmaceutical Council Pharmaceutical Benefits 2003
Maine-4
Claims Submission Contact
Marcia Pykare
Manager of Data Processing
Goold Health Systems
P.O. Box 1090
Augusta, ME 04332-1090
T: 207/622-7153
F: 207/623-5125
E-mail: movkare@ghsinc.com
Medicaid Managed Care Contact
Jude Walsh
207/287-1815
Mail Order Pharmacy Program
State has a mail order Medical Assistance
pharmacy program.
Disease Management Program/Initiative
Contact
Jude Walsh
207/287-1815
Human Services Department Officials
Peter Walsh, Acting Commissioner
Department of Human Services
State House Station 11
Augusta, ME 04333-0011
T: 207/287-2736
F: 207/287-3005
E-mail: peter.e.walsh@maine.gov
Internet address: www.maine.gov/dhs

Chris Zukus Lessard, Director
Bureau of Medical Services
Department of Human Services
State House Station 11
Augusta,ME 04333-0011
T: 207/287-2674
F: 207/287-2675
E-mail: chris.zukas.lessard@maine.gov
Internet address: www.maine.gov/bms
Executive Officers of State Medical and
Pharmaceutical Societies
Maine Medical Association
Gordon Smith, Esq.
Executive Vice President
Frank O. Stred Building
P. O. Box 190
Manchester, ME 04351-0190
T: 207/622-3374
F: 207/622-3332
E-mail: info@mainemed.com
Internet address: www.mainemed.com

Maine Pharmacy Association
Christopher R. Gauthier, President
127 Pleasant Hill Road
Scarborough, ME 040704
T: 207/396-5340
F: 207/396-5341
E-mail: cgauthierrph@adelphia.net
Internet address: www.mparx.com

Maine Osteopathic Association
Kellie Miller, M.S.
Executive Director
693 Western Avenue, #1
Manchester, ME 04351
T: 207/623-1101
F: 207/623-4228
E-mail: kmiller@mainedo.org
Internet address: www.mainedo.org

Maine Board of Pharmacy
Geraldine “Jeri” Betts, Board Administrator
35 State House Station
Augusta, ME 04333
T: 207/624-8620
F: 207/624-8637
E-mail: geraldine.l.betts@maine.gov
Internet address: www.maine.gov/prf/olr/

Maine Society of Health-System Pharmacists
Carl Grove, President
25 June Street
Sanford, ME 04073
207/324-4310
E-mail: cgrove@goodallhosp.org

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 Pharmaceutical Benefits 2003
Maryland-1

MARYLAND
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $417,080,496 413,755 $297,291,733

RECEIVING CASH ASSISTANCE, TOTAL $250,086,652 146,902
Aged $32,434,284 16,402
Blind / Disabled $195,329,917 69,078
Child $8,287,280 40,807
Adult $14,035,171 20,615

MEDICALLY NEEDY, TOTAL $86,459,198 53,223
Aged $46,136,023 18,138
Blind / Disabled $29,821,999 11,626
Child $4,769,778 13,221
Adult $5,731,398 10,238

POVERTY RELATED, TOTAL $59,823,561 186,809
Aged $11,344,463 7,589
Blind / Disabled $14,225,876 5,162
Child $31,413,643 154,271
Adult $2,839,579 19,787

TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,711,085 26,821

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-2
C. ADMINISTRATION
State Department of Health and Mental Hygiene.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
legend drugs; prescribed insulin; disposable needles
and syringe combinations used for insulin. Covered
under DME: blood glucose test strips; urine ketone
test strips total parenteral nutrition; and interdialytic
parenteral nutrition. Products not covered:
cosmetics; fertility drugs; experimental drugs;
DESI drugs; prescriptions and injections for central
nervous system stimulants; food supplements or
infant formulas; products for which Federal
Financial Participation is not allowed, i.e., "less
than effective" drugs and products whose
manufacturers have not signed rebate agreements;
and certain other items as specified in The State's
Medicaid Plan.
Over-the-Counter Product Coverage: Products
covered: contraceptives; oral ferrous sulfate; and
aspirin for arthritis. Products not covered: allergy,
asthma and sinus products; analgesics; cough and
cold preparations; digestive products (H2 and non-
H2 antagonists); feminine products (except
contraceptives); topical products; and smoking
deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; prescribed smoking
deterrents; sympathominetics (adrenergic); and
thyroid agents. Prior authorization required for:
growth hormones; synagis; and nutritional
supplements for tube-fed recipients. Therapeutic
categories not covered: anorectics.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities, and through both the
Prescription Drug Program and physician payment
when used in physician offices.
Vaccines: Vaccines reimbursable as part of the
Vaccines for Children Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary with a preferred drug
list (PDL). Prior authorization required for non-
PDL products.
Prior Authorization: State currently has a Prior
Authorization procedure. A general appeals
procedure is available when a physician can
provide additional information to justify the
medical necessity of a particular product.
Preauthorization is needed for any prescription with
a usual and customary charge exceeding $400.
Prior authorization is also needed for early refills,
nutritional supplements, brand medically necessary
and excessive quantities.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Maximum of eleven
refills. The original prescription and its refills may
not exceed a 360-day supply.
Monthly Quantity Limit: The amount of medication
to be dispensed on a prescription at one time is
limited to a less than 34-day supply except for
specific maintenance drugs for chronic conditions,
where up to a 100-day supply may be dispensed at
one time.
Drug Utilization Review
PRODUR system implemented January 1993. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.69 - $5.65 as of November
2002.
$3.69 - non-PDL Brand.
$4.69 - PDL Generic
$4.65-Nursing Home non-PDL
Brand
$5.65 - Nursing Home PDL or
Generic

Ingredient Reimbursement Basis: Estimated
Acquisition Cost (EAC) equals/lowest of:
1. Wholesale Acquisition Cost (WAC) plus 9%.
2. Direct cost plus 9%.
3. Distributor's price plus 9%.
4. Average Wholesale Price (AWP) minus 11%.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-3
Prescription Charge Formula: Reimbursement will
be the lower of: (1) the calculated ingredient cost
plus a dispensing fee; (2) the usual and customary
fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Approximately 1,000 drugs are
listed on the State-specific MAC list. Override
requires “Brand Medically Necessary” and a
reason.
Incentive Fee: $1.00 higher for dispensing a lower
cost multisource product.
Patient Cost Sharing: Copayment = $2.00 for
Brands not on the PDL. Does not apply to
managed care, family planning, nursing home
residents, recipients under 21 years old, or generic
drugs.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 444,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through the State and
managed care plans. (Mental health drugs are
“carved out” of managed care.)
Managed Care Organizations
United Healthcare Family First
Lyndwood Executive Center
6095 Marshalee Drive
Elkridge, MD 21075
410/277-6000

Helix Family Choice, Inc.
8094 Sandpiper Circle
Baltimore, MD 21236
410/933-3021

Jai Medical Systems, Inc.
5010 York Road
Baltimore, MD 21212
410/433-2200

Maryland Physicians Care MCO
7104 Ambassador Road
Suite 100
Baltimore, MD 21244
410/277-9710

Priority Partners MCO
Bay Meadow Industrial Park
6704 Curtis Court
Glen Burnie, MD 21060
410/424-4400

Ameri Group
857 Elkridge Landing Road, #300
Linthicum, MD 21090
410/859-5800
F. STATE CONTACTS
State Drug Program Administrator
Mr. Joseph L. Fine
Director
Maryland Pharmacy Program
DHMH, Office of Operation and Eligibility
201 West Preston Street
Baltimore, MD 21201
T: 410/767-1455
F: 410/333-5398
E-mail: jfine@dhmh.state.md.us
Internet address: www.dhmh.state.md.us
New Brand Name Products Contact
Frank T. Tetkoski
Manager
Services and Preauthorization
DHMH, Division of Pharmacy Services
201 West Preston Street, Room 409
Baltimore, MD 21201
T: 410/767-1460
F: 410/333-5398
E-mail: tetkoskif@dhmh.state.md.us
Prior Authorization Contact
Tuong Nguyen, P.D.
Pharmacist Consultant
DHMH-Office of Operations and Eligibility
Division of Pharmacy Services
201 W. Preston St.
Baltimore, MD 21201
T: 410/767-8701
F: 410/333-5398
E-mail: nguyent@dhmh.md.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-4
DUR Contact
Judy Geisler, P.D.
Pharmacist Consultant
DHMH-Office of Operations and Eligibility
Division of Pharmacy Services
201 W. Preston Street
Baltimore, MD 21201
T: 410/767-1455
F: 410/333-5398
E-mail: geislerj@dhmh.state.md.us
DUR Board
Deneen Pieri, M.D.
John Boronow, M.D.
Michelle A. Forrest-Smith, Pharm.D.
Myron Miller, M.D. (Chair)
Lori Fantry, M.D., M.P.H.
Vincent Ferrari, R.Ph.
Steve A. Anifowshe, R.Ph.
Elliot S. Gottlieb, R.Ph.
Bernard J. Lechman, R.Ph.
Prescription Price Updating
First DataBank
1111 Bayhill Dr.
San Bruno, CA 94066
T: 415/588-5454
F: 415/827-4578
Medicaid Drug Rebate Contacts
Technical: Ed Ellis, 410/767-1455
Policy: Jeffrey Gruel, 410/767-1455
Disputes: Alex Taylor, 410/263-7048
Claims Submission Contact
First Health Services Corporation
Division of Claims Processing
James Demery
Manager, Pharmacy Services
201 W. Preston St.
Baltimore, MD 21201
T: 410/767-1460
F: 410/333-5398
E-mail: demeryj@dhmh.state.md.us
Medicare Managed Care Contact
Jim Gardner
Chief
Division of Health Choice Management
201 W. Preston St., Room 208
Baltimore, MD 21201
410/767-1482
Mail Order Pharmacy Benefit
None
Expanded Drug Coverage Program
Paul Roeger, Chief
Division of Eligibility Services
Montgomery Park Business Center
1800 Washington Boulevard, Suite 400
Baltimore, MD 21230
T: 443/263-7031
F: 443/263-7065
E-mail: roegerp@dhmh.state.md.us
Health and Mental Hygiene Department
Officials
Nelson J. Sabatini, Secretary
Department of Health and Mental Hygiene
201 W. Preston Street
Baltimore, MD 21201
T: 410/225-6500
F: 410/161-6489
E-mail: nsabatini@dhmh.state.md.us

Joseph Davis
Executive Director
Office of Operations and Eligibility
201 W. Preston Street
Baltimore, MD 21201

Joseph Fine
Director
Maryland Pharmacy Program
201 W. Preston Street
Baltimore, MD 21201

Jeffrey Gruel,Chief
Division of Pharmacy Services
Office of Operations and Eligibility
201 W. Preston Street
Baltimore, MD 21201
410/767-1455

Paul Roeger
Program Manager - Eligibility
Pharmacy Assistance Program
PO Box 386
Baltimore, MD 21203
Medical Assistance Staff Committee
Members
Judy Geisler, P.D.
Division of Pharmacy Services
201 W. Preston Street
Baltimore, MD 21201

National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-5
Mr. Frank Tetkoski, P.D., Manager
Services and Preauthorization
Division of Pharmacy Services
201 W. Preston Street, Room 409
Baltimore, MD 21201

Phil Cogan
Preferred Drug List
Division of Pharmacy Services
201 W. Preston Street
Baltimore, MD 21201

Tuong Nguyen, P.D.
Division of Pharmacy Services
201 W. Preston St.
Baltimore, MD 21201
Executive Officers of State Medical and
Pharmaceutical Societies
Maryland State Medical Society
T. Michael Preston
Executive Director
1211 Cathedral Street
Baltimore, MD 21201
T: 410/539-0872
F: 410/547-0915
E-mail: mpreston@medchi.org
Internet address: www.medchi.org

Maryland Association of Osteopathic Physicians
John Kylan Lynch, D.O.
President
3603 Southside Drive
Phoenix, MD 21131
T: 410/683-8100
F: 410/683-8200
E-mail: 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
E-mail: MPHA@erols.com
Internet address: www.marylandpharmac.street.org

Maryland Society of Health-System Pharmacists
David A. Kotzin, President
8480-M Baltimore National Pike, Ste. 252
Ellicott City, MD 21042
T: 410/465-9975
F: 410/465-7073
E-mail: 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

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

Health Facilities Association of Maryland
Adele Wilzack, President
7060 Oakland Mills Road, Suite M
Columbia, MD 21046
T: 410/792-4390
T: 301/490-8413
F: 410/792-4617
E-mail: awilzack@hfam.org
Internet address: www.hfam.org





























National Pharmaceutical Council Pharmaceutical Benefits 2003
Maryland-6


































National Pharmaceutical Council Pharmaceutical Benefits 2003
Massachusetts-1
MASSACHUSETTS
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $795,309,302 664,891 $958,972,520

RECEIVING CASH ASSISTANCE TOTAL $398,769,692 233,547
Aged $43,882,222 27,199
Blind/Disabled $325,512,115 126,497
Child $9,394,346 50,397
Adult $19,981,009 29,454

MEDICALLY NEEDY, TOTAL $33,106,079 16,380
Aged $13,532,409 8,577
Blind/Disabled $19,573,670 7,823
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $222,673,963 225,206
Aged $57,479,842 29,452
Blind/Disabled $133,146,461 46,414
Child $30,025,642 144,510
Adult $2,022,018 4,830

TOTAL OTHER EXPENDITURES/RECIPIENTS* $140,759,568 189,758

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Massachusetts-2
C. ADMINISTRATION
Executive Offices of Health and Human Services,
Division of Medical Assistance, Office of
Medicaid.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered (except in
LTC facilities): disposable needles and syringe
combinations used for insulin; blood glucose test
strips; urine ketone test strips. Products covered
with restrictions: total parenteral nutrition (prior
authorization required). Ritalin and amphetamines
are limited to treatment of hyperkinesis for children
under age 17, except by prior authorization; and
ADD by prior authorization (not covered for
appetite control). Products not covered: cosmetics;
fertility drugs; experimental drugs; interdialytic
parenteral nutrition; DESI drugs; legend vitamins
not on Drug List, non-legend drugs not on Drug
List; propoxyphene-containing products and
products rated by the FDA as less-than-effective.
Over-the-Counter Product Coverage: Products
covered with restrictions (limited OTC list-generics
only- not covered in LTC facilities): allergy,
asthma and sinus products; analgesics; cough and
cold preparations; digestive products; feminine
products and topical products. Products not
covered: smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
chemotherapy agents; contraceptives; and thyroid
agents. Prior authorization required for: growth
hormones; Erythropoeitin; and selected biotech
drugs. Partial coverage for: prescribed cold
medications. Partial coverage with prior
authorization required for: analgesic, antipyretics,
and NSAIDs; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamines; antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; ENT anti-inflammatory
agents; hypotensive agents; misc. GI drugs;
andsympathominetics (adrenergic). Therapeutic
categories not covered: anoretics; prescribed
smoking deterrents; weight loss or gain
medications; medications to treat sexual
dysfunction; experimental or investigational drugs;
and less than effective drugs.


Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities and through both the
Prescription Drug Program and physician payment
when used in physician offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT service if not provided by the Department
of Public Health.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open Formulary managed through
restrictions on use, prior authorization, and
physician profiling.
Prior Authorization: State currently has a prior
authorization procedure. A fair hearing process by
the recipient on an individual basis is required for
appealing a prior authorization decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Prescription may be
refilled, as authorized, with a limit of up to 5 refills
from the filling of the original prescription
Monthly Quantity Limit: Schedule II and III drugs
are limited to a 30-day supply, except Ritalin and
Dexedrine, which may be dispensed up to a 60-day
supply.
Monthly Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in October 1995.
State currently has a DUR Board with a quarterly
review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: Brand: $3.00 (basic) plus $1.00-
$2.00 additional for compounded Rx’s, effective
1/1/2004.
Ingredient Reimbursement Basis: EAC = WAC +
6%.
Prescription Charge Formula: Payment shall be for
the lowest of:
1. EAC plus dispensing fee;
2. The usual and customary charge defined as
the lowest price charged or accepted by a
provider for any payor; or
3. FULP plus a dispensing fee.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Massachusetts-3
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Dispense as
Written,” and/or “Brand Medically Necessary” plus
prior authorization.
Patient Cost Sharing: Copayment = $3.00 (Brands)
and $1.00 (Generics), effective 2/1/2004.
Institutionalized patients
− Children under age 19
− Pregnant and postpartum women
− Hospice care
− Family planning items
Incentive Fee: None.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 238,000 Medicaid recipients in
MCOs were enrolled in MCOs in FY 2002 with
another 411,000 enrolled in pre-paid health plans
(PHPs). Recipients receive pharmaceutical benefits
through managed care plans. Enrollees in the
PCCM program receive pharmaceutical benefits
from the State.
Managed Care Organization
Primary Care Clinician Plan
Boston Medical Center HealthNet Plan
Fallon Community Health Plan
Neighborhood Health Plan
Network Health
F. STATE CONTACTS
State Drug Program Administrator
Paul L. Jeffrey
Director of Pharmacy
Office of Medicaid
600 Washington Street, 5
th
Floor
Boston, MA 02111
T: 617/210-5319
F: 617/210-5865
E-mail: pjeffrey@nt.dma.state.ma.us
Internet Address: www.state.ma.us/dma
Prior Authorization Contact
Paul L. Jeffrey
617/210-5319
DUR Contact
Paul L. Jeffrey
617/210-5319
Medicaid DUR Board
Spencer Wilking, MD (Chairman)
C. Michael Bliss, MD
Sarah Cheeseman, MD
Thomas Hewitt, MD
Anne Marie McCloskey, R.Ph.
Leo McKenna, R.Ph.
Dave Morgan, R.Ph.
Robert Portney, MD
James Scanlon, R.Ph.
David Kosegarten, Ph.D.
Gerry Longnecker, Pharm.D.
New Brand Name Products Contact
Christopher T. Burke
Policy Analyst
Office of Medicaid
600 Washington Street, 5
th
Floor
Boston, MA 02111
T: 617/210-5592
F: 617/210-5597
E-mail: cburke@nt.dma.state.ma.us
Prescription Price Updating
First Data Bank
111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Martha Kessenich
Rebate Analyst
ACS State Health Care
365 North Ridge Road, Suite 400
Atlanta, GA 30350
800/358-2381
Claims Submission Contact
ACS State Health Care
365 North Ridge Road, Suite 400
Atlanta, GA 30350
800/358-2381
National Pharmaceutical Council Pharmaceutical Benefits 2003
Massachusetts-4
Medicaid Managed Care Contact
Kate Willrich-Nordahl, Director
Massachusetts Health MCO Program
Department of Public Health
250 Washinton Street, 6
th
Floor
Boston, MA 02108
T: 617/624-5693
F: 617/624-5698
E-mail: kate.willrich-nordahl@state.ma.us
Mail Order Pharmacy Benefit
None
Disease Management Program/Initiative
Contact
N/A
Executive Offices of Health and Human
Services
Ronald Preston, Secretary
Executive Office of Health and Human Services
One Ashburton Place, Room 1109
Boston, MA 02108
T: 617/727-0077
F: 617/727-5134
E-mail: ronald.preston@state.ma.us
Internet address: www.masscares.org

Beth Waldman, Director
Office of Medicaid
One Ashburton Place, Room 1109
Boston, MA 02108
T: 617/573-1770
F: 617/573-1894
E-mail: bwaldman@nt.dma.state.ma.us
Internet address: www.state.ma.us/dma
Executive Officers of State Medical and
Pharmaceutical Societies
Massachusetts Medical Society
Corrine Broderick
Executive Vice President
860 Winter Street
Waltham Woods Corporate Center
Waltham, MA 02451-1411
T: 781/893-4610
F: 781/893-9136
E-mail: broderick@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.
William Seeglitz
President
P.O. Box 487
Winchester, MA 01890
781/721-9900
E-mail: nocdos@shore.net
Internet address: www.northeastosteo.org

Massachusetts Board of Registration in Pharmacy
Charles R. Young
Executive Director
239 Causeway Street, Suite 500
Boston, MA 02114
T: 617/727-9953
F: 617/727-2197
E-mail: charles.r.young@state.ma.us
Internet address: www.state.ma.us/reg/boards/ph

Massachusetts Society of Health-Systems
Pharmacists
Martin Goldberg
President
500 West Commings Park, Suite 3475
Woburn, MA 01801
T: 781/937-0175
F: 781/937-0176
E-mail: admin@mashp.org
Internet address: www.mashp.org

Massachusetts Hospital Association
Ronald M. Hollander
President
Five New England Executive Park
Burlington, MA 01803
T: 617/272-8000
F: 781/272-8000
E-mail: info@mhalink.org
Internet address: www.mhalink.org

Massachusetts Extended Care Federation
Abraham E. Morse
President
2310 Washington Street, Suite 300
Newton, MA 02462
T: 617/558-0202
F : 617/558-3546
E-mail: amorse@mecf.org
Internet address: www.mecf.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-1
MICHIGAN
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services
B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $604,759,491 551,593 $674,222,281

RECEIVING CASH ASSISTANCE TOTAL $278,471,171 199,600
Aged $34,781,401 18,971
Blind/Disabled $232,639,786 127,875
Child $3,532,094 24,915
Adult $7,517,890 27,839

MEDICALLY NEEDY, TOTAL $33,663,061 48,285
Aged $8,419,629 5,074
Blind/Disabled $14,322,748 5,269
Child $2,043,913 10,523
Adult $8,876,771 27,419

POVERTY RELATED, TOTAL $33,072,967 114,030
Aged $1,984,861 1,503
Blind/Disabled $14,408,432 5,343
Child $13,531,563 85,310
Adult $3,148,111 21,874

TOTAL OTHER EXPENDITURES/RECIPIENTS* $259,552,292 189,678

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-2
C. ADMINISTRATION
Michigan Department of Community Health,
Medical Services Administration.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered
with restrictions: total parenteral nutrition (prior
authorization for equipment and supplies) and
interdialytic parenteral nutrition (prior authorization
required for self administration). Prior authorization
required for: brand name products equivalent to
MACs; Accutane & Retin-A; Dexedrine and
Adderall; Persantine; Lactulose (Cephulac);
Methylphenidate (selected ages); selected
benzodiazepines; Epogen administered in the home
setting; dietary formulas; and drugs not listed on the
formulary. Products not covered: cosmetics;
fertility drugs; and experimental drugs.
Over-the-Counter Product Coverage: Products
covered with restrictions (only selected products in
each category): allergy, asthma and sinus products
(antihistamines); analgesics (payment limits,
considered part of nursing home per diem
reimbursement); non-H2 antagonists (payment
limits, considered part of nursing home per diem
reimbursement); H2 antagonist (payment limits);
feminine products (payment limits); topical
products; and smoking deterrent products (tablets,
patches and gum-quanity limits per beneficiary per
year). Products not covered: cough and cold
preparations.
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents;
misc. GI drugs; sympathominetics (adrenergic); and
thyroid agents. Partial coverage for: anabolic
steroids (prior authorization required); prescribed
cold medications; and prescribed smoking deterrents
(prior authorization required). Therapeutic
categories not covered: anoretics.

Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities, and through physician
payment when used in physician offices.
Vaccines: Vaccines reimbursable at cost plus a
fee/or vaccine replacement as part of the EPSDT
service the Children Health Insurance Program,
and the Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Closed formulary and a preferred drug
list (PDL). (See www.michigan.fhsc.com for
listing of drugs on the PDL.) Formulary managed
through restrictions on use, prior authorization
requirements, age/gender editing; and clinical
editing for “first line” therapy.
Prior Authorization: State currently has a formal
prior authorization procedure. Beneficiaries have a
right to appeal prior authorization decisions on the
basis of medical necessity. Informal review of
additional information can be conducted at any
time. Beneficiaries also have fair hearing rights to
appeal denial of coverage for an excluded product.
Prescribing or Dispensing Limitations
Prescription Refill Limit: None
Monthly Quantity Limit: Prescribed quantities
should be limited to an amount necessary to keep
the recipient supplied during the therapy regimen.
Quanity limits for selected pharmaceuticals (e.g.,
sedative hypnotics). In certain cases and
conditions, more than a month’s supply will be
appropriate. However, in no instance may more
than 100 days supply be dispensed per
prescription.
Drug Utilization Review
PRODUR system implemented in July 2000. State
currently has a DUR Board with a quarterly
review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.77, (included in annual
Appropriations Act.)
Ingredient Reimbursement Basis: 1-4 stores =
AWP-13.5%, 5 or more stores = AWP-15.1%.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-3
Prescription Charge Formula: Reimbursement for
legend drugs is limited to the lower of:
1. AWP-13.5% for 1 to 4 stores & AWP-15.1%
for 5 or more stores or LTC, plus dispensing
fee minus selected $1.00 patient copay, or
2. The MAC rate, plus dispensing fee, or
3. The provider’s usual and customary charge to
the general public.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Necessary” and prior authorization.
Incentive Fee: None.
Patient Cost Sharing: Ambulatory recipients age 21
and older are required to pay a $1.00 copayment for
most legend drugs. If the recipient is unable to pay
a required copayment on the date of service, the
pharmacy cannot refuse to render the service.
However, the pharmacy may bill the recipient for
the copayment amount, and he/she is responsible for
paying it. If the recipient fails to pay a copayment,
the pharmacy could, in the future, refuse to serve the
recipient as a Medicaid recipient.
Drugs not requiring a co-payment include
pregnancy-related and family planning products.
Recipients are not required to make a copayment if:
− They are under age 21, or
− They reside in a long-term care facility (nursing
home, hospital long-term care facility, or
medical care facility), or
− Health Maintenance Organization (HMO), or a
capitated Clinic Plan.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 800,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through managed care
plans. Psychotropics, antidepressants, anti-mania,
central nervous system stimulants, and other select
classes of drugs are administered by managed care
organizations but paid for by the State.




Managed Care Organizations
Botsford Health Plan
28050 Grand River
Farmington Hills, MI 48336
800/479-5122
Internet address: www.botsfordhealthplan.org

Cape Health Plan
26711 Northwestern Highway, Suite 300
Southfield, MI 48034
248/386-3000
888/354-2273
Internet address: www.capehealth.com

Community Choice Michigan
2369 Woodlake Drive
Okemos, MI 48864
517/349-9922
800/390-7102
Internet address: www.ccmhmo.org

Great Lakes Health Plan, Inc.
17117 W. Nine Mile, Suite 1600
Southfield, MI 48075
248/559-5656
800/903-5253
Internet address: www.glhp.com

Health Plan of Michigan, Inc.
17515 W. Nine Mile, Suite 650
Southfield, MI 48075
248/557-3700
888/437-0606
Internet address: hpmich.com

HealthPlus Partners, Inc.
2050 S. Linden Road
P.O. Box 1700
Flint, MI 48501-1700
810/230-2132
800/322-9161
Internet address: www.healthplus.com

M-Caid
2301 Commonwealth Blvd.
Ann Arbor, MI 48105-1573
800/527-5549
Internet address: www.mcare.org

McLaren Health Plan
G 3245 Beacher Road, Suite 200
Flint, MI 48532
888/327-0671
Internet address: www.mclaren.org




National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-4
Midwest Health Plan
5050 Schaefer Road
Dearborn, MI 48126
313/581-3700
888/654-2200
Internet address: www.midwesthealthplan.com

Molina Healthcare of Michigan
100 W. Big Beaver Road, Suite 600
Troy, MI 48084
248/925-1700
888/898-7969
Internet address: www.molinahealthcare.com

OmniCare Health Plan
1155 Brewery Park Blvd.
Suite 250
Detroit, MI 48207
313/259-4000
800/955-4578
Internet address: www.ochp.com

PHP of Mid-Michigan, Inc.
P.O. Box 30377
Lansing, MI 48909-7877
517/364-8400
800/661-8299
Internet address: www.phpmm.org

PHP of Southwest Michigan, Inc.
106 Farmers Alley, Suite 300
Kalamazoo, MI 49007
269/341-7200
800/261-0084
Internet address: www.ibahealthplans.com

Priority Health, Government Programs, Inc.
1231 E. Beltline, NE
Grand Rapids, MI 49525-4501
616/942-0954
888/975-8102
Internet address: www.priority-health.com

Total Health Care
3011 W. Grand Blvd., Suite 1600
Detroit, MI 48202
313/871-2000
800/826-2862
Internet address: totalhealthcareonline.com

Upper Peninsula Health Plan
228 W. Washington Street
Marquette, MI 49855
906/225-7500
800/835-2556
Internet address: www.uphp.com



The Wellness Plan
7700 Second Avenue
Detroit, MI 48202
313/202-8500
800/875-9355
Internet address: www.wellplan.com
F. STATE CONTACTS
State Drug Program Administrator
Giovannino A. Perri, M.D.
Chief Medical Consultant
MDCH/Medical Services Administration
400 South Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: perrig@michigan.gov
Internet address: www.michigan.gov/mdhc
New Brand Names Products Contact
Donna Hammel
Office of Medical Affairs
MDCH/ Medical Services Administration
400 South Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: hammeld@michigan.gov
Prior Authorization Contact
First Health Service Corporation
4300 Cox Road
Glen Allen, VA 23060
T: 877/864-9014
F: 888/603-7696
DUR Contact
Deberah Eggleston, M.D.
MDCH- Medical Services Administration
400 S. Pine St.
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: egglestond@michigan.gov
National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-5
Medicaid DUR Board
Richard Henderson, M.D.
34650 Versailles Court
Farmington Hills, MI 48331
810/474-1397

Frank Check, M.D.
St. Joseph Mercy Hospital
900 Woodward Avenue
Pontiac, MI 48341
313/858-3233

Duane Kirking, Ph.D.
College of Pharmacy
University of Michigan
Ann Arbor, MI 48109-1065
313/764-4483
313/764-7312

William Overkamp
2929 Walker, N.W.
Grand Rapids, MI 49544

Karen Jonas, R.Ph.
13121 Willow Grove Road
Dewitt, MI 48820
517/315-1243

James Kenyon, R.Ph.
Michigan Department of Community Health
Medical Services Administration
P.O. Box 30479
Lansing, MI 48909

Otto Graesser, DO
1421 W. Mt. Hope
Lansing, MI 48910
Prescription Price Updating
First Health Services Corporation
4300 Cox Road
Glen Allen, VA 23060
T: 877/864-9014
F: 888/603-7696












Medicaid Drug Rebate Contacts
Technical: Dawn Parsons
Pharmacy Consultant
MDCH/ Medical Services
Administration
400 South Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: parsonsd@michigan.gov

Audits: First Health Services Corporation
877/864-9014
Claims Submission Contact
First Health Services Corp
T: 877/864-9014
F: 888/603-7696
Medicaid Managed Care Contact
Sue Moran, Chief
Bureau of Medicaid Operations and Quality
MDCH- Medical Services Administration
400 S. Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: morans@michigan.gov
Disease Management Program/Initiative
Contact
Giovannino A. Perri, M.D.
517/335-5181
Mail Order Pharmacy Program
None
Elderly Expanded Drug Coverage Contact
Thomas Chisnell
MDCH/ Medical Services Administration
400 South Pine Street
P.O. Box 30479
Lansing, MI 48909-7979
T: 517/335-5181
F: 517/241-8135
E-mail: chisnellt@michigan.gov







National Pharmaceutical Council Pharmaceutical Benefits 2003
Michigan-6
Michigan Dept. of Community Health
(MDCH)
Janet Olszewski, Director
MCDH/ Lewis Cass Building
320 South Walnut Street
Lansing, MI 48913
T: 517/335-0267
F: 517-373-4288
E-mail: norris@michigan.gov

Patrick Barrie, Deputy Director
Health Programs Administration
Michigan Department of Community Health
400 South Pine Street
Lansing, MI 48909
T: 517/335-5001
F: 517/335-5007
E-mail: barriep@michigan.gov
Formulary Review Committee
James Kenyon, R.Ph.
Giovannino Perri, M.D.
Debera Eggleston, M.D.
Max Robins, D.O.
Lawerence Nagel, D.D.S.
Chris Farrell
Robert Pheteplace, R.Ph. (Alternate)

Addresses for all members:
Medical Services Administration
Michigan Department of Community Health
400 S. Pine Street
Lansing, MI 48933
Michigan Pharmacy and Therapeutics
Committee
David R. Johnson, M.D., M.Ph. (Chair)
Robert P. Coffey, Pharm.D.
Debera Hayes Eggleston, M.D.
Robert Ernst, M.D.
Jonathan G.A. Henry, M.D.
Edward J. Keating, R.Ph.
Giovannino A. Perri, M.D.
Max Robins, D.O.
Sandra Campbell, Pharm.D.
Executive Officers of State Medical and
Pharmaceutical Societies
Michigan State Medical Society
William E. Madigan, Executive Director
120 West Saginaw Street
East Lansing, MI 48823
T: 517/337-1315
F: 517/337-2490
E-mail: wmadigan@msms.org
Internet address: www.msms.org
Michigan Pharmacists Association
Larry D. Wagenknecht, CEO
815 N. Washington Avenue
Lansing, MI 48906-5198
T: 517/484-1466
F: 517/484-4893
E-mail: larry@michiganpharmacists.org
Internet address: www.michigan pharmacists.org

Michigan Osteopathic Association
Dennis Paradis, Executive Director
2445 Woodlake Circle
Okemos, MI 48864
T: 800/657-1556
F: 517/347-1566
E-mail: dennis@moa-do.com
Internet address: www.moa-do.com

State Board of Pharmacy
Roberta Armstrong, Chairperson
Licensing Manager
611 W. Ottawa, First Floor
P.O. Box 30670
Lansing, MI 48909-8170
517/335-0918
Internet address: www.michigan.gov/cis/

Michigan Health and Hospital Association
Spencer C. Johnson, President
6215 West St. Joseph Highway
Lansing, MI 48917
T: 517/323-3443
F: 517/323-0946
E-mail: 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

National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-1
MINNESOTA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)

Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $265,240,353 188,566 $310,174,144

RECEIVING CASH ASSISTANCE, TOTAL $148,264,320 78,475
Aged $7,108,479 4,018
Blind / Disabled $129,186,438 46,033
Child $5,008,680 16,345
Adult $6,960,723 12,079

MEDICALLY NEEDY, TOTAL $17,151,129 6,590
Aged $4,624,706 2,823
Blind / Disabled $12,502,998 3,665
Child $22,225 92
Adult $1,200 10

POVERTY RELATED, TOTAL $1,456,490 1,725
Aged $695,335 1,177
Blind / Disabled $753,128 472
Child $7,795 61
Adult $232 15

TOTAL OTHER EXPENDITURES/RECIPIENTS* $98,368,414 101,776

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

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-2
C. ADMINISTRATION
Minnesota Department of Human Services, Health
Care Management Division, Medical Assistance
Program.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; syringe combinations used for
insulin; total parenteral nutrition; and interdialytic
parenteral nutrition. Products not covered: drugs
used for cosmetic purposes; drugs used for hair
growth; fertility drugs; appetite supressants; and
experimental drugs; disposable needles used for
insulin; blood glucose test strips; and urine ketone
test strips. Products covered with limitations:
sildenafil, methylphenidate (including d-
methylphenidate), Adderall, pemoline,
dextroamphetamine, vitamins, and cough and cold
preparations. Prior authorization required for:
alglucerase; Interferon Alfa N-3; Interferon
Gamma-1B; Ondansetron; Granisetron; omeprazole
(including s-omeprazole); sertraline 25mg and
50mg tablets; Butulinum Toxin Types A & B;
valdecoxib; Esomeprazole; dolasetron; celecoxib;
rofecoxib; escitalopram 10mg; citalopram 10mg
and 20mg; paroxetine 10mg; modafinil 100mg;
trandolapril; trandolapril/verapamil combination;
quinapril; quinapril/HCTZ; amlodipine/benazepril;
benazepril/HCTZ; benazepril; fosinopril; and
fosinopril/HCTZ. (For a complete list of products
requiring prior authorization, contact the Pharmacy
Program at The Minnesota Department of Human
Services, Health Care Management Division,
Medical Assistance Program.)
Over-the-Counter Product Coverage: Products
covered: smoking deterrent products. Products
covered with limitations: allergy, asthma and sinus
products; analgesics; cough and cold preparations;
digestive products (H2 and antagonist); feminine
products (antifungals covered); topical products;
and smoking deterrent products; vitamins; ocular
lubricants; pediculocides; and activated charcoal
and ipecac.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidiabetic agents;
antihistamine drugs (OTC loratadine products are
preferred second generation antihistamines, all
other require prior authorization); antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; prescribed smoking
deterrents; sympathominetics (adrenergic); thyroid
agents; and prescribed cold medications. Prior
authorization required for: analgesics, antipyretics,
and NSAIDS; antidepressants; cardiac drugs; and
misc. GI drugs. Therapeutic categories not covered:
anoretics; DESI drugs.
Coverage of Injectables: Injectable medicines
reimbursable through the pharmacy benefit when
dispensed by a pharmacy and through physician
payment when used in physician offices.
Vaccines: Vaccines reimbursable when billed as
part of EPSDT services, the Children’s Health
Insurance Program, and the Vaccines for Children
Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/ Prior Authorization
Formulary: Open formulary with general
exclusions, restrictions, and preferred products.
Prior Authorization: State currently has a prior
authorization procedure and a Drug Formulary
Committee. Recipient has the right to appeal prior
authorization decisions and coverage of an
excluded product by appeals referee followed by an
appeal in court.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: 3 month supply. Minimum
30-days for maintenance drugs. Contraceptives may
be filled to provide a 3-month supply.
Drug Utilization Review
PRODUR system implemented in February 1996.
State currently has a DUR Board with a quarterly
review. Heritage Information Systems provides
software and assistance with RetroDUR.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.65, effective 7/1/99.
Ingredient Reimbursement Basis: EAC = AWP –
11.5%.
Prescription Charge Formula: Reimbursement is
based on the lesser of submitted AWP minus 11.5%
plus a dispensing fee, MAC plus a dispensing fee,
or usual and customary. Special rules for IV
admixtures.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-3
Maximum Allowable Cost: State imposes a
combination of Federal Upper Limits and State-
specific MAC on generic drugs. Override requires
or “dispense as written.” No pre-printed DAW
allowed.
Incentive Fee: None.
Patient Cost Sharing: Brand: $3.00
Generic: $1.00
Cognitive Services: State pays for professional
services (e.g., clozaril monitoring).
E. USE OF MANAGED CARE
Approximately 370,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through managed care
plans.
Managed Care Organizations
Itasca Medical Care
Itasca Resource Center
1209 SE 2
nd
Ave.
Grand Rapids, MN 55744-3983
T: 218/327-6133
F: 218/327-5545

Blue Plus
P.O. Box 64179
St. Paul, MN 55164-0179
651/662-5200

First Plan Blue
1601 London Road
Duluth, MN 55812
T: 218/728-6706
F: 218/724-9176

HealthPartners
8100 34th Avenue South
P.O. Box 1309
Minneapolis, MN 55414-1309
T: 952/967-6633

Medica
P.O. Box 9310
Mail Route 80920
Minneapolis, MN 55440-9310
T: 952/992-3200
F: 952/992-3198

Metropolitan Health Plan
822 South 3rd Street, Suite 140
Minneapolis, MN 55415
T: 612/347-8584
F: 612/904-4493
UCare Minnesota
P.O. Box 52
Minneapolis, MN 55440-0052
T: 612/626-3300
F: 612/676-6555

South County Health Alliance
303 South Cedar Street
Owatonna, MN 55060
T: 507/444-7770
F: 507/444-7774
F. STATE CONTACTS
State Drug Program Administrator
Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager
Minnesota Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3853
T: 651/296-8515
F: 651/282-6744
E-mail: cody.c.wiberg@state.mn.us
Internet address: www.dhs.state.mn.us
Prior Authorization Contact
Cody C. Wiberg, Pharm.D., R.Ph.
651/296-8515
DUR Contact
Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator
444 Lafayette Road North
St. Paul, MN 55155-3853
T: 651/215-1239
F: 651/282-6744
E-mail: mary.beth.reinke@state.mn.us
Medicaid DUR Board
Physicians
Michael F. Koch, M.D.
Director, Child Psychiatry
Hennepin County Medical Center
701 Park Avenue South
Minneapolis, MN 55402
Andrew R. Baron, M.D.
1930 17th Street South
St. Cloud, MN 56301
Roger E. Hofer, M.D.
Mayo Clinic
200 SW First Street
Rochester, MN 55905

National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-4
Health Care Professional
Marilyn M. Ulseth, MS., RN., CNP.
2909-33
rd
Ave South
Minneapolis, MN 55406

Pharmacists
Lynne M. Schneider, R.Ph.
12910 37
th
Avenue North
Plymouth, MN 55441

Ron Johnson, R.Ph.
Lloyd’s Pharmacy
720 North Snelling
St. Paul, MN 55104

Peter Marshall, Pharm. D.
HealthPartners Pharmacy Services
P.O. Box 1309
8100 - 34th Avenue South
Minneapolis, MN 55440-1309

Wendy L. St. Peter, Pharm.D.
Hennepin County Medical Center
Nephrology Analytical Services
USRDS Coordinating Center
914 Eighth Avenue South
Minneapolis, MN 55404

Consumers Representative
Vacant

DHS Staff
Cody C. Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager

Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator
New Brand Names Product Contact
Cody C. Wiberg, Pharm.D., R.Ph.
651/296-8515
Prescription Drug Updating
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/588/4003
Claims Submission Contact
Dwaine Voas
MMIS Unit Supervisor
Minnesota Department of Human Services
800 Minnehaha Avenue
St. Paul, MN 55155
Medicaid Drug Rebate Contacts
Jarvis Jackson, R.Ph.
Drug Rebate Coordinator
Minnesota Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3853
T: 651/282-5881
F: 651/282-6744
E-mail: jarvis.p.jackson@state.mn.us
Disease Management Program/Initiative
Contact
Mary Claire Wohtetz
Clinical Pharmacist
Minnesota Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3853
T: 651/215-1632
F: 651/282-6744
E-mail: mary.c.whohetz@state.mn.us
Mail Order Pharmacy Benefit
None
Elderly Expanded Drug Coverage Program
Contact
Cody C. Wiberg, Pharm.D., R.Ph.
651/296-8515
Department of Human Services Officials
Kevin Goodno
Commissioner
Department of Human Services
444 Lafayette Road North
St. Paul, MN 55155-3815
T: 651/297-7515
F: 651/297-3230
E-mail: commissioner.dhs@state.mn.us

Mary Kennedy
Medicaid Director
Department of Human Services
444 Lafayette Road
St. Paul, MN 55155-3852
T: 651/297-7515
F: 651/297-3230
E-mail: mary.kennedy@state.mn.us
Drug Formulary Committee
Al Heaton, Pharm.D., R.Ph.
Senior Director
Prime Therapeutics
1020 Discovery Road, No. 100
Eagan, MN 55121
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-5
Charlene Nusman, Consumer Representative
2534 Lynn Avenue So.
St. Louis Park, MN 55416

William P. Korchik, M.D.
Veterans Affairs Medical Center
One Veteran Drive (11L)
Minneapolis, MN 55417

Jack Alexander, M.D.
Chief Medical Officer
Fairview Red Wing Clinic
2835 South Service Clinic
Red Wing, MN 55066-0095
Paul Johnson, M.D.
Metropolitan Health Plan
822 South 3rd Street, Suite 140
Minneapolis, MN 55415
Kim Allan Macnab, M.D., Pharm.D., CCFP (EM)
714 Barton Ave, N.W.
Buffalo, MN 55313
Lynne M. Schneider, R.Ph.
12910-37th Avenue North
Plymouth, MN 55441
Robert Straka, Pharm.D.
University of Minnesota College of Pharmacy
7-148 Weaver-Densford Hall
308 Harvard Street, S.E.
Minneapolis, MN 55455

DHS Staff
Cody Wiberg, Pharm.D., R.Ph.
Pharmacy Program Manager

Mary Beth Reinke, Pharm.D., R.Ph.
DUR Coordinator

Executive Officers of State Medical and
Pharmaceutical Societies
Minnesota Medical Association
Robert K. Meiches
Chief Executive Officer
1300 Godward Street, NE, Suite 2500
Minneapolis, MN 55413-1878
T: 612/378-1875
F: 612/378-3875
E-mail: rmeiches@mnmed.org
Internet address: www.mnmed.org







Minnesota Pharmacists Association
Julie K. Johnson, R.Ph.
Executive Vice-President
1935 W. County Road, B2 #450
Roseville, MN 55113
T: 651/697-1771
F: 651/697-1776
E-mail: 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
E-mail: David.Holstrom@state.mn.us
Internet address: www.phcybrd.state.mn.us

Minnesota Hospital and Healthcare Partnership
Bruce Rueben
President
2550 University Avenue West, Suite 350S
St. Paul, MN 55114-1900
T: 651/641-1121
F: 651/659-1477
E-mail: brueben@mnhospitals.org
Internet address: www.mhlp.com

Minnesota Society of Health System-Pharmacists
Scott Marin
Executive Director
13911 Ridgedale Drive, Suite 260
Minnetonka, MN 55305
T: 952/541-9499
F: 952/541-9684
E-mail: dstanton@mnshp.org
Internet address: www.mnshp.org

Care Providers of Minnesota
Rick E. Carter
President & CEO
7851 Metro Parkway
Suite 200
Bloomington, MN 55425
T: 612/854-2844
F: 612/854-6214
E-mail: rcarter@careproviders.org
Internet address: www.careproviders.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Minnesota-6




National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-1
MISSISSIPPI
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult

Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Nursing Facility Services
Skilled Nursing Home Services
Physician Services
Dental Services


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

TOTAL $494,805,247 478,404 $567,313,801

RECEIVING CASH ASSISTANCE TOTAL $273,269,878 214,993
Aged $40,460,923 21,661
Blind/Disabled $206,625,503 105,509
Child $12,577,330 59,540
Adult $13,606,122 28,283

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $163,081,425 238,963
Aged $57,308,548 28,431
Blind/Disabled $65,540,551 24,427
Child $35,839,110 161,784
Adult $4,393,216 24,321

TOTAL OTHER EXPENDITURES/RECIPIENTS* $58,453,944 24,448

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-2
C. ADMINISTRATION
Division of Medicaid, Office of the Governor.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; total parenteral nutrition; and
interdialytic parenteral nutrition. Prior
authorization required for: brand name multisource
products; Sandimmune; oral erectile dysfunction
agents; enteral feeding products; nutritional
products; immunosuppressant agents; Clozaril
(must be prescribed by Board Certified or Board
Eligible Psychiatrist); * Xenical, Benzodiazepines,
NSAD, Protropin and Humatrope; * all
Antihemophilic Factors including VIII and IX; *
Synagis; Enbrel; Brand SR opioid agonists; and all
Home IV drug therapies. Products not covered:
cosmetics; fertility drugs; experimental drugs;
disposable needles and syringe combinations used
for insulin; blood glucose test strips; and urine
ketone test strips.
* These products are covered only for children ages
0-21 years through the Early and Periodic
Screening, Diagnosis and Treatment Program
(EPSDT).
Over-the-Counter Product Coverage: Products
covered with restrictions; (i.e.must be on limited
formulary, requires a prescription, and counts
against monthly service limits): allergy, asthma,
and sinus products (Benadryl); analgesics (ASA,
generic Tylenol); cough and cold preparations
(generic Robitussin); digestive products (non-H2
antagonist); feminine products; topical products;
smoking deterrent products; certain vitamins
(prenatal and dialysis). Products not covered: H2
antagonists.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; anti-psychotics; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents;
prescribed smoking deterrents, antilipemic agents
(PA required for xenical); sympathominetics
(adrenergic); and thyroid agents. Prior
authorization required for: analgesics, antipyretics,
NSAIDs; antihistamines; chemotherapy agents; and
misc. GI drugs. Partial coverage for: prescribed
cold medications. Products not covered: anoretics;
weight loss drugs; fertility drugs; vitamins and
minerals (except prenatal); and DESI drugs.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities, and through physician
payment when used in physicians’ offices.
Unit Dose: Unit dose packaging is reimbursable.
Vaccines: Vaccines reimbursable as part of the
Vaccine for Children Program.
Formulary/Prior Authorization
Formulary: Open formulary with preferred drug list
(PDL). General exclusions include:
1. Drugs used for anorexia or weight gain.
2. Drugs when used for the symptomatic relief of
cough and colds (except quaifenesin syrup 100
mg/5 ml, iodinated glycerol tablets 30 mg,
which are covered).
3. Prescription vitamins and mineral products
(except prenatal vitamins and fluoride
preparations, which are covered).
4. Covered outpatient drugs for which the
manufacturer requires (as a condition of sale)
that associated tests or monitoring services be
purchased exclusively from the manufacturer
or its designee.
5. Barbiturates (except amobarbital, butabarbital,
mephobarbital, pentobarbital, phenobarbital,
secobarbital, which are covered).
6. Benzodiazepines (except Klonopin,
Lorazapam, Diazepam and Temazepam which
are covered).
7. DESI drugs (those drugs that are designated
less than effective by the FDA).
Prior Authorization: State currently has a prior
authorization procedure. A written request
(including medical justification for beneficiaries
under age 21) must be made within 30 days of
denial to appeal a prior authorization decision.
Review and determination made within 3 days of
receipt. All parties notified in writing within 24
hours of decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Limited to five (5).
Monthly Quantities Limit: 34-day supply or 100
units or doses, whichever is greater. Birth control
pills may be supplied in 3-month quantities.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-3
Monthly Prescription Limit: Total prescriptions
dispensed per month per recipient are limited to 5.
Two additional prescriptions per month may be
allowed with prior authorization. Beneficiaries
under age 21 years old or in long term care
facilities are exempt from monthly prescription
limits.
Drug Utilization Review
PRODUR system implemented in 1993. State has a
12 member DUR Board that meets quarterly.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.91 (effective 4/1/02). IV
mixtures can receive up to a $30 per liter
dispensing fee.
Ingredient Reimbursement Basis: EAC = AWP-
12%, effective July 1, 1990.
Prescription Charge Formula: Reimbursement for
legend drugs will be at the lessor of AWP-12% plus
a dispensing fee or usual and customary charge.
OTC drugs will be paid at lessor of AWP plus a
dispensing fee, usual and customary price, or
estimated shelf price plus a dispense fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” or prior authorization
for brand multi-source drugs.
Incentive Fee: None.
Patient Cost Sharing: Tiered copayment of $1.00-
$3.00.
$1.00 - preferred generic
$2.00 - preferred brand
$3.00 - non-preferred brand
Cognitive Services: Pays for Disease Management
Services for diabetes, hyperlipidemia, asthma, and
coagulatory disorders (effective 8/1/98). Pays $20
for average 30-minute encounter.
E. USE OF MANAGED CARE
No Medicaid recipients receive health benefits
through MCOs.




F. STATE CONTACTS
State Drug Program Administrator
Judith P. Clark, R.Ph.
Pharmacy Director
Division of Medicaid
Robert E. Lee Building
239 North Lamar Street, Suite 801
Jackson, MS 39201
T: 601/359-5253
F: 601/359-9555
E-mail: phipc@medicaid.state.ms.us
Internet address: www.dom.state.ms.us
Division of Medicaid Official
Warren A. Jones, M.D., Executive Director
Division of Medicaid
Suite 801, Robert E. Lee Building
239 North Lamar Street
Jackson, MS 39201
T: 601/359-6050
F: 601/359-6048
E-mail: exfmp@medicaid.state.ms.us

DUR Contact
Judith P. Clark, R.Ph.
601/359-5253
Mississippi DUR Board
Sara Weisenberger, M.D.
UMC-Department of Pediatrics
2500 North State Street
Jackson, MS 39216

Tim Alford, M.D. (Chair)
Kosciusko Medicaid Clinic
Highway 12
Kosciusko, MS 39090

John R. Mitchell, M.D.
Tupelo Family Medicine Residency Center
1665 South Green Street
Tupelo, MS 38804

Cynthia Undesser, M.D.
P.O. Box 5102
Brandon, MS 39047

Andrea Phillips, M.D.
Phillips Medical Services
P.O. Box 21214
Jackson, MS 39289

Joe McGuffee, R.Ph.
McGuffee Drugs
102 North Main Street
Mendenhall, MS 39114
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-4
D. Montez Carter, Pharm.D.
P.O. Box 1414
Greenwood, MS 38935

Leigh Ann Ramsey, Pharm.D.
231 Winged Foot Circle
Jackson, MS 39211

Diana McGowan, R.Ph., M.B.A
328 Dover Lane
Madison, MS 39110

Clarence DuBose, R.Ph. (Vice-Chair)
Medi-Mart Pharmacy
3737 Main Street
Moss Point, MS 39563

Bob Broadus, R.Ph.
7147 Creekwood Drive
Mandeville, LA 70471
New Brand Names Product Contact
Judith P. Clark, R.Ph.
601/359-5253
Prescription Price Updating
Judith P. Clark, R.Ph.
601/359-5253
Medicaid Drug Rebate Contact
Robert Reedy, C.Ph.T.
DRAMS Business Analyst
ACS State Healthcare
385-B Highland Colony Parkway
Ridgeland, MS 39157
T: 601/206-2936
F: 601/206-3119
E-mail: robert.reedy@acs-inc.com
Claims Submission Contact
Bob Parenteu, PBM Account Manager
ACS State Healthcare
385-B Highland Colony Parkway
Ridgeland, MS 39157
T: 601/296-2934
F: 601/296-3119
E-mail: bob-parenteau@acs-inc.com
Disease Management/Patient Education
Programs
Disease/Medical State: Asthma
Program Name: Asthma Disease Management (eff.
2/03)
Program Manager: Mckesson


Disease/Medical State: Diabetes
Program Name: Diabetes Disease Management
(eff. 2/03)
Program Manager: Mckesson

Disease/Medical State: Hypertension
Program Name: Hypertension Disease
Management (eff. 2/03)
Program Manager: Mckesson
Disease Management/Patient Education
Contact
Alicia K. Crowder, R.N., M.P.H.
Director of Medical Services
Division of Medicaid
Robert E. Lee Building
239 North Lamar Street
Jackson, MS 39201
T: 601/359-5243
F: 601/359-5252
E-mail: maskc@medicaid.state.ms.us
Mail Order Pharmacy Program
Pilot Program
Medicaid Managed Care Contact
Melzana Fuller
Director of Provider and Beneficiary Relations
Division of Medicaid
Robert E. Lee Building
239 North Lamar Street,
Jackson, MS 39201
T: 601/359-6063
F: 601/359-4185
E-mail: mcmmf@medicaid.state.ms.us
Pharmacy and Therapeutics Committee
Craig Dawkins, M.D.
1213 Broad Avenue
Gulfport, MS 39501

Yolanda Wilson, M.D.
1600 North State Street, Suite 301
Jackson, MS 39202

Shannon Johnson, M.D.
South Mississippi Psychiatric Group
1101 B. South 28
th
Avenue
Hattiesburg, MS 39402

Gary Davis, M.D.
571 East Beasley Road, Suite D
Jackson, MS 39206

Charles Brock, M.D.
498 Hillcrest
Cleveland, MS 38732
National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-5
Myrna Alexander, M.D.
971 Lakeland Drive, Suite 850
Jackson, MS 39216

Betsy Commings, C.F.N.P
1740 McClain Street
Greenville, MS 38701

Guy Phillips, R.Ph.
903 Highway 82 East
Indianola, MS 38751

David Hudson, R.Ph.
389 NW Depot Street
Durant, MS 39063

Todd Barrett, R.Ph.
Covenant Pharmacy
2506 Lakeland Drive, Suite 101
Flowood, MS 39232

Jeff Jones, R.Ph.
Carthage Discount Drugs
602 Highway 16E
Carthage, MS 39051-4212

Larry Calvert, R.Ph.
720 Sarazen Drive
Gulfport, MS 39507
Executive Officers of State Medical and
Pharmaceutical Societies
Mississippi State Medical Association
William F. Roberts
Executive Director
P.O. Box 2548
Ridgeland, MS 39158-2548
601/853-6733
E-mail: wroberts@msmaonline.com
Internet address: www.msmaonline.com

Mississippi Pharmacists Association
Bo Dalton, R.Ph.
Executive Director
341 Edgewood Terrace Drive
Jackson, MS 39206-6217
601/981-0416
E-mail: mpha@bellsouth.net
Internet address: www.mspharm.org









Mississippi State Board of Pharmacy
Leland “Mac” McDivitt
Executive Director
625 North State Street
Jackson, MS 39202
T: 601/354-6750
F: 601/354-6071
E-mail: 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
E-mail: info@moma-net.org
Internet address: www.moma-net.org

Mississippi Hospital Association
Sam W. Cameron
President/CEO
P.O. Box 16444
6425 Lakeover Road
Jackson, MS 39236-6444
T: 800/289-8884
F: 601/368-3200
E-mail: scameron@mhanet.org
Internet address: www.mhanet.org

Mississippi Society of Health-System Pharmacists
Dianna McGowan
Association Manager
328 Dover Lane
Madison, MS 39110
T: 601/856-9273
F: 601/856-8539
E-mail: johnnymcg@msn.com
Internet address: www.pharmd.org/mshp

Mississippi Health Care Association
Vanessa P. Henderson
Executive Director
114 Marketridge Drive
Ridgeland, MS 39157
T: 601/956-3472
F: 601/977-0273
E-mail: vanessa@mshca.com
Internet address: www.mshca.com



National Pharmaceutical Council Pharmaceutical Benefits 2003
Mississippi-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-1
MISSOURI


A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $680,574,899 472,624 $790,853,387

RECEIVING CASH ASSISTANCE TOTAL $302,169,328 173,944
Aged $52,969,010 21,219
Blind/Disabled $220,471,969 71,356
Child $12,427,726 46,893
Adult $16,300,623 34,476

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $46,561,919 108,561
Aged $6,632,609 3,988
Blind/Disabled $14,729,020 4,105
Child $23,680,913 87,976
Adult $1,519,377 12,492

TOTAL OTHER EXPENDITURES/RECIPIENTS* $331,843,652 190,119

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-2
C. ADMINISTRATION
Division of Medical Services, Missouri Department
of Social Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Categories or
drugs that are covered: prescribed insulin;
disposable needles and syringe combinations used
for insulin; blood glucose test strips; urine ketone
test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Limited coverage
(limited to OTC formulary) for: allergy, asthma,
and sinus products; analgesics; cough and cold
preparations; digestive products (non-H2
antagonists); and topical products. Prior
authorization required for: amphetamines;
barbiturates; Isotretinoin; and Retinoic Acid.
Products not covered: cosmetics; fertility drugs;
experimental drugs; smoking deterrent products and
feminine products.
Therapeutic Catogory Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonsulants; anti-depressants; antidiabetic
agents; anti-psychotics; cardiac drugs;
chemotherapy agents; contraceptives; ENT anti-
inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); thyroid
agents; and anxiolytics, sedatives, and hypnotics
(PA required). Partial coverage for: anabolic
steroids; analgesics, antipyretics, and NSAIDs;
antihistamines; antilipemic agents; prescribed cold
medications; growth hormones; and misc. GI drugs
(PA required). Categories not covered: anoretics;
prescribed smoking deterrents.
(For additional information on products and/or
category coverage, see the pharmacy provider
bulletin at www.medicaid.state.mo.us.)
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in physician offices, home
health care settings, and extended care facilities.
Vaccines: Vaccines reimbursable as part of the
Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.

Formulary/Prior Authorization
Formulary: Open formulary with exclusions and
restrictions, including preferred products, physician
profiling, prior authorization, clinical edits, and step
therapy.
Prior Authorization: State currently has a prior
authorization procedure and a Drug Prior
Authorization Committee composed of 9 members
who meet quarterly. Fair hearing process to appeal
prior authorization decisions.
Prescribing or Dispensing Limitations
Prescription Refill Limit: None
Monthly Quantity Limit: Physician encouraged to
prescribe 34-day or 100 dose supply but may, at
own discretion, prescribe up to a maximum 90-day
supply.
Dose Limit: Prescriptions for the following must be
dispensed for at least 200 units per prescriptions:
Aspirin 5 gr.; Aspirin buffered 5 gr.; Aspirin
enteric-coated 5 gr.; Acetaminophen 5 gr. Prenatal
vitamins must be dispensed in a quantity of at least
100.
Drug Utilization Review
PRODUR system implemented in 1993. State
currently has a 13 member DUR Board with a
quarterly review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $4.09 (out-of-state), $8.04 (in-
state), $8.19 (long-term care pharmacies).
Ingredient Reimbursement Rate: EAC = AWP-
10.43% or WAC+10%.
Prescription Charge Formula:
1. Method of reimbursement payment is based on
acquisition cost plus a dispensing fee per
prescription filled. Acquisition may vary
depending whether it is based on AWP and
Federal or Missouri MAC.
2. Any drug that is not a Federal or Missouri
MAC drug will be based on the AWP-10.43%
or the WAC+10%. The majority of drugs listed
are based on AWP. The method of pricing will
be taken from the NDC number.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-3
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. 910 drugs are listed on the State-
specific MAC list. Override requires prior
authorization and a MedWatch form.
Incentive Fee: None.
Patient Cost Sharing: Variable copayment:
Drug Ingredient Cost Copayment
$0.00 to $10.00 $0.50
$10.01 to $25.00 $1.00
$25.01 or more $2.00
($5.00 copayment for certain 1115 waiver
populations (see Pharmacy Bulletin).)
Copayment retained by pharmacist.
Cognitive Services: Payment for cognitive services
is provided to qualified pharmacies who enroll to
provide asthma, diabetes, heart failure, and
depression education.
E. USE OF MANAGED CARE
Approximately 402,000 Medicaid recipients are
enrolled in managed care organizations in 2002.
All receive pharmacy services through managed
care. Protease inhibitors are carved out of managed
care.
Managed Care Organizations
Healthcare USA
100 South 4th Street, Suite 1100
St. Louis, MO 63102
314/444-7239

Blue Advantage Plus Health Plan
P.O. Box 419130
2301 Main St.
Kansas City, MO 64141
816/395-3891

Mercy Health Plan
425 S. Woods Mill Road
Chesterfield, MO 63017
314/214-8000

Care Partners Health Plan
The Clayton Center
120 S. Central, 8
th
Floor
St. Louis, MO 63105
314/505-5400
Community Care Plus Health Plan
5615 Pershing Avenue, Suite 29
St. Louis, MO 63112
314/454-0055 ext. 234

HealthNet Health Plan
2300 Main Street, Suite 700
Kansas City, MO 64108
816/221-8400

FirstGuard Health Plan
3801 Blue Parkway
Kansas City, MO 64130
816/922-7250

Family Health Partners Health Plan
215 W. Pershing Road, Suite 310
P.O. Box 411806
Kansas City, MO 64141
816/855-1871

Missouri Care Health Plan
2404 Forum Boulevard
Columbia, MO 65203
573/441-2100
F. STATE CONTACTS
State Drug Program Administrator
George L. Oestreich, Pharmacy Program Director
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/751-6961
F: 573/522-8514
E-mail: George.L.Oestreich@dds.mo.gov
Internet address: www.dss.mo.gov/dms
Social Services Department Officials
Steve Roling, Director
Department of Social Services
Broadway State Office Building
221 West High Street
P.O. Box 1527
Jefferson City, MO 65102
T: 573/751-4815
F: 573/751-3203
E-mail: dorisia.lorts@dss.mo.gov

National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-4
Christine Rackers, Director
Department of Social Services
Division of Medical Services
615 Howerton Court, P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/751-3425
F: 573/751-6564
E-mail: crackers@dss.state.mo.us
New Brand Name Products Contact
Rhonda A. Driver
Clinical Pharmacist
Department of Social Services
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102- 6500
T: 573/751-6961
F: 573/522-8514
E-mail: Rhonda.Driver@dss.mo.gov
Prior Authorization Contact
Rhonda A. Driver
573/751-6961
DUR Contact
Jayne Zemmer
DUR Coordinator
Division of Medical Services
P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/751-1612
F: 573/526-4650
E-mail: Jayne.A.Zemmer@dss.mo.gov
DUR Board
John W. Newcomer, M.D. (Chair)
Associate Professor of Psychiatry
Washington University, School of Medicine
Campus Box 8134
660 S. Euclid
St. Louis, MO 63110

Ronald Graham, Pharm.D.
Government Relations Manager
Novartis Corporation
1311 Granite Creek Drive
Blue Springs, MO 64015

Randall Huss, M.D.
Rolla Family Practice
910 W. 10th Street
Rolla, MO 65401

Joy S. Gronstedt, D.O.
30580 Summers Drive
Sedalia, MO 65301

Joseph M. Yasso, D.O.
3513 NW Primrose Lane
Lee’s Summit, MO 64064

Harold Lurie, M.D.
Springfield, MO

Karla Dwyer, R.Ph.
901 Cherry Lane
Kirksville, MO 63501

Susan Abdel-Rahman, Pharm.D.
Division of Clinical Pharmacology
Children’s Mercy Hospital
2401 Gillham Road, Suite 0411
Kansas City, MO 64108

Peggy Wanner-Barjenbrunch, M.D.
Mexico Health Services
809 Medical Park Drive, Suite 104
Mexico, MO 65265

Sandra Bollinger, Pharm.D.
Health Priorities, Inc.
707 Specialty Drive
Dexter, MO 63841

Stephen Calloway, Pharm.D.
Columbia, MO

Robert Dale Potter, R.N.
422 West Robin Ridge Road
Columbia, MO 65203
Drug Prior Authorization Committee
Patrick J. Bryant, Pharm.D.
Drug Information Center
School of Pharmacy
University of Missouri - Kansas City
MG-200 Medical School Building
2411 Holmes Street
Kansas City, MO 64108-2792

M. Dale Terrell, M.D.
Washington University School of Medicine
Division of Geriatric Medicine
Room M238
1402 South Grand Blvd.
St. Louis, MO 63104

Gene Forrester, R.Ph.
2400 S. Blackthorne
Columbia, MO 65201

Henry Petry, D.O.
Laurie Clinic
P.O. Box 1277
Laurie, MO 65038
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-5
James E. Edwards, M.D.
1000 Executive Pkwy, Suite 103
St. Louis, MO 63141

Lorraine C. Brown, D.O.
Rt. 2, Box 247C
Camdenton, MO 65020

Conrad S. Balcer, D.O.
1241 W. Stadium Boulevard
Jefferson City, MO 65109
Prescription Price Updating
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
T: 650/588-5454
F: 650/872-4510
Medicaid Drug Rebate Contact
Lynn Hebenheimer
Medicaid Unit Supervisor
Division of Medicaid Services
Drug Rebate Unit
P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/526-5664
F: 573/522-2594
E-mail: Lynn.Hebenheimer@dss.mo.gov
Claims Submission Contact
Diane Twehous
Claims Process Administrator
Verizon Data Services
905 Weathered Rock Road
Jefferson City, MO 65109
573/635-2434
Medicaid Managed Care Contact
Judy Muck
Assistant Deputy Director
Division of Medical Services
Managed Care Unit
P.O. Box 6500
Jefferson City, MO 65102-6500
T: 573/526-2886
F: 573/526-3946
E-mail: Judy.Muck@dss.mo.gov
Mail Order Pharmacy Program
None

Disease Management/ Patient Education
Programs
Disease Medical States: Asthma
Cardiovascular Disease
Depression
Diabetes
Program Manager: Jennifer Cornelious
Program Sponsor: State of Missouri
Disease Management Initiatives Contact
George Oestreich
573/781-6961
Pharmacy Subcommittee Roster
Bill Fitzpatrick, R.Ph.
Interlock Pharmacy Systems
2292 Weldon Parkway
St. Louis, MO 63146

Philip A. Bangert, R.Ph.
Bangert Pharmacy, Ltd.
13300 New Halls Ferry
Florissant, MO 63033

Tom Beetem, R.Ph., Chairman
1425 Eastview Drive
Holts Summit, MO 65043

Robert D. Hurley, R.Ph.
Walgreens
440 N. Highway 67
Florissant, MO 63031

Craig Leonard, R.Ph.
Lee’s Summit Pharmacy
615 W. 3rd Street
Lee’s Summit, MO 64063
Executive Officers of State Medical and
Pharmaceutical Societies
Missouri State Medical Association
C. C. Swarens
Executive Secretary
113 Madison Street, P.O. Box 1028
Jefferson City, MO 65102
T:573/636-5151
F: 573/636-8552
E-mail: cswarens@msma.org
Internet address:
www.momed.net/momed/index.htm
National Pharmaceutical Council Pharmaceutical Benefits 2003
Missouri-6
Missouri Pharmacy Association
Ron Fitzwater
Chief Executive Officer
211 East Capitol Avenue
Jefferson City, MO 65101-3001
T: 573/636-7522
F: 573-636-7485
E-mail: ron@morx.com
Internet address: www.morx.com

Missouri Assoc. of Osteopathic
Physicians/Surgeons, Inc.
Bonnie M. Bowles
Executive Director
1423 Randy Lane - P.O. Box 748
Jefferson City, MO 65102
T: 573/634-3415
F: 573/634-5635
E-mail: maopsemail@cs.com
Internet address: www.maops.com

State Board of Pharmacy
Kevin E. Kinkade
Executive Director
3605 Missouri Boulevard
P. O. Box 625
Jefferson City, MO 65102
T: 573/751-0091
F: 573/526-3464
E-mail: pharmacy@mail.state.mo.us
Internet address:
www.ecodev.state.mo.us/pr/pharmacy

Missouri Hospital Association
Marc Smith
President
4712 Country Club Drive
P.O. Box 60
T: 573/893-3700
F: 573/893-2809
E-mail: msmith@mail.mhanet.com
Internet address: www.mhanet.com















































National Pharmaceutical Council Pharmaceutical Benefits 2003
Montana-1
MONTANA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $69,552,397 63,338 $77,845,461 67,341

RECEIVING CASH ASSISTANCE, TOTAL $33,656,590 25,847 $37,412,054 28,190
Aged $2,737,151 1,546 $2,999,604 1,524
Blind / Disabled $26,502,817 10,510 $28,765,236 10,729
Child $1,528,685 8,838 $2,074,230 9,751
Adult $2,887,937 4,953 $3,572,984 6,186

MEDICALLY NEEDY, TOTAL $19,932,987 7,701 $22,229,084 7,821
Aged $11,577,514 5,327 $12,853,926 5,336
Blind / Disabled $8,337,077 2,318 $9,364,165 2,449
Child $18,336 55 $10,665 34
Adult $60 1 $328 2

POVERTY RELATED, TOTAL $1,798,235 11,913 $2,534,084 13,561
Aged $0 - $14 1
Blind / Disabled $0 - $0 -
Child $1,509,510 9,980 $2,079,724 11,322
Adult $288,725 1,933 $454,346 2,238

TOTAL OTHER EXPENDITURES/RECIPIENTS* $14,164,585 17,877 $15,670,239 17,769

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data provided by Montana Department of Public Health and Human Services, Medicaid Services Bureau.

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


National Pharmaceutical Council Pharmaceutical Benefits 2003
Montana-2
C. ADMINISTRATION
Department of Public Health and Human Services,
Medicaid Services Bureau.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
legend drugs, prescribed insulin; certain prescribed
over-the-counter products, vaccines except children
18 and under and clients with Medicare Part B
coverage; compounded prescriptions; contraceptive
supplies and devices. Products not covered:
cosmetics; fertility drugs; experimental drugs;
disposable needles used for insulin, syringe
combinations for insulin use; blood glucose test
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition.
Prior authorization required for non-steroidal anti-
inflammatory drugs; all single source NSAIDs;
Celebrex, Vioxx; disease-modifying anti-rheumatic
drugs (Arava, Enbrel, Remicade); growth
hormones; single-source benzodiazepines; gastro-
intestinal drugs (including H2 antagonists, proton
pump inhibitors, Carafate and Cytotec); migraine
headache drugs for certain monthly quantities on
Imitrex, Maxalt, Zomig, Migranal, Amerge; weight
reduction drugs (Fastin, Ionamin, Meridia,
Xenical); smoking-cessation drugs; Toradoloral;
Dipyridamole; Aggrenox; Trental, Pletal; Ambien
and Sonata; Viagra; Thalomid; Zyvox; Tretinoin;
Zoloft; Hismanal; Bextra; Kineret; Stadol;
Isoetherine; and Isoproterenol.
Over-the-Counter Product Coverage: Products
covered with restrictions (i.e., when prescribed):
analgesics (aspirin only); allergy, asthma, and sinus
products (Loratadine only); insulin; laxatives;
antacids; head lice treatment; H2 antagonist GI
products; bronchosaline; and smoking deterrent
products. Products not covered: cold and cough
preparations; feminine products; and topical
products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents; antilipemic agents; anti-
psychotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents.
Partial coverage for: prescribed cold medications.
Prior authorization required for: anorectics;
antihistamines; anxiolytics, sedatives, and
hypnotics; analgesics, antipyretics, NSAIDs; and
growth hormones.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities, and through physician
payment when used in physician offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT service, the Children Health Insurance
Program, and the Vaccines for Children Program.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. Drugs classified as
less-than-effective (LTE) by the FDA are not
covered. Drugs with no manufacturer rebate are
not covered.
Prior Authorization: State has a formal prior
authorization procedure. Prescriber letter
documenting evidence for use of prescribed
medication in treatment of disease is reviewed by
DUR Board for appeal of excluded product. An
appeal procedure through the Department possible
for PA decisions.
Prescribing or Dispensing Limitations
Prescription Refill Limit: 25% grace period over a
3-month period is allowed.

Monthly Quantity Limit: 34-day supply.
Drug Utilization Review
PRODUR system implemented in September 1994.
State DUR Board (DUE Care Program) has 6
members and meets monthly.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $2.00-$4.70; effective 7/1/02.
Pharmacies submit documentation showing their
costs. Dispensing fee is based on their cost up to a
maximum of $4.70. Pharmacies that do not submit
documentation receive a dispensing fee of $2.00.
Ingredient Reimbursement Basis: EAC = AWP -
15%.
Prescription Charge Formula: The lower of EAC,
the Federal MAC (plus a dispensing fee), or the
provider usual and customary charge.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Necessary” or prior authorization.
Incentive Fee: None.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Montana-3
Patient Cost Sharing: Copayment of $1.00 - $5.00.
Recipient pays 5% of Medicaid allowable cost
between $1.00 and $5.00. $5.00 copayment cap per
prescription. $25.00 copayment cap per month.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
HMO availability began November 1995, to FAIM
recipients. SSI and SSI-related clients were eligible
to enroll October 1, 1997. HMO coverage ended
June 30, 2000.
F. STATE CONTACTS
State Drug Program Administrator
Dan Peterson Pharmacy Program Officer
Department of Public Health and Human Services
Medicaid Services Bureau
P.O. Box 202951
1400 Broadway
Helena, MT 59620-2951
T: 406/444-2738
F: 406/444-1861
E-mail: danpeterson@state.mt.us
Internet address: www.dphhs.state.mt.us
Public Health and Human Services Officials
Dr. Gail Gray, Director
Department of Public Health and Human Services
P.O. Box 4210
111 N. Sauders
Helena, MT 59604
T:406/444-5622
F: 406/444-1970
E-mail: ggray@state.mt.us

Chuck Hunter, Administrator
Division of Health Policy and Services
Department of Public Health and Human Services
1400 Broadway
Helena, MT 59601
T: 406/444-4458
F: 406/444-1861
E-mail: chunter@state.mt.us

John Chappuis
Medicaid Director
406/444-4084

Duane Pershinger, Bureau Chief
Acute Services Section
406/444-4144

Mary Angela Collins, Bureau Chief
Managed Care Section
406/444-4146

Brett Williams, Bureau Chief
Hospital and Clinic Section
406/444-9614
Prior Authorization Contact
Mark Eichler, R.Ph., FASCP
DUR Coordinator
Mountain-Pacific Quality Health Foundation
3404 Cooney Drive
Helena, MT 59602
T: 406/443-4020
F: 406/443-4585
E-mail: meichler@mpqhf.org
DUR Contact
Mark Eichler, R.Ph., FASCP
T: 406/443-4020
Montana DUR Board
Mark Eichler, R.Ph., FASCP
DUR Coordinator

V. Lee Harrison, M.D.
Richard Sargent, M.D.
Marcella Barnhill, R.Ph.
Lori Fitzgerald, Pharm. D.
Prescription Price Updating
First DataBank
1111 Bayhill Dr.
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Betty DeVaney, Drug Rebate Coordinator
Department of Public Health & Human Services
Medicaid Services Bureau
P.O. Box 202951
1400 Broadway
Helena, MT 59620-2591
T: 406/444-3457
F: 406/444-1861
E-mail: bdevaney@state.mt.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Montana-4
Claims Submission Contact
Kevin Quinn, Executive Account Manager
ACS, Inc.
34 N. Last Chance Gulch, Suite 200
Helena, MT 59601
T: 406/442-7693
F: 406/442-2819
E-mail: kevin.quinn@acs-inc.com
Medicaid Managed Care Contact
Jo Thompson, Program Officer
Dept. of Public Health and Human Services
Medicaid Services Bureau
P.O. Box 202951
1400 Broadway
Helena, MT 59620-2951
T: 406/444-4148
F: 406/444-1861
E-mail: jothompson@state.mt.us
Disease Management/Patient Education
Programs
Disease/Medical State: Asthma
Program Name: Nurse First Asthma Program
Program Manager: Ted Weldon
Program Sponsor: Mckesson Health Solutions

Disease/Medical State: Cardiovascular disease
Program Name: Nurse First Asthma Program
Program Manager: Ted Weldon
Program Sponsor: Mckesson Health Solutions

Disease/Medical State: Diabetes
Program Name: Nurse First Asthma Program
Program Manager: Ted Weldon
Program Sponsor: Mckesson Health Solutions

Disease/Medical State: Chronic Pain
Program Name: Nurse First Asthma Program
Program Manager: Ted Weldon
Program Sponsor: Mckesson Health Solutions
Disease Management Program/Initiative
Contact
Jacklynn Thiel, Quality Assurance Program Officer
Dept. of Public Health and Human Services
Medicaid Services Bureau
P.O. Box 202951
1400 Broadway
Helena, MT 59620-2951
T: 406/444-1834
F: 406/444-1861
E-mail: jthiel@state.mt.us
Mail Order Pharmacy Benefit
None
Executive Officers of State Medical and
Pharmaceutical Societies
Montana Medical Association
G. Brian Zins
Executive Vice President/CEO
2021 11th Avenue, Suite 1
Helena, MT 59601-4890
T: 406/443-4000
F: 406/443-4042
E-mail: brian@mmaoffice.com
Internet address: www.mmaoffice.com

Montana Pharmacy Association
Jim E. Smith
Executive Director
P. O. Box 1569
34 West 6
th
Avenue, Suite 2E
Helena, MT 59601-5074
T: 406/449-3843
F: 406/443-1592
E-mail: jimesmith@qwestreet.net
Internet address: www.rxmt.org

State Board of Pharmacy
Rebecca Deschamps, R.Ph.
Executive Director
P.O. Box 200513
301 South Park, 4
th
Floor
Helena, MT 59620-0513
T: 406/841-2355
F: 406/841-2343
E-mail: dlibspdha@state.mt.us
Internet address:
discoveringmontana.com/dli/bsd/license/bsd_board
s/pha_board/board_page.htm

Montana Osteopathic Medical Association
Carmen Bell
Executive Director
1600 2
nd
Avenue, SW, Suite 120
Minot, ND 58701
701/852-8789
E-mail: drbillmunro@macn.net

Montana Hospital Association
Dick Brown
Sr. Vice President/Executive Director
P.O. Box 5119
Helena, MT 59604
406/442-1911, Ext. 26
E-mail: dick@mtha.org
Internet address: www.medassets.com/mtha.htm
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-1
NEBRASKA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients
TOTAL $161,577,499 178,365 $196,409,250 194,714

RECEIVING CASH ASSISTANCE TOTAL $58,978,402 45,490 $69,279,614 48,501
Aged $8,756,182 3,959 $9,843,626 3,983
Blind/Disabled $42,225,001 15,234 $49,388,569 15,517
Child $3,734,776 17,651 $4,534,213 19,350
Adult $4,262,443 8,646 $5,513,206 9,651

MEDICALLY NEEDY, TOTAL $40,152,899 30,671 $48,643,338 33,381
Aged $25,640,472 9,676 $29,632,049 9,808
Blind/Disabled $5,365,283 1,463 $6,684,567 1,527
Child $1,810,841 6,569 $2,260,713 6,761
Adult $7,336,303 12,963 $10,066,009 15,285

POVERTY RELATED, TOTAL $50,564,381 78,571 $65,092,478 90,996
Aged $13,567,579 6,293 $15,871,572 6,505
Blind/Disabled $22,577,439 7,496 $29,727,730 8,077
Child $13,960,793 60,808 $18,756,628 71,240
Adult $458,570 3,974 $736,548 5,174

TOTAL OTHER EXPENDITURES/RECIPIENTS* $11,881,817 23,633 $13,393,820 21,836

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data provided by the Nebraska Department of Health and Human Services, Finance and Support, Medicaid Division.

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-2
C. ADMINISTRATION
State Department of Health and Human Services,
Finance and Support, Medicaid Division.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
legend drugs, compound prescriptions, prescribed
insulin with prior approval (i.e., must be medically
necessary on pre-filled syringes). Products covered
under the supplier program: disposable needles
used for insulin; blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and
interdialytic parenteral nutrition. Products not
covered: DESI drugs, drugs for weight control;
cosmetics; fertility drugs; and experimental drugs.
Prior authorization required for: methadone; IV
infusions; and protein replacement supplements.
Over-the-Counter Product Coverage: Products
covered: (must be prescribed and subject to rebate)
allergy, asthma, and sinus products; analgesics;
topical products; cough and cold preparations;
digestive products; and feminine products.
Products not covered: smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids;
anticoagulants; anticonvulsants; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: analgesics,
antipyretics, NSAIDs; antibiotics (Zyvox); anti-
depressants (Zoloft 25+ 50mg); antidiabetic agents
(Glucovance); antihistamine (low sedating); growth
hormones; misc. GI drugs (PPIs); sunscreens;
Erythropoetin (e.g., Epogen, Procrit); modified
versions of FUL or SMAC drugs; convenience
packaged drugs (e.g., Refresh Ophthalmic 0.3 ml
and Novalin penfil insulin); drugs to prevent or
treat Respiratory Syncytial Virus Immune Globulin
(e.g., Palivizumab, RSV-IG); and drugs for sexual
dysfunction (e.g., Sildenafil, Alprostadil). Partial
coverage for: anxiolytics, sedatives, and hypnotics.
Therapeutic categories not covered: anorectics and
prescribed smoking deterrents.
Coverage of Injectables: Injectables reimbursable
through the Pharmacy program when used in home
health care and extended care facilities, and through
physician payment when used in physician offices.
Vaccines: Vaccines reimbursable by Medicaid for
individuals under 21 years of age as part of EPSDT
services, through the Children’s Health Insurance
Program, and through the Vaccines for Children
Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. General exclusions
include:
1. More than a three-month supply of birth
control tablets;
2. Experimental drugs or non-FDA approved
drugs;
3. Drugs or items when the prescribed use is not
for a medically accepted indication;
4. Liquors (any alcoholic beverages);
5. DESI drugs and all identical, related, or similar
drugs;
6. Personal care items (e.g. non-medical
mouthwashes, deodorants, talcum powders,
bath powders, soaps, dentrifices, eye washes,
and contact solutions);
7. Medical supplies and certain drugs for nursing
facility and intermediate care facility for the
mentally retarded (ICF/MR) patients;
8. Over-the-counter (OTC) drugs not listed on the
Department’s Drug Name/License Number
Listing microfiche;
9. Baby foods or metabolic agents (Lofenalac,
etc.,) normally supplied by the Nebraska
Department of Health;
10. Drugs distributed or manufactured by certain
drug manufacturers or labelers that have not
agreed to participate in the drug rebate
program.

Drugs, items, or manufacturers that are identifiable
as non-covered are so designated on the NE-POP
system, and on the Department’s Drug
Name/License Number Listing microfiche or
website.
Prior Authorization: State currently has a formal
prior authorization procedure. The Department
requires that authorization be granted prior to
payment for certain products. Prior authorization
can be verified through the NE-POP System, or by
contacting the Department. (or its designated
contractor) if authorization is not verified through
the NE-POP System.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-3
Prescribing or Dispensing Limitations
Prescription Refill Limit: As authorized by the
prescribing physician. For controlled substances,
maximum 5 refills every 6 months.
Monthly Quantity Limit: 90-day supply or 100
dosage units, whichever is greater. 31-days for
injectables.
Drug Utilization Review
PRODUR system implemented in April 1995.
State currently has a DUR Board with a monthly
review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.27 - $5.00. The Nebraska
Department of Health and Human Services assigns
a dispensing fee to each individual pharmacy based
on location, services, volume, and other third-party
participation. The fee is calculated from
information obtained through the Department’s
Prescription Survey.
Ingredient Reimbursement Basis: EAC = AWP -
11%.
Prescription Charge Formula: Lower of:
1. Product cost (EAC, SMAC, or FUL) plus a
dispensing fee, or
2. The usual and customary price to the general
public.
Listed OTCs are reimbursed at the lower of:
1. Product cost (EAC, SMAC, or FUL) plus a
dispensing fee,
2. The usual and customary shelf price to the
general public, or
3. Product cost (EAC, SMAC, or FUL) plus a
50% mark-up.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Approximately 1,400 drugs are
listed on the State-specific MAC list. Override
requires a “Medically Necessary” form signed by
the physician.
Incentive Fee: None.
Patient Cost Sharing: Copayment = $2.00.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 156,000 unduplicated Medicaid
recipients were enrolled in managed care in 2002.
Recipient enrolled in MCOs receive pharmaceutical
services through the State.
Managed Care Organizations
Share Advantage
United HealthPlans of the Midlands
2717 North 118
th
Circle
Omaha, NE 68164

Primary Care +
Blue Cross/Blue Shield of Nebraska
P.O. Box 241739
Omaha, NE 68124

Value Options Mental Health
10330 Regency Parkway
Omaha, NE 68114
F. STATE OFFICIALS
State Drug Program Administrator
Dyke Anderson, R.Ph
Pharmacy Consultant
Department of Health and Human Services
Finance and Support Medicaid Division
301 Centennial Mall South, 5
th
Floor-NSOB
P.O. Box 95026
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
Health and Human Services Department
Officials
Stephen Curtiss, Director
Department of Health and Human Services
Finance and Support
P.O. Box 95026
Lincoln, NE 68509-5026
T: 402/471-8553
F: 402/471-9449
E-mail: kelly.ostrander@hhss.state.ne.us

National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-4
Robert J. Seiffert, Administrator
Medicaid Division
Department of Health and Human Services
Finance and Support
P.O. Box 95026
301 Centennial Mall South, 5
th
Floor
Lincoln, NE 68509-5026
T: 402/471-9223
F: 402/471-9092
E-mail: bob.seiffert@hhs.state.ne.us

Richard Raymond, M.D., Chief Medical Official
Department of Health and Human Services
402/471-9105

Kris Azimi
Utilization Review Consultant
402/471-7620

Christine Wright, M.D., Medical Director
Medicaid Division
402/471-9136
Prior Authorization Contacts
Dyke Anderson, R.Ph.
402/471-9379
Barbara Mart
Clinical Pharamacist
Health and Human Services
301 Centennial Mall South
5th Floor-NSOB
P.O. Box 95026
Lincoln, NE 68509-5026
T: 402/471-9301
F: 402/471-9092
E-mail: barb.mart@hhhs.state.ne.us
DUR Contact
Beth Wilson
DUR Director
Nebraska Pharmacists Association
6221 South 58
th
, Suite A
Lincoln, NE 68516
T: 402/420-1500
F: 402/420-1406
E-mail: beth@npharm.org
Nebraska DUR Board
Pharmacist Members:
Kevin Borcher, R.Ph.
Elissa Carney, R.Ph.
Patty Gollner, R.Ph.
David Hutsell, R.Ph.
John Franklin, R.Ph.
Kim Hamik, R.Ph.
Shannon Nelson, R.Ph.
Phillip Vuchetich, R.Ph.
Physician Members:
Kay Anderson, M.D.
Fred Ayers, M.D.
Kirk Muffly, M.D.
Thomas B. Murray, M.D.
Sam Perry, M.D.
New Brand Name Products Contact
Dyke Anderson, R.Ph.
402/471-9379
Prescription Price Updating
First DataBank
1111 Bayhill Dr.
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Technical
Karen Jaques
Accountant II
Health and Human Services – Finance and Support
301 Centennial Mall South
5
th
Floor – NSOB
P.O. Box 95026
Lincoln, NE 68509-5026
F: 402/471-9397
E-mail: karen.jaques@hhss.state.ne.us

Policy
Dyke Anderson, R.Ph.
402/471-9379
Claims Submission Contact
Steve Smith
Account Representative
ACS State Healthcare
365 Northridge Road
Northridge Center One, Suite 400
Atlanta, GA 30350
T: 770/901-5002
F: 770/730-5198
E-mail: stephen.m.smith@acs-inc.com
Medicaid Managed Care Contact
David Cygan
Managed Care Program Administrator
HHSS-Finance & Support-Medicaid
301 Centennial Mall South
Lincoln, NE 68509
T: 402/471-9050
F: 402/471-9455
E-mail: David.Cygan@hhss.state.ne.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-5
Mail Order Pharmacy Program
None
Medical Advisory Committee
Marlene Brondel
League of Human Dignity
1701 P Street
Lincoln, NE 68508

Tim Bruner
Director of Fiscal Services
Lincoln General Hospital
2300 South 16th Street
Lincoln, NE 68502

Joni Cover, J.D.
Executive Vice President
Nebraska Pharmacists Association
6221 South 58th Street, Suite A
Lincoln, NE 68502

Karen Miller
Health Insurance Specialist
Room 227, Federal Building
601 East 12
th
Street
Kansas City, MO 64106

Edmund A. Schneider, O.D.
Lincoln Vision Clinic
810 North 48
th
Street
Lincoln, NE 68504

Steven Lorenzen
Director, Federal Programs
Blue Cross/Blue Shield of NE
Main P.O. Station Box 3248
Omaha, NE 68180

John Milligan
Legal Services of Southeast Nebraska
825 Terminal Building
Lincoln, NE 68508

Joan Penrod, Ph.D.
Department of Preventive and Social Medicine
UNMC
Box 984350, 600 S. 42
nd
Street
Omaha, NE 68198

Larry Rennecker
NAHHS
1640 L Street, Suite D
Lincoln, NE 68508





Sandy Johnson
Executive Secretary
Nebraska Medical Association
First Bank Bldg., Suite 1512
Lincoln, NE 68508

Pat Snyder
Executive Director
Nebraska Health Care Association
421 South 9th Street, Suite 137
Lincoln, NE 68508

James Walker, D.D.S.
1640 South 70
th
, Suite 200
Lincoln, NE 68506
Executive Officers of State Medical and
Pharmaceutical Societies
Nebraska Medical Association
Sandra Johnson
Executive Vice President
233 S. 13
th
Street, Suite 1512
Lincoln, NE 68508-2091
402/474-4472
E-mail: nebmed@nebmed.org
Internet address: www.nebmed.org

Nebraska Pharmacists Association
Joni Cover, J.D.
Executive Vice President
6221 South 58
th
, Suite A
Lincoln, NE 68516-3679
T: 402/420-1500
F: 402/420-1406
E-mail: joni@npharm.org
Internet address: www.npharm.org

Nebraska Assn. of Osteopathic Physicians &
Surgeons
Arthur A. Weaver, D.O.
Secretary
16556 Dorcas Street
Omaha, NE 68130
402/554-2374

State Board of Pharmacy
Becky Wisell
Executive Secretary
P. O. Box 94986
Lincoln, NE 68509
T: 402/471-2115
F: 402/471-3577
E-mail: becky.wisell@hhss.state.ne.us
Internet address: www.hhs.state.ne.us/lis/lis.asp

National Pharmaceutical Council Pharmaceutical Benefits 2003
Nebraska-6
Nebraska Association of Hospitals and Health
Systems
Laura J. Redoutey, FACHE
President
1640 L Street, Suite D
Lincoln, NE 68508-2509
T: 402/458-4900
F: 402/475-4091
E-mail: lredoutey@nhanet.org
Internet address: www.nhanet.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nevada-1
NEVADA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $62,849,319 55,580 $86,929,536

RECEIVING CASH ASSISTANCE TOTAL $45,602,458 29,090
Aged $9,830,256 5,917
Blind/Disabled $34,597,803 16,240
Child $588,847 4,156
Adult $585,552 2,777

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $1,863,191 10,403
Aged $97,513 157
Blind/Disabled $259,384 255
Child $806,164 5,859
Adult $700,130 4,132

TOTAL OTHER EXPENDITURES/RECIPIENTS* $15,383,670 16,087

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
Note: Nevada estimates 2003 drug expenditures to be approximately $102.8 million.

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nevada-2
C. ADMINISTRATION
Division of Health Care Financing and Policy of
the Department of Human Resources.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products covered
under DME: total parental nutrition; interdialytic
parenteral nutrition. Products not covered:
cosmetics; fertility drugs; and experimental drugs.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics; cough and cold preparations; digestive
products; and smoking deterrent products. Products
covered with restrictions: topical products. OTC
drugs are reimbursed at EAC+$4.76 or the usual
and customary amount, whichever is less, and
require prior authorization. Products not covered:
feminine products.
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamine drugs; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT
anti-inflammatory agents; hypotensive agents;
misc. GI products; prescribed smoking deterrents;
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: CNS stimulants;
Hemapopoiletic; PPIs; Cox2 inhibitors; erectile
dysfunction medications; duragisic patches; HCG;
Gonadotropin, Gonadotropin releasing hormone
analog; Erythropoetin; Interferon; IV antibiotic;
Methylpenidate, Peomoline; vitamins; and
Remicade. Partial coverage for: growth hormones
(prior authorization required); estrogens; and
anabolic steroids. Therapeutic categories not
covered: anorectics; amphetamine combinations;
radiopague and radiographic products; DESI drugs;
yohimbine; and drugs not participating in the drug
rebate program.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities, and through physician
payment when used in physicians’ offices.
Vaccines: Vaccines reimbursable at cost plus an
administration fee ($3.83) as part of the EPSDT
service.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. General exclusions
include:
1. Agents used for cosmetic purposes or hair
growth.
2. Yohimbine (e.g., Yocon).
3. Radiopaque agents (e.g., Telepaque, Hypaque,
Barium Sulfate).
4. Radiographic adjuncts (e.g., Perchloracap).
5. Pharmaceuticals designed “ineffective,” or
“less than effective” (including identical,
related, or similar drugs) by the FDA.
6. Non-rebated medications.
Prior Authorization: State currently has a prior
authorization procedure with appeals process. Prior
authorization procedure screening for individual
drugs. Drugs requiring PA include:
1. Amphetamine (e.g., Dexedrine)
2. Chorionic Gonadotropin (HCG)
3. Dipyridamole (e.g., Persantine)
4. Erythropoietin (e.g., Epogen, Procrit)
5. Gonadotropin releasing hormone analog (e.g.,
Lupron, Zoladex)
6. Growth hormone (e.g., Protropin, Nutropin)
7. Interferon (all combinations manufactured by
recombinant DNA technology)
8. Intravenous antibiotic therapy
9. Methylphenidate (e.g., Ritalin)
10. Non-legend pharmaceuticals
11. Nutritional supplements or replacements
12. Pemoline (e.g., Cylert)
13. Pulmozyme
14. Vitamins, vitamin/mineral combinations or
hematinics
Prescribing or Dispensing Limitations
Monthly Quantity Limit: The maximum dispensable
quantity is limited to a 34-day supply. Maintenance
medications limited to a 100 day supply.
Drug Utilization Review
State currently has a DUR Board with a quarterly
review by a PRODUR contractor. PRODUR system
implemented in 2003.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nevada-3
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $4.76, effective 10/1/98. IV
dispensing fee is $16.80 for first ingredient; $5.60
for other ingredients.
Ingredient Reimbursement Basis: EAC = AWP-
15%.
Prescription Charge Formula: The lowest of (1)
specific upper limit (SUL) plus a dispensing fee, (2)
estimated acquisition cost (EAC) plus a dispensing
fee, or (3) the pharmacy's usual charge to the
general public.
Maximum Allowable Cost: State does not impose
Upper Limits on generic drugs.
Incentive Fee: None.
Patient Cost Sharing: None.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 61,000 Medicaid recipients are
enrolled in MCOs in 2002; all receive pharmacy
benefits through their managed care plan.
Managed Care Organizations
Health Plan of Nevada
P.O. Box 15645
Las Vegas, NV 89114

NevadaCare, Inc.
1701 W. Charleston Blvd.
Suite 420
Las Vegas, NV 89102
F. STATE CONTACTS
State Drug Program Administrator
Dionne Coston, R.N.
Medical Services Specialist
Division of Health Care Financing and Policy
Pharmacy Program
1100 E. Williams Street
Carson City, NV 89701
T: 775/684-3775
F: 775/684-3762
Email: dcpstpm@dhcfp.state.nv.us
Internet address: www.dhcfp.state.nv.us
Human Resources Department Officials
Michael J. Willden, Director
Department of Human Resources
State Capital Complex
505 East King Street, Room 600
Carson City, NV 89710
T: 775/684-4000
F: 775/684-4010
E-mail: slindsey@dhr.state.nv.us

Chuck Duarte
Administrator
Division of Health Care Financing and Policy
1100 E. Williams Street, Suite 116
Carson City, NV 89710
T: 775/684-3676
F: 775/684-8792
E-mail: cduarte@govmail.state.nv.us
Prior Authorization Contact
Dionne Coston, R.N.
775/684-3775
Steve Espy, R.Ph.
Director of Drug Utilization
Health Information Design, Inc.
1550 Pumphrey Avenue
Auburn, AL 36832
T: 205/402-9530
F: 205/402-9531
DUR Contact
Dionne Coston, R.N.
775/684-3775
DUR Board
Joseph W. Johnson, M.D.
110 E. Lake Mead Boulevard, #201
Henderson, NV 89015

Steven W. Parker, M.D.
75 Pringle Way, #603
Reno, NV 89503

David England, R.Ph.
University Medical Center Pharmacy
1800 W. Charleston Boulevard
Las Vegas, NV 89102

Lori Winchell, R.N.
341 Pinnacle Court
Henderson, NV 89014

Vanetta Christopherson
2149 Hidden Ranch Terrace
Henderson, NV 89052
National Pharmaceutical Council Pharmaceutical Benefits 2003
Nevada-4
New Brand Name Products Contact
Dionne Coston, R.N.
775/684-3775
Prescription Price Updating
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Technical: Anita Sheard, 775/684-3749
Policy: Dionne Coston, R.N., 775/684-3755
Rebate: Anita Sheard, 775/684-3749
Claims Submission Contact
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
800/884-3238
Medicaid Managed Care Contact
Hilary Jones, R.N.
Medicaid Services Specialist III
1100 E. Williams Street, Suite 204
Carson City, NV 89701
775/684-3697
E-mail: hjones@dhcfp.state.nv.us
Mail Order Pharmacy Program
None
Physician-Administered Drug Program
Contact
Coleen Lawrence, 775-684-3744
Medical Care Advisory Group
David England, Pharm.D.
Trudy Larson, M.D.
Dr. William Bannen, Medical Director, Anthem
BC/BS
Mr. Paul Boyar, Administrator, Plaza Regency at
Sun Mountain
Patricia Craddock, D.D.S.
Ms. Jessie Harris
Mr. Keith MacDonald, RPh.
Mr. Ken Richardson, Clinic Director, Walker River
Tribal Health Clinic
Ms. Linda Sheldon, State Coordinator, Nevada
Covering Kids Coalition
Mary Guinan, M.D., Nevada State Health officer,
Health Division
Executive Officers of State Medical and
Pharmaceutical Societies
Nevada State Medical Association
Lawrence P. Matheis
Executive Director
3660 Baker Lane, Suite 101
Reno, NV 89509
T: 775/825-6788
F: 775/825-3202
E-mail: nsma@nsmadocs.org
Internet address: www.nsmadocs.org

Nevada Pharmacy Alliance
Mary Grear, R.Ph.
Executive Vice President
c/o Nevada College of Pharmacy
5740 S. Eastern Avenue, Suite 240
702/990-4433
E-mail: nvphall@ludi.net
Internet address: www.nvphall.org

Nevada Osteopathic Medical Association
Denise Selleck Davis
Executive Director
2920 N. Green Valley Parkway, Suite 527
Las Vegas, NV 89014
T: 702/434-7112
F: 702/434-7110
E-mail: nvoma@aol.com
Internet address: www.nevadaosteopathic.com

State Board of Pharmacy
Keith W. MacDonald, R.Ph.
Executive Secretary
555 Double Eagle Court, Suite 1100
Reno, NV 89511-8991
T: 775/850-1440
F: 775/850-1444
E-mail: pharmacy@govmail.state.nv.us
Internet address: www.state.nv.gov/pharmacy

Nevada Hospital Association
Bill M. Welch
President/CEO
5250 Neil Road
Suite 302
Reno, NV 89502
T: 775/827-0184
F: 775/827-0190
E-mail: bill@nvha.net
Internet address: www.nvha.net



National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-1
NEW HAMPSHIRE
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $90,927,579 73,489 $99,682,997

RECEIVING CASH ASSISTANCE, TOTAL $25,669,473 18,137
Aged $3,216,921 1,436
Blind/Disabled $18,263,975 5,335
Child $1,567,158 7,533
Adult $2,621,419 3,833

MEDICALLY NEEDY, TOTAL $24,027,775 9,047
Aged $10,097,853 4,233
Blind/Disabled $11,643,790 2,676
Child $328,662 819
Adult $1,957,470 1,319

POVERTY RELATED, TOTAL $6,948,883 26,834
Aged $421,825 293
Blind/Disabled $437,532 257
Child $5,787,235 24,563
Adult $302,291 1,721

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,281,448 19,471

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-2
C. ADMINISTRATION
Office of Health Planning and Medicaid,
Department of Health and Human Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition;
and interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; and
experimental drugs.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics; cough and cold preparations; digestive
products (including H2 antagonists); feminine
products smoking deterrents; and topical products.
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
anticoagulants; anticonvulsants; anti-depressants;
antidiabetic agents; antihistamine drugs;
antilipemic agents; anti-psychotics; anxiolytics,
sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents;
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterrents. Therapeutic
categories/products requiring prior authorization:
anorectics; erectile dyfunction products; PPIs; Cox
IIs; Oxycontin; CNS stimulants; anti-fungals for
nail fungus; and rheumatoid arthritis agents. Brand
approval overrides required for NSAIDs, controlled
substances, and GI drugs for which there are
therapeutically equivalent (A-rated) generics
available.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home healthcare and
extended care facilities, and through physician
payment when used in physicians’ offices.
Vaccines: Vaccines reimbursable as part of the
EPSDT, CHIP, and VCP service. Childhood
immunization vaccine is provided to all children
through the Division of Public Health Services.
The Medicaid program does not reimburse
providers for routine vaccines, although an
administration fee is allowed.
Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. General exclusions
include cosmetic agents for hair growth,
experimental and fertility drugs. Management of
formulary includes prior authorization and quantity
limits on certain products (e.g., anti-emetics, anti-
migraine agents, etc.).
Prior Authorization: State currently has a formal
prior authorization procedure with an associated
grievance and appeal procedure.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: Limited to 30-day supply
Maintenance Medications: Limited to 90-day
Supply
Monthly Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in July 1995. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $1.75, effective 1/24/2004.
Ingredient Reimbursement Basis: EAC = AWP-
16%.
Prescription Charge Formula: Lesser of usual and
customary charge or AWP-16%, Federal Upper
Limit; State MAC; or DOJ pricing, plus a
dispensing fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Necessary.”
Incentive Fee: None.
Patient Cost Sharing: Copayment – Generics:
$1.00; Brand: $2.00, effective 3/1/04. Copayments
apply to all recipients except nursing home patients
in SNF or ICF facilities; home and community
based care waived recipients holding form 949;
pregnant women; children under 18 years; and
prescriptions for family planning drugs.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
None as of June 2003.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-3
F. STATE CONTACTS
State Drug Program Administrator
Margaret A. Clifford
Pharmacy Administrator
Office of Health Planning & Medicaid
129 Pleasant Street, Annex 1
Concord, NH 03301
T: 603/271-4210
F: 603/271-8701
E-mail: mclifford@dhhs.state.nh.us
Internet address: www.dhhs.state.nh.us
Department of Health and Human Services
Officials
John Stephen
Commissioner
Department of Health and Human Services
129 Pleasant Street
Concord, NH 03301-3857
T: 603/271-4331
F: 603/271-4912
E-mail: jstephen@dhhs.state.nh.us
Stephen Norton
Acting Director
Office of Health Planning & Medicaid
129 Pleasant Street
Concord, NH 03301
603/271-4297
snorton@dhhs.state.nh.us
DUR Contact
Lisè Farrand, R.Ph.
Pharmaceutical Services Specialist
Office of Health Planning & Medicaid
129 Pleasant Street, Annex 1
Concord, NH 03301
T: 603/271-4419
F: 603/271-8701
E-mail: lfarrand@dhhs.state.nh.us
Medicaid DUR Board
Paul S. Collins, M.D.
Mark Henschke, D.O.
Emory Kaplan, M.D.
Steve Lawrence, M.D.
Thomas Mellman, M.D.
Elizabeth Gower, R.Ph.
Helen Pervanas, R.Ph.
Michael Smith, R.Ph.
John Zinka, R.Ph.
New Brand Name Products Contact
Lisé Farrand, R.Ph.
603/271-4419
Prescription Price Updating
Sherrill Bryant
Plan Administrator
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
T: 800/884-2822
F: 804/965-7647
E-mail: bryantsh@fhsc.com
Medicaid Drug Rebate Contacts
John Cox
Rebate Pharmacist
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
T: 800/884-2822
F: 804/965/7647
E-mail: coxjo@fhsc.com
Claims Submission Contact
Sherrill Bryant
800/884-2822
Medicaid Managed Care Contact
Margaret A. Clifford
603/271-4210
Mail Order Pharmacy Benefit
None
Disease Management/Patient Education
Contact
Doris Lotz, M.D.
Medicaid Medical Director
Office of Health Planning & Medicaid
129 Pleasant Street, Annex 1
Concord, NH 03301
T: 603/271-8166
F: 603/271-8701
E-mail: dlotz@dhhs.state.nh.us









National Pharmaceutical Council Pharmaceutical Benefits 2003
New Hampshire-4
Pharmacy & Therapeutics Advisory
Committee
William Kassler, M.D., M.P.H.
Stephen Bartels, M.D.
Doris Lotz, M.D.
Bryan King, M.D.
Steven Paris, M.D.
Richard Lafleur, M.D.
Eric Pollak, M.D., M.P.H.Lenny Parker, R.Ph.
Margaret Clifford, R.Ph.
Roger Hebert, R.Ph.
Paul Santos, Pharm.D.
Robert Lenza, R.Ph.
Executive Officers of State Medical and
Pharmaceutical Services
New Hampshire Medical Society
Palmer P. Jones
Executive Vice President
7 N. State Street
Concord, NH 03301-4018
T: 603/224-1909
F: 603/226-2432
E-mail: 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.newhampshirepharmacistree.org
New Hampshire Osteopathic Association, Inc.
Robert Soucy, D.O.
President
7 North State Street
Concord, NH 03301
603/224-1909
E-mail: osteo@worldpath.net
Internet address: www.nh-osteopath.org

State Board of Pharmacy
Paul G. Boisseau
Executive Secretary
57 Regional Drive
Concord, NH 03301-8518
603/271-2350
E-mail: nhpharmacy@nhsa.state.nh.us
Internet address: www.state.nh.us/pharmacy




New Hampshire Hospital Association
Michael J. Hill, C.H.E.
President
125 Airport Road
Concord, NH 03301-7300
T: 603/225-0900
F: 603/225/4346
E-mail: mhill@nhh.org
Internet address: www.nhha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
New Jersey-1
NEW JERSEY
1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients
TOTAL $649,274,352 307,798 $694,669,924

RECEIVING CASH ASSISTANCE, TOTAL $364,861,677 165,644
Aged $66,082,464 30,760
Blind / Disabled $291,316,345 96,878
Child $1,682,939 14,742
Adult $5,779,929 23,264

MEDICALLY NEEDY, TOTAL $8,848,818 3,531
Aged $7,865,157 3,213
Blind / Disabled $948,839 230
Child $34,822 88
Adult $0 -

POVERTY RELATED, TOTAL $100,274,542 57,346
Aged $32,401,984 14,695
Blind / Disabled $64,930,600 16,665
Child $2,513,691 20,113
Adult $428,267 5,873

TOTAL OTHER EXPENDITURES/RECIPIENTS* $175,289,315 81,277


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

1
The State of New Jersey did not respond to the 2002 or 2003 NPC Surveys. Using CMS data and other source materials, we have, to the
extent possible, updated the Profile and the tables in other sections of the Compilation. Users should contact the New Jersey Medicaid
program to assess the accuracy and currency of the information included.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Jersey-2
C. ADMINISTRATION
Division of Medical Assistance and Health
Services, Department of Health and Human
Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations for insulin use; blood glucose test
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs;
and experimental drugs, and DESI drugs. Prior
authorization required for: methadone; IV
infusions; and protein replacement supplements.
Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics; topical products; cough and cold
preparations for children under age 21;
contraceptive devices and supplies; family planning
supplies (e.g., pregnancy test kits); and smoking
deterrent products (inhaler or nasal spray).
Products not covered: digestive products; feminine
products; contraceptives; pregnancy test kits;
inhalation drugs; and antacids.
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics,
NSAIDs; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic
agents; antihistamine drugs; anti-psychotics;
anxiolytics, sedatives, and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications;
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); and thyroid agents.
Prior authorization required for: antilipemic agents.
Partial coverage for: anabolic steroids; anorectics
(for ADD); growth hormones; and prescribed
smoking deterrents.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facilities and through physician
payment when used in physician offices.
Vaccines: Vaccines reimbursable at AWP as part of
the EPSDT program and the Vaccines for Children
Program.
Unit Dose: Unit dose packaging reimbursable in
long-term care facilities only, not in retail settings
(unless u/d is only way item is packaged).
Formulary/Prior Authorization
Formulary: Open formulary. General exclusions
include experimental drugs, cosmetics, fertility
drugs, DESI drugs, and drugs for which FFP is not
available (OBRA '90).
Prior Authorization: State currently has a formal
prior authorization procedure. Periodic review for
reconsideration possible for excluded product from
formulary. Fair hearings possible for appealing
prior authorization decisions.
Prescribing or Dispensing Limitations
Prescription Refill Limit: 5 times within a 6-month
period.
Monthly Quantity Limit: Original, 34-day supply.
Refills, 34 days or 100 units, whichever is more.
Drug Utilization Review
PRODUR system implemented in October 1996.
State currently has a DUR Board with a quarterly
review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.73 for legend drugs.
Additional add-ons per/Rx shall be given to
pharmacy providers who provide the following:
1. 24-hr Emergency Service: add $0.11
2. Patient Consultation: add $0.08
3. Impact Area Location: add $0.15 (provider
shall have a combined Medicaid, NJ KidCare
and PAAD prescription volume equal to or
greater than 50% of total prescription volume.
Ingredient Reimbursement Basis: EAC = AWP-
10%, WAC + 30%. AAC for injectables, effective
5/1/00.
Prescription Charge Formula: “Maximum
Allowable Cost,” or Average Wholesale Price-10%
(reduction from AWP is pharmacy specific) plus a
dispensing fee or the provider’s usual and
customary charge, whichever is lower.
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary”.
Incentive Fee: None.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Jersey-3
Patient Cost Sharing: None.
Cognitive Services: State pays for cognitive
services.
E. USE OF MANAGED CARE
Approximately 460,000 Medicaid recipients
received pharmacy benefits through managed care
in 2001. All receive pharmaceutical benefits from
MCOs.
Managed Care Organizations
AMERIGROUP New Jersey, Inc
399 Thornall Street, 9
th
Floor
Edison, NJ 08837
800/600-4441

Health Net of New Jersey, Inc.
CNA Building
3501 State Highway 66
Neptune, NJ 07754
800/555-2604

AmeriChoice of New Jersey, Inc.
Two Gateway Center, 13
th
Floor
Newark, NJ 07102
800/941-4647

Horizon Mercy
275 Phillips Boulevard
Trenton, NJ 08618-1426
800/656-3729

University Health Plans, Inc.
550 Broad Street, 17
th
Floor
Newark, NJ 07102
800/564-6847
F. STATE CONTACTS
State Drug Program Administrator
Edward J. Vaccaro, R.Ph.
Assistant Director, Office of Utilization
Management
Department of Human Services
Division of Medical Assistance and Health Services
P.O. Box 712, Bldg. 11-A
Trenton, NJ 08625
T: 609/588-2726
F: 609/588-3889
E-mail: ejvaccaro@dhs.state.nj.us

Department of Human Services Officials
Gwendolyn L. Harris, Commissioner
Department of Human Services
Capitol Place One CN-700, 5
th
Floor
P.O. Box 700
Trenton, NJ 08625
T: 609/292-3717
F: 609/292-3824
E-mail: webmaster@dhs.state.nj.us

Ann Clemency Kohler, Director
Division of Medical Assistance and Health Services
Department of Human Services
P.O. Box 712
Trenton, NJ 08625-0712
T: 609/588-2600
F: 609/588-3583
E-mail: ann.kohler@dhs.state.nj.us
DUR Contact
Edward J. Vaccaro, R.Ph.
T: 609/588-2726
Medicaid DUR Board
Christopher A. Cella, R.Ph.
Alfred F. Sorbelo, D.O.
Edith Kessler-Feinstein, R.Ph.
Joseph Nicholas Micale, M.D.
Rochelle Dallago, R. Ph..
Thomas A. Cavalieri, D.O.
Linda Gooen, R.Ph.
Mary E Petit, Pharm.D.
David Ethan Swee, M.D.
New Brand Name Products Contact
Edward J. Vaccaro, R.Ph.
T: 609/588-2726
Prescription Price Updating
First DataBank
1111 Bayhill Dr.
San Bruno, CA 94066
415/588-5454
Medicaid Drug Rebate Contacts
Technical: Daniel Upright, 609/588-2792
Policy: Edward J. Vaccaro, 609/588-2726
PA: Carl Tepper, 609/588-2744
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Jersey-4
Claims Submission Contact
Peter Ringel
Deputy Project Director
Unisys
3705 Quakerbridge Road, Suite 101
Trenton, NJ 08619
T:609/588-6000
F: 609/584-8270
E-mail: ringelp@nipo1.him.unisys.com
Medicaid Managed Care Contact
Edward J. Vaccaro
609/588-2726
Mail Order Benefit Program
State currently has a mail order benefit program.
All Medicaid recipients are entitled to participate.

Elderly Expanded Drug Coverage Contact
Kathleen Mason
Assistant Commissioner, Benefits and Utilization
Management
Dept. of Health and Senior Services
P.O. Box 715
Trenton, NJ 08625
T: 609/588-7032
F: 609/584-7037
Physician-Administered Drug Program
Contact
Edward J. Vaccaro
609/588-2726
Executive Officers of State Medical and
Pharmaceutical Societies
Medical Society of New Jersey
Vincent A. Maressa
Executive Director
2 Princess Road
Lawrenceville, NJ 08648-2302
T: 609/896-1766
F: 609/896-1368
E-mail: 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
Frank Cagliari
President
1 Distribution Way, Suite 201
Monmouth Junction, NJ 08852
T: 732/940-9000
F: 732/940-8899
E-mail: frank@njosteo.com
Internet address: www.njosteo.org

State Board of Pharmacy
Remi Erdos
Executive Director
P.O. Box 45013
Newark, NJ 07101
973/504-6450
E-mail: askconsumeraffairs@dca.lps.state.nj.us
Internet address:
www.state.nj.us/lps/ca/brief/pharm.htm

New Jersey Hospital Association
Gary S. Carter, FACHE
President & CEO
760 Alexander Road, P.O. Box 1
Princeton, NJ 08543-0001
609/275-4000
E-mail: gcarter@njha.com
Internet address: www.njha.com
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-1
NEW MEXICO
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002*

Expenditures Recipients Expenditures Recipients

TOTAL $70,147,344 75,669 $73,877,785

RECEIVING CASH ASSISTANCE TOTAL $38,536,342 33,554
Aged $7,975,843 6,366
Blind/Disabled $29,447,155 15,664
Disabled $350,900 5,397
Child $762,444 6,127
Adult
$0 -
MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult
$2,087,207 23,345
MEDICALLY NEEDY, TOTAL $96,973 176
Aged $342,469 425
Blind/Disabled $1,478,634 19,624
Child $169,131 3,120
Adult

TOTAL OTHER EXPENDITURES/RECIPIENTS* $29,523,795 18,770

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

Source: CMS, MSIS Report, FY 2001and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-2
C. ADMINISTRATION
Human Services Department (HSD), Medical
Assistance Division.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; urine ketone test strips; total parenteral
nutrition; and interdialytic parenteral nutrition. Prior
Authorization required for: amphetamines and
stimulants for ADD (adults only); nutritional
supplements. Products not covered: drugs for
treatment of tuberculosis; cosmetics; experimental
drugs; fertility drugs; drugs and immunizations
available from any other source; medications
supplied by the New Mexico State Hospital to
clients on convalescent leave from hospital;
hormones; stimulants; drugs classified by FDA as
“ineffective;” hypnotic drugs (barbiturates); and
drugs without Medicaid rebate participation
agreement.
Over-the-Counter Product Coverage: Products
Covered: insulin; antacids for active gastric and
duodenal ulcers; infant vitamin drops for up to 1
year; Salicylates and acetaminophen; vitamins; iron;
minerals; and pediculocides; laxatives, stool
softeners, calcium, nicotine replacement, ibuprofen,
antihistamines, decongestants, expectorants, cough
suppressants, anti-candida, and antifungals.
Products covered with restriction: topical products
(specific therapeutic categories). Products not
covered: personal care items (i.e., over-the-counter
shampoo and soap); feminie products.
Therapeutic Category Coverage: Products Covered:
anabolic steroids; analgesics; antipyretics; and
NSAIDs (prior authorization required); antibiotics;
anticoagulants; anticonvulsants; antidepressants;
antidiabetic agents, antihistamines; antilipemic
agents; anti-psychotics; anxyolitics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives; ENT
anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; and
sympathominetics (adrenergic-prior authorization
required for adults); and thyroid agents. Partial
coverage for: Viagra (prior authorization required).
Coverage of Injectables: Injectable medicines
reimbursable through both the Prescription Drug
Program and physician payment when used in
physician offices, home health care, and extended
care facilities.
Vaccines: Vaccines reimbursable as part of the
EPSDT service, the Children’s Health Insurance
Program, and the Vaccine for Children Program.
Unit Dose: Does not reimburse for unit dose
packaging.
Formulary/Prior Authorization
Formulary: Open formulary
Prior Authorization: State currently has a formal
prior authorization procedure screening for drug
classes.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: 34-day supply maximum,
excluding birth control pills (1 year). Number of
refills must conform to applicable State and Federal
laws.
Drug Utilization Review
PRODUR system implemented in October 1993.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.65, effective 6/12/02. State
currently has a DUR Board that meets at least
quarterly.
Ingredient Reimbursement Basis: EAC = AWP-
12.5%, effective 7/1/97.
Prescription Charge Formula: Prescriptions
reimbursed at the lesser of the following:
1. Cost (EAC or MAC) dispensed plus a
dispensing fee or,
2. The usual and customary charge by the
pharmacy to the general public.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Medically
Necessary” or “Brand Necessary.” Also prescriber
is not prohibited from generic substitution and, if
due to drug shortage, requesting reimbursement at
the brand level.
Incentive Fee: None.
Patient Cost Sharing: No copayment, except $2.00
for CHIP clients and working disabled clients.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-3
E. USE OF MANAGED CARE
Approximately 250,000 Medicaid recipients
enrolled in are MCOs in FY 2002. Recipients
receive pharmaceutical benefits through managed
care plans.

F. STATE CONTACTS
State Drug Program Administrator
Neal Solomon, M.P.H., R.Ph.
Pharmacist, Human Services Department
Medical Assistance Division
P.O. Box 2348
Santa Fe, NM 87504-2348
T: 505/827-3174
F: 505/827-3185
E-mail: neal.solomon@state.nm.us
DUR Contact
Neal Solomon, M.P.H., R.Ph.
505/827-3174
DUR Board
Denise Cuellar, Pharm.D.
Greg D’Armour, Pharm.D.
Gregory Toney, R.Ph., Ph.C.
John Piper, Pharm.D.
John Lauriello, M.D.
Gayle Chacon, M.D.
John Seibel, M.D.
Judy Romero, Pharm.D.
Manual Archuleta, M.D.
Prior Authorization Contact
Neal Solomon, M.P.H., R.Ph.
505/827-3174
Medicaid Drug Rebate Contact
Delfinia Dandoval, Human Services Department
ASD
729 St. Michaels Drive
Santa Fe, NM 87504-2348
T: 505/476-8920
F: 505/827-1147
E-mail: delfinia.sandoval@state.nm.us
New Brand Name Products Contact
Neal Solomon, M.P.H., R.Ph.
505/827-3174

Prescription Price Updating Contact
Neal Solomon, M.P.H., R.Ph.
505/874-3174
Claims Submission
ACS, Inc.
365 Northridge Road
Northridge Center One, Suite 400
Atlanta, GA 30350
T: 770/352-8592
F: 770/730-5198
Medicaid Managed Care Contact
Alana Reeves
Human Services Department
P.O. Box 2348
Santa Fe, NM 85705-2348
T: 505/827-3131
F: 505/827-3185
E-mail: alana.reeves@state.nm.us
Mail Order Pharmacy Program
None
Human Services Department Officials
Pamela Hyde
Secretary
New Mexico Department of Human Services
P.O. Box 2348
Santa Fe, NM 87504-2348
T: 505/827-7750
F: 505/827-6286
E-mail: pam.hyde@state.nm.us

Carolyn Ingram
Director
New Mexico Department of Human Services
Medicaid Assistance Division
P.O. Box 2348
Santa Fe, NM 87504-2348
T: 505/827-3100
F: 505/827-3185
E-mail: carolyn.ingram@state.nm.us
Medical Advisory Committee Members
Linda Sechovec
Executive Director
NM Health Care
6400 Uptown Boulevard, NE, Suite 520-W
Albuquerque, NM 87110

National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-4
Yvette Ramirez Ammerman
Policy Analyst
New Mexico Primary Care Association
2309 Renard, S.E., Suite 209
Albuquerque, NM 87106

Chris Isengard
Executive Director
Developmental Disabilities Planning Council
435 St. Michael’s Drive, Bldg. D
Santa Fe, NM 87501

Michelle Lujan-Grisham
New Mexico State Agency on Aging
228 East Palace Avenue
Santa FE, NM 87501

Sam Cata, Commissioner
Office of Indian Affairs
224 E. Palace Avenue
Santa FE, NM 87501

Loyola Burgess
1801 Dorothy Street, NE
Albuquerque, NM 87112

Walace Begay, Co-Chairman
Pueblo Health Council/All Indian Pueblo Council
P.O. Box 56
New Laguna, NM 87038

Rosalyn Curtis
Director of the Navajo Nation
Division of Health
P.O. Box 1390
Window Rock, AZ 86515

Lila Maples, R.N.
2769 Villa Venado
Santa Fe, NM 87505

Clarice Pick, D.D.S
1405 Luisa Street
Suite #2
Santa Fe, NM 87505

Richard L. Ragel, D.O.
1010 Bridge Boulevard, SW, Suite D
Albuquerque, NM 87105-3734

Kathy Minoli, C.F.N.P.
1835 Solano, NE
Albuquerque, NM 87110

Mary Lou Edward
16 Applewood Lane, N.W.
Albuquerque, NM 87107
505/898-5103

Richard Honsinger, M.S.
Los Alamos Medical Center
Los Alamos, NM 87544

Maureen Boshier
New Mexico Hospital Association
2121 Osuna Road NE
Albuquerque, NM 87113

Joie Glen
Executive Director
New Mexico Association for Home Care
3200 Carlisle N.E., Suite 115
Albuquerque, NM 87110

Bert Umland, M.D.
Division of Family Practice
UNM Medical Center
Albuquerque, NM 87131
505/277-2165
Executive Officers of State Medical and
Pharmaceutical Societies
New Mexico Medical Society
G. R. “Randy” Marshall
Executive Director
7770 Jefferson NE, Suite 400
Albuquerque, NM 87109
T: 505/828-0237
F: 505/828-0336
E-mail: rmarshal@nmms.org
Internet address: nmms.org

New Mexico Pharmaceutical Association
R. Dale Tinker
Executive Director
4800 Zuni, S.E.
Albuquerque, NM 87108-2898
T: 505/265-8729
F: 505/255-8476
E-mail: daletinker@cs.com
Internet address: www.nm-pharmacy.com

New Mexico Osteopathic Medical Association
Elizabeth “Betty” Barrett
Executive Director
P. O. Box 53098
Albuquerque, NM 87153-3098
T: 505/332-2146
F: 505/332-4861
E-mail: admin@nmoma.org
Internet address: www.nmoma.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-5
State Board of Pharmacy
Jerry Montoya
Chief Inspector/Director
111 Lomas Boulevard, Suite 412
Albuquerque, NM 87102
T: 505/222-9130
F: 505/222-9145
E-mail: joseph.montoya@state.nm.us
Internet address: www.state.nm.us/pharmacy

New Mexico Hospitals and Health Systems
Association
Maureen L. Boshier
President/CEO
2121 Osuna Road, NE
Albuquerque, NM 87113
T: 505/343-0010
F: 505/343-0012
E-mail: mboshier@nmhsa.com
Internet address: www.nmhsa.org
National Pharmaceutical Council Pharmaceutical Benefits 2003
New Mexico-6




























































































National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-1
NEW YORK
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2002** 2003***
Expenditures Recipients Expenditures Recipients

TOTAL $3,660,427,024 $3,949,177,519 2,567,097

RECEIVING CASH ASSISTANCE, TOTAL $2,340,874,399 840,496
Aged $419,244,725 140,438
Blind/Disabled $1,799,235,899 450,143
Child $47,920,289 181,271
Adult $74,473,486 68,544

MEDICALLY NEEDY, TOTAL $1,021,426,022 1,030,106
Aged $265,858,105 113,314
Blind/Disabled $478,087,980 114,547
Child $140,836,085 553,923
Adult $136,643,853 248,322

POVERTY RELATED, TOTAL $552,607,313 635,184
Aged $1,914 28
Blind/Disabled $0 -
Child $68,148,436 289,938
Adult $484,456,964 345,218

TOTAL OTHER EXPENDITURES/ RECIPIENTS* $34,269,785 61,311

* Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
***2003 data provided by the New York State Department of Health, Office of Medicaid Management.
Source: CMS, CMS-64 Report, FY 2002 and New York State Medicaid Statistical Information System, FY 2003.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-2
C. ADMINISTRATION
State Department of Health, Office of Medicaid
Management.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations for insulin; blood glucose test strips;
urine ketone test strips; total parenteral nutrition;
and interdialytic parenteral nutrition. Products not
covered: cosmetics; fertility drugs; and
experimental drugs.
Over-the-Counter Product Coverage: Products
covered with restrictions: allergy, asthma and sinus
products; analgesics; cough and cold preparations;
digestive products (non H2 antagonist); feminine
products; smoking deterrent products (max, 2
courses of treatment/year); and topical products.
Products not covered: digestive products (H2
antagonists).
Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; anticoagulants;
anticonvulsants; antidepressants; antidiabetic
agents; antihistamine drugs; antilipemic agents;
anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents;
estrogens; hypotensive agents; prescribed smoking
deterrents; sympathominetics (adrenergic); and
thyroid agents. Therapeutic categories partially
covered: prescribed cold medication and misc. GI
drugs. Therapeutic categories requiring prior
authorization: antibiotics (zyvox only); second
generation antihistamines; growth hormones;
(serostim) medical/surgical supplies; orthopedic
shoes; compression stockings; and some DME
items. Therapeutic categories not covered:
anorectics and agents used for hair growth.
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care facilities
and through physician payment when used in
physician offices. In extended care facilities
reimbursement for non-self administered injectable
medicines is included in the facility rate. No special
coverage policies exist for self-administered
injectable medicines.

Vaccines: Vaccines are reimbursable under the
EPSDT service, CHIP, and the Vaccines for
Children program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary. Utilization managed
through restrictions on use, prior authorization, and
quantity limits. General Exclusions: New York
State follows OBRA '90 guidelines in the
reimbursement of prescription drugs.
Prior Authorization: State currently has a formal
prior authorization procedure and a Pharmacy and
Therapeutics Committee that meets quarterly.
Although there is no formal method for appealing a
prior authorization decision, the ordering prescriber
may call the voice interactive system until the
system issues a prior authorization number. All
requests are approved. Beginning in November
2002, all brand name drugs with A-rated generics
require prior authorization.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Maximum of 5 refills
within 6 months. Also, annual limits on number of
prescriptions and prescription and nonprescription
drugs without an override.

Monthly Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in March 1995.
State currently has a DUR Board which meets
bimonthly.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $3.50 for brand name drugs, $4.50
for generic drugs. Effective 8/1/98.
Ingredient Reimbursement Basis: EAC = AWP-
12% (effective 7/1/03)
Prescription Charge Formula:
1. Payment for multiple source drugs must not
exceed the aggregate of the specified upper
limit set by the federal Centers for Medicare
and Medicaid Services (CMS), plus a
dispensing fee, for a particular drug; and
2. Payment for brand name drugs and other
multiple source drugs not covered by clause (1)
will be the lower of: EAC plus a dispensing
fee; or
3. The billing pharmacy's usual and customary
price charged to the general public.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-3
Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs must get prior
authorization for most brand name products. (see
www.health.state.ny.us/nysdoh/medicaid/
ptcommittee/mandatorggen.htm)
Incentive Fee: $1.00 for dispensing a lower cost
multi- source product.
Patient Cost Sharing: Copayment is $2.00 for
brand name drugs, $0.50 for generic and OTC
drugs. Exceptions include psychotropic drugs as
well as drugs FDA approved for the treatment of
tuberculosis and family planning drugs.
Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 1.1 million Medicaid recipients
were enrolled in MCOs in FY 2002. Recipients
receive pharmaceutical benefits through the State.
Health Maintenance Organizations
− ABC Health Plan
− Affinity Health Plan
− AmeriChoice of New York
− Broome MC
− Buffalo Community Health
− Care Plus Health Plan
− CDPHP
− Community Choice HP
− Community Premier Plus
− Excellus
− Fidelis/NYS Catholic Health
− Health Choice
− HealthFirst PHPS
− Health Plus PHPS
− HealthNow/BCBS-WNY/Community Blue
− HealthNow/Blue Shield of NENY
− HealthSource/Hudson Health Plan
− HIP
− IHA
− Manhattan PHSP/CenterCare
− Metropolitan Plus Health Plan
− Neighborhood Health Providers
− NY Hospital Community PHSP
− NYPS Select Health
− NYS Catholic Health
− PCMP
− Preferred Care
− Primary Health
− Southern Tier
− St. Barnabas/Partners in Health
− Suffolk Co PHSP
− Total Care/Syracuse PHSP
− United Healthcare Plan of NY, Inc.
− United Healthcare of Upstate
− VitaCare, Inc.
− Vytra
− Wellcare
− Westchester Prepaid Health Services Plan
F. STATE CONTACTS
State Drug Program Administrator
Mark-Richard A. Butt, M.S., R.Ph.
Director, Pharmacy Policy and Operations
Bureau of Program Guidance
Office of Medicaid Management
NYS Department of Health
99 Washington Avenue, Suite 606
Albany, NY 12210
T: 518/474-9219
F: 518/473-5508
E-mail: mrb01@health.state.ny.us
Internet address: www.health.state.ny.us
Pharmacy Advisory Committee
Kandyce Daley, R.Ph.
Patricia Donato, R.Ph.
Steven Giroux, R.Ph.
Thomas Golden, R.Ph.
John Navarra, R.Ph. (Chairman)
Dilip Patel, R.Ph.
Mohammed Saleh, R.Ph.
John Westerman, R.Ph.
Formulary Contact
Mark-Richard A. Butt, M.S., R.Ph.
518/474-9219
Prior Authorization Contact
Mark-Richard A. Butt, M.S., R.Ph.
518/474-9219
Pharmacy and Therapeutics Committee
Roxanne Hall Richardson, R.Ph.
Maria Amodio-Groton, Pharm.D.
Andrew G. Flynn, R.Ph., C.G.P.
William P. Scheer, R.Ph.
Carl R. Reed, R.Ph., M.B.A.
Judy K. Shaw, M.S., A.C.R.N., ANP-C
Marc A. Johnson, M.D.
Scott C. Bello, M.D.
Steven E. Barnes, D.O.
Aaron Satloff, M.D.
Glenn A. Martin, M.D.
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-4
DUR Contact
Lydia Kosinski, R.Ph.
DUR Manager
Office of Medicaid Management
NYS Department of Health
99 Washington Avenue, Suite 601
Albany, NY 12210
T: 518/474-6866
F: 518/473-5332
E-mail: ljk02@health.state.ny.us
DUR Committee
Physicians
Richard S. Blum, M.D.
Ronald J. Dougherty, M.D.
David F. Lehmann, M.D.
Jill Braverman-Panza, M.D., R.Ph.

Pharmacists
Sidney Falow, R.Ph.
John Gotowko, R.Ph., M.S., M.B.A.
Marc L. Speert, R.Ph.
Frank Barone, R.Ph.
James R. Suhrbier, R.Ph.
New Brand Name Products Contact
Mark-Richard A. Butt, M.S., R.Ph.
518/474-9219
Prescription Price Updating
Carl T. Cioppa, R.Ph.
Manager, Pharmacy Operations
Pharmacy Policy and Operations
NYS Dept. of Health, Office of Medicaid
Management
99 Washington Avenue, Suite 606
Albany, NY 12210
T: 518/474-9219
F: 518/473-5508
E-mail: ctc02@health.state.ny.us

Sally Nelson, R.Ph.
E-mail: sxn02@health.state.ny.us
Medicaid Drug Rebate Contacts
Audit & Policy: Mark-Richard Butt, 518/474-9219
Disputes: Joseph Maiello, 518/474-9219
PRODUR: Dennis Pidgeon, 518/474-6866
Claims Submission Contact
eMedNY
Computer Sciences Corporation (CSC)
One CSC Way
Rensselaer, NY 12144
800/343-9000
E-mail: general@emedny.org
Medicaid Managed Care Contact
Elizabeth Macfarlane, Director
Bureau of Managed Care Program Planning
NYS Department of Health
Office of Managed Care
Room 1927, Corning Tower ESP
Albany, NY 12237-0064
T: 518/473-0122
F: 518/474-5886
E-mail: eag01@health.state.ny.us
Disease Management/Patient Education
Programs
Disease/Medical State: AIDS/HIV
Program Name: Aids Intervention Management
Program
Program Sponser: AIDS Institute, NYSDOH

Disease/Medical State: Asthma
Program Name: Asthma Quality Improvement
Project
Program Sponser: NYSDOH

Disease/Medical State: Diabetes
Program Name: Diabetes Quality Improvement
Project
Program Sponser: NYSDOH

Disease/Medical State: Smoking Cessation
Program Name: Smokers’ Quit Line
Program Sponser: Roswell Park
Disease Management Program/Initiative
Contacts
Karen A. Fuller, Ph.D.
Director, Bureau of Program Guidance
NYS Department of Health
Office of Medicaid Management
99 Washington Avenue, Suite 606
Albany, NY 12210
T: 518/474-9219
F: 518/473-5508
E-mail: kaf01@health.state.ny.us

Donna Haskin
E-mail: dlh04@health.state.ny.us

Denise Spor
E-mail: des06@health.state.ny.us
Mail Order Pharmacy Program
None
National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-5
Expanded Drug Program Contact
Julie Naglieri
Acting Director
NYS Department of Health Program
Elderly Prescription Insurance Coverage (EPIC)
1 Corporate Plaza, Suite 101
260 Washington Avenue
Albany, NY 12203
T: 518/452-6828
F: 518/452-6882
E-mail: jab15@health.state.ny.us
Internet address:
www.health.state.ny.us/nysdoh/epic/faq.htm
Department of Health Officials
Antonia C. Novello, M.D, M.P.H., Dr. Ph.
Commissioner
NYS Department of Health
Corning Tower
The Governor Nelson A. Rockefeller Empire State
Plaza
Albany, NY 12237
T: 518/474-2011
F: 518/474-5450
E-mail: acn01@health.state.ny.us

Kathryn Kuhmerker, Deputy Commissioner
Office of Medicaid Management
NYS Department of Health
Corning Tower
The Governor Nelson A. Rockefeller Empire State
Plaza
Albany, NY 12237
T: 518/474-3018
F: 518/486-6852
E-mail: klk03@health.state.ny.us

Karen A. Fuller, Ph.D.
Assistant Director, Bureau of Program Guidance
Division of Policy and Program Guidance/Office of
Medicaid Management
99 Washington Avenue, Suite 606
Albany, NY 12210
518/474-9219

Mark-Richard A. Butt, MS, R.Ph.
Assistant Director, Pharmacy Policy and
Operations
518/474-9219
E-mail: mrb01@health.state.ny.us

Carl T. Coppa, R.Ph.
Manager, Pharmacy Operations
518/474-9219
E-mail: ctc02@health.state.ny.us



Anita Murray, R.Ph.
Manager, Pharmacy Policy
E-mail: alm04@health.state.ny.us

Joseph Maiello, R.Ph.
Manager, Pharmacy Rebates
518/474-9219
E-mail: jam22@health.state.ny.us
Title XIX Medical Care Advisory Committee
Ruben P. Cowart, D.D.S., (Chairman)
John Angerosa, M.D.
Steven E. Barnes, D.O.
Russel N. Cecil, M.D.
David Cerniglia, D.C.
Stoner E. Horey, M.D.
Mary K. Lashomb
Norman R. Loomis, M.D.
Hugo M. Morales, M.D., P.C.
Tanton Mustapha, M.D.
Leon Nadrowski, M.D.
Dennis P. Norfleet, M.D.
Elena Padilla, Ph.D.
Carl P. Sahler, M.D., Ph.D.
Robert A. Schwartz, M.D.
Gavin Setzen, M.D.
Kathleen Benson Smith
Patricia Stevens, Deputy Commissioner, NYS
Office of Temporary and Disability Assistance
(DSS Representative)
Roger W. Trifthauser, D.D.S., M.S.
Executive Officers of State Medical and
Pharmaceutical Societies
Medical Society of the State of New York
Charles Aswad, M.D.
Executive Vice President
420 Lakeville Road
P.O. Box 5404
Lake Success, NY 11042-5404
T: 516/488-6100
F: 516-488-6136
E-mail: mssny@mssny.org
Internet address: www.mssny.org

Pharmasists Society of the State of New York
Craig Burridge, M.S., CAE
Executive Director
210 Washington Avenue Extension
Albany, NY 12203
T: 518/869-6595
F: 518/464-0618
E-mail: craigb@ppssny.org
Internet address: www.pssny.org/index_new.htm

National Pharmaceutical Council Pharmaceutical Benefits 2003
New York-6
New York State Osteopathic Medical Society, Inc.
Martin Diamond, D.O.
Executive Director
1855 Broadway, Suite 1102A
New York, NY 10023
T: 212/261-4137
F: 312/202-1786
E-mail: nysoms@nysoms.org
Internet address: www.nysoms.org

New York State Board of Pharmacy
Lawrence H. Mokhiber
Executive Secretary
89 Washington Avenue, Second Floor W
Albany, NY 12234-1000
T: 518/474-3848
F: 518/473-6995
E-mail: pharmbd@mail.nysed.gov
Internet address: www.nysed.gov/prof/pharm.htm

Healthcare Association of New York State
Daniel Sisto
President
One Empire Drive
Rensselaer, NY 12114
T: 518/431-7800
F: 518/431-7915
E-mail: dsisto@hanys.org
Internet address: www.hanys.org

Greater New York Hospital Association
Subsidiaries and Affiliates
Kenneth E. Raske
President
555 W. 57
th
Street
15
th
Floor
New York, NY 10019
T: 212/246-7100
F: 212/262-6350
E-mail: raske@gnyha.org
Internet address: www.gnyha.org




National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina-1
NORTH CAROLINA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $971,066,103 907,413 $1,100,822,176

RECEIVING CASH ASSISTANCE TOTAL $558,673,839 432,859
Aged $154,115,092 65,618
Blind/Disabled $315,225,407 127,822
Child $27,022,573 121,937
Adult $62,310,767 117,482

MEDICALLY NEEDY, TOTAL $64,926,538 28,652
Aged $44,433,190 17,372
Blind/Disabled $16,408,373 6207
Child $614,556 899
Adult $3,470,419 4,174

POVERTY RELATED, TOTAL $327,242,251 402,313
Aged $135,848,480 60,081
Blind/Disabled $128,536,123 50,197
Child $56,963,937
255,320

Adult $5,893,711 36,715

TOTAL OTHER
EXPENDITURES/RECIPIENTS*
$20,223,475 43,589

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

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina-2
C. ADMINISTRATION
Division of Medical Assistance, Department of
Health and Human Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
select OTC products; total parenteral nutrition; and
interdialytic parenteral nutrition. Product covered
under DME: disposable needles and syringe
combinations used for insulin; blood glucose test
strip; and urine ketone test strips. Products not
covered: cosmetics; fertility drugs; OTC drugs not
listed on the selected coverage list; and those
products mentioned below under “Therapeutic
Category Coverage” section.
Over-the-Counter Product Coverage: North
Carolina covers a select list of OTC products. (see
www.dhhs.state.nc.us/dma/mp/mpindex.htm)
Therapeutic Category Coverage: North Carolina
provides coverage for all therapeutic categories
except products used for cosmetic purposes;
fertility drugs; diaphragms; IV fluids(Dextrose
500ml or greater) and irrigations fluids used in an
inpatient facility; Drugs on DESI list; any drug
manufactured by a company who has not signed the
federal rebate agreement; and experimental drugs.
Prior authorization required for: Drugs used to
treat ADHD; Procrit/Epogen; Neupogen; Aransep;
OxyContin; Growth Hormones;Provigil; Rebetron;
Vioxx; Celebrex; Bextra; Enbrel; Botox; Mybloc;
Zyban, Nicotrol, Nicotine Patch; Synagis; and
RespiGam. (see www.ncmedicaidpbm.com for
additional information.)
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug
Program when used in home health care and
extended care facility, and through both the
Prescription Drug Program and physician payment
when used in physician offices.
Vaccines: Vaccines reimbursable as part of the
ESPDT service and The Vaccines for Children
Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.

Prior Authorization: Formal prior authorization
process can be found at: ww.ncmedicaidpbm.com.
A prescriber’s written justification is required to
appeal a prior authorization decision.
Prescribing or Dispensing Limitations
Monthly Quantity Limit: 34-day supply maximum.
Except birth control tablets and hormonal
replacement therapy dial packs: 3 months;
maintenance non-controlled medications, tied with
the FUL and/or SMAC after a prior successful fill
may receive a 3 month supply upon the prescribers
discretion.
Monthly Prescription Limit: Six prescriptions per
month per recipient.
Prescription Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in May 1996. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: B: $4.00; G: $5.60, effective 2002.
Ingredient Reimbursement Basis: EAC = AWP-
10%.
Prescription Charge Formula: The lowest price of
AWP minus 10%, State MAC or Federal MAC plus
a dispensing fee or usual and customary, whichever
is lowest. The pharmacist filling the original
prescription will not be reimbursed for refills for
the same drug within a calendar month.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits generic drugs. 367
drugs are listed on the State-specific MAC list.
Override requires “Brand Medically Necessary”
written on the face of the prescription by the
prescriber.
Incentive Fee: None.
Patient Cost Sharing: $1.00 copayment/Rx
(includes refills) for generic prescriptions; $3.00
copayment/Rx for brand name prescriptions.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina-3
E. USE OF MANAGED CARE
Approximately 30,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
pharmaceutical benefits through the State.
Managed Care Organizations
SouthCare/Coventry
2815 Coliseum Center Drive
Charlotte, NC 28217
F. STATE CONTACTS
State Drug Program Administrator
Sharman C. Leinwand, R.Ph., M.P.H.
Pharmacy Program Manager
Division of Medical Assistance
Department of Health and Human Services
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501
T: 919/857-4034
F: 919/715-1255
E-mail: sharman.leinwand@ncmail.net
Internet address: www.dhhs.state.nc.us/dma
Prior Authorization Contact
Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034
DUR Contact
Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034
Medicaid Drug Utilization Review Board
Physicians:
Patricia Burns, M.D.
Edward Treadwell, M.D.
LaVie Ellison, M.D.
David Gremillion, M.D.
Steve Wegner, M.D.

Pharmacists:
Joseph S. Moose, R.Ph., Pharm. D.
Dale Christensen, Ph.D.
Wayne Creech, R. Ph.
Martha Jones, Pharm. D.
New Brand Name Products Contact
Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034

Prescription Price Updating
Sharon Greeson, R.Ph.
Pharmacy Program Manager
EDS
4905 Waters Edge Drive
Raleigh, NC 27606
T: 919/816-4475
F: 919/816-4399
E-mail: sharon.greeson@eds.com
Medicaid Drug Rebate Contact
Audits: Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034

Rebate Disputes: Sharon Greeson, R.Ph.
919/816-4475
Claims Submission Contact
Sharon Greeson, R.Ph.
919/816-4475
Medicaid Managed Care Contact
Jeffrey Simms
919/857-4267
Mail Order Pharmacy Program
None
Disease Management Program/Initiative
Contact
Sharman C. Leinwand, R.Ph., M.P.H.
919/857-4034
Department of Human Resources Officials
Gary Fuquay, Director
Department of Health and Human Services
Division of Medical Assistance
1985 Umstead Drive
2501 Mail Service Center
Raleigh, NC 27699-2501
T: 919/857-4011
F: 919/733-6608
E-mail: gary.fuquay@ncmail.net

Carmen Hooker Odom
Secretary
Department of Health and Human Services
2001 Mail Service Center
101 Blair Drive
Raleigh, NC 27699-2001
T: 919/733-4534
F: 919/715-4645
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Carolina-4
Office of Research Demonstration and
Rural Health Development
Torlen Wade
311 Ashe Avenue
Raleigh, NC 27606
919/857-4267
Executive Officers of State Medical and
Pharmaceutical Societies
North Carolina Medical Society
Bob Seligson, M.B.A., CAE
Executive Vice President & CEO
P.O. Box 27167
Raleigh, NC 27611-7167
T: 919/833-3836
F: 919/833-2023
E-mail: 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
Jeffrey J. LeBoeuf
Executive Director
8311 Brier Creek Parkway
Raleigh, NC 27617
T: 888/626-6248
F: 910/763-4666
E-mail: jeffrey@ncoma.org
Internet address: www.ncoma.org

State Board of Pharmacy
David R. Work
Executive Director
P.O. Box 4560
Chapel Hill, NC 27515-4560
T: 919/942-4454
F: 919/967-5757
E-mail: 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
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-1
NORTH DAKOTA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


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

TOTAL $43,288,363 39,758 $52,495,878

RECEIVING CASH ASSISTANCE, TOTAL $20,469,921 18,113
Aged $4,465,220 1,978
Blind/Disabled $12,892,102 5,031
Child $1,238,624 7,216
Adult $1,873,975 3,888

MEDICALLY NEEDY, TOTAL $19,371,705 10,427
Aged $12,570,047 5,815
Blind/Disabled $6,083,620 2,136
AFDC-Child $318,364 1,577
AFDC-Adult $399,674 899

POVERTY RELATED, TOTAL $586,363 3,898
Aged $5,838 21
Blind/Disabled $7,750 25
AFDC-Child $481,791 3,324
AFDC-Adult $90,984 528

TOTAL OTHER EXPENDITURES/RECIPIENTS* $2,860,374 7,320

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-2
C. ADMINISTRATION
North Dakota Department of Human Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and total parenteral nutrition. Products not
covered: cosmetics; fertility drugs; urine ketone test
strips; interdialytic parenteral nutrition; drugs used
for hair growth; prescription vitamins (except
prenatal vitamins); and DESI drugs. Prior
authorization required for: nutritional supplements;
and orlistat.
Over-the-Counter Product Coverage: Products
covered: antacids; analgesics; iron supplements;
artificial tears; digestive products; and anti-ulcer
medications. Products covered with restriction:
allergy, asthma, and sinus products; smoking
deterrent products (lifetime limits). Products not
covered: cough and cold preparations; feminine
products; and topical products.
Therapeutic Category Coverage: Categories
covered: anabolic steroids; antibiotics;
anticoagulants; anticouvulsants; anti-depressants;
antidiabetic agents; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents;
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents,
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterrents. Prior authorization
required for: brand name NSAIDs, anoretics
(orlistat); antihistamines; and PPIs. Categories not
covered: prescribed cold medications.
Coverage of Injectables: Injectable medicines
reimbursable through both the Prescription Drug
Program and physician payment when used in
physician offices, home health care, and extended
care facilities.
Vaccines: Vaccines reimbursable as part of the
EPSDT service.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary
Prior Authorization: State currently has a formal
prior authorization procedure. Beneficiary can
request a fair hearing to appeal a prior authorization
decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: A prescription drug may
be refilled for 12 months after the date of the
original prescription, provided that such refills have
been authorized by the physician. Limits on the
number of refills by class (e.g., 0 for C-IIs; 5 for C-
IIIs, IVs, and Vs).
Monthly Quantity Limit: 34-day supply.
Monthly Dollar Limits: None.
Drug Utilization Review
PRODUR system implemented in July 1996. State
has a DUR Board that meets quarterly.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: $5.60 for generic, $4.60 for brand
effective 8/1/03.
Ingredient Reimbursement Basis: EAC = AWP-
10%.
Prescription Charge Formula: Acquisition Cost
plus a dispensing fee per prescription or the usual
and customary retail charge, whichever is lower.
Acquisition Cost = EAC or MAC.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Dispense As
Written.”
Incentive Fee: None.
Patient Cost Sharing: $3.00 (brand-name drugs)
Cognitive Services: Does not pay for cognitive
services
E. USE OF MANAGED CARE
Approximately 600 Medicaid recipients were
enrolled in managed care organizations in 2002.
Recipients enrolled in MCO’s receive pharmacy
benefits through the State.
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-3
F. STATE CONTACTS
State Drug Program Administrator
Brendan K. Joyce, Pharm.D., R.Ph.
Administrator, Pharmacy Services
Department of Human Services
600 East Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0250
T: 701/328-1544
F: 701/328-1544
E-mail: sojoyb@state.nd.us

Prior Authorization Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
DUR Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
DUR Board
Mark Biel, RPh
Term Expires: 06/30/2005

Patricia Churchill, RPh
Term Expires: 06/30/2004

Leann Ness, PharmD
Term Expires: 06/30/2004

Greg Pfister, PharmD
Term Expires: 06/30/2006

John Savageau, RPh
Term Expires: 06/30/2006

Robert Treitline, RPh
Term Expires: 06/30/2005

Kamille Sherman, MD
Term Expires: 06/30/2005

Ronald Burd, MD
Term Expires: 06/30/2006

Norman Byers, MD
Term Expires: 06/30/2006


Albert Samuelson, MD
Term Expires: 06/30/2004

Robert Thompson, MD
Term Expires: 06/30/2005

John Windsor, DO
Term Expires: 06/30/2004
Ex-Officio Members
Gary Betting, M.D.
Medical Consultant, DHS

Brendan K. Joyce, Pharm.D., R.Ph.
Medical Services, DHS

Mary Koenecke, RPH
PHRMA
Term Expires: 06/30/2004

New Brand Name Products Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
Prescription Price Updating
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
Medicaid Drug Rebate Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
Claims Submission Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-1544
Medicaid Managed Care Contact
Tom Solberg, Administrator
Managed Care
ND Department of Human Services
600 East Boulevard Avenue, Dept. 325
Bismark, ND 58505-0250
T: 701/328-1884
F: 701/328-1544
E-mail: sosolt@state.nd.us
Disease Management Program/Initiative
Contact
Brendan K. Joyce, Pharm.D., R.Ph.
701/328-41544
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-4
Mail Order Pharmacy Benefit Program
State currently has a mail order pharmacy program
capability in which all Medicaid recipients are
entitled to participate. However, the mail order
pharmacy must be a North Dakota Medicaid
provider.
Department of Human Services Officials
Carol K. Olson
Executive Director
ND Dept. of Human Services
600 E. Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0250
T: 701/328-2538
F: 701/328-2359
E-mail: dhseo@state.nd.us

Dave Zentner
Medicaid Director
600 E. Boulevard Avenue, Dept. 325
Bismarck, ND 58505-0261
T: 701/328-2321
F: 701/328-1544
E-mail: sozend@state.nd.us
Department of Human Services Advisory
Committees
Medical Care Advisory Committee
Terry Dwelle, M.D.
State Health Officer
State Health Department

Lynn Blakeman
St. Vincent’s Care Center

Alison Fallgater, D.D.S.

Amy Fleck, O.D.

Howard Anderson, R.Ph.

Terry Johnson, MD

David Peske
ND Medical Association

Gary Betting, M.D.
DHS-Medical Consultant

2 Medicaid Recipients




Commission on Socio-Economic Affairs
Robert F. Szczys, M.D., Chairman
Grand Forks Clinic Ltd.
Grand Forks, ND 58206

Russel J. Kuzel, M.D., Vice Chairman
Dakota Clinic Ltd.
Fargo, ND 58103

Bipin B. Amin, M.D.
Mid Dakota Clinic
Bismarck, ND 58502

William W. Barnes, M.D.
307 5th Avenue, SE
Minot, ND 58701

Norman E. Bystol, M.D.
Dakota Clinic Ltd.
Fargo, ND 58108

James R. Carpenter, M.D.
Meritcare Medical Group
Fargo, ND 58123

Stanley T. Diede, M.D.
Heart and Lung Clinic
Bismarck, ND 58502

Harold W. Evans, M.D.
Grand Forks Clinic Ltd.
Grand Forks, ND 58206

Gregory A. Gapp, M.D.
Grand Forks Clinic Ltd.
Grand Forks, ND 58206

Stephen H. Goldberger, M.D.
Grand Forks Clinic Ltd.
Grand Forks, ND 58206

Genevieve M. Goven, M.D.
Meritcare Clinic Valley City
Valley City, ND 58072

Mark B. Hart, M.D.
The Bone and Joint Center
Bismack, ND 58504

George H. Hilts, M.D.
Dakota Eye Institute
Bismarck, ND 58504

Mark O. Jensen, M.D.
300 Main Avenue
Fargo, ND 58103
National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-5
Donald R. Lamb, M.D.
100 4th Street, S., Suite 504
Fargo, ND 58103

Gregory J. Post, M.D.
Meritcare Medical Group
Fargo, ND 58123

David A. Rinn, M.D.
Towner County Medcenter
Cando, ND 58324

Pierre A. Rioux, M.D.
307 5th Avenue, SE, Suite 300
Minot, ND 58701
Thomas R. Templeton, M.D.
Great Plains Clinic
Dickinson, ND

Brian C. Willoughby, M.D.
West River Health Clinics
Hettinger, ND 58639

Councilors Assigned
David H. Lane, M.D.
Anesthesia Associates Ltd.
Grand Forks, ND 58208

Larry E. Johnson, M.D.
Dakota Clinic Ltd.
P. O. Box 1980
Jamestown, ND 58402
Pharmacy Advisory Committee
Robert L. Treitline, Chair
941 9th Avenue West
Dickinson, ND 58601

Anton P. Welder, R.Ph.
P.O. Box 835
Bismarck, ND 58502

Doreen M. Beiswanger, R.Ph
1140 SE 6 Street, Unit 10
Valley City, ND 58072

David L. Just, R.Ph.
P.O. Box 99
Beulah, ND 58523

David J. Olig, R.Ph.
2400 32nd Avenue South
Fargo, ND 58103


DuWayne Schlittenhard, R.Ph.
3408 Par Street
Fargo, ND 58102

Mary Beth Reinke, R.Ph.
3530 SW 28 #301
Fargo, ND 58104

Cindy Yeager, R.Ph.
Box 9512
Fargo, ND 58108
Executive Officers of State Medical and
Pharmaceutical Societies
North Dakota Medical Association
Bruce Levi
Executive Vice President
204 W. Thayer Avenue
P.O. Box 1198
Bismarck, ND 58502-1198
T: 701/223-9475
F: 701/223-9476
E-mail: blevi@ndmed.com
Internet address: www.ndmed.com

North Dakota State Osteopathic Association
Carmen Christianson Bell
President Director
1600 2
nd
Avenue, SW, Suite 20
Minot, ND 58701
701/852-8798
Internet address: www.ndoma.org

North Dakota Pharmaceutical Association
Wade B. Bilden
Executive Vice President
1906 E. Broadway
Bismarck, ND 58501-4700
T: 701/258-4968
F: 701/258-9312
E-mail: ndpha@nodakpharmacy.com
Internet address: www.nodakpharmacy.com

State Board of Pharmacy
Howard C. Anderson
Executive Director
P. O. Box 1354
Bismarck, ND 5807-7340
T: 701/328-9535
F: 701/224-9529
E-mail: ndboph@btinet.net




National Pharmaceutical Council Pharmaceutical Benefits 2003
North Dakota-6
North Dakota Hospital Association
Arnold R. Thomas, President
3205 E. Thayer Avenue
Bismarck, ND 58501
701/224-9732
E-mail: athomas@ndha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-1
OHIO
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001 2002**

Expenditures Recipients Expenditures Recipients
TOTAL $1,087,552,923 904,380 $1,333,992,298

RECEIVING CASH ASSISTANCE, TOTAL $540,895,726 292,077
Aged $84,684,721 32,916
Blind/Disabled $430,791,473 161,509
Child $11,864,467 66,278
Adult $13,555,065 31,374

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $35,401,852 148,249
Aged $2,188,262 1,883
Blind/Disabled $5,157,289 2,989
Child $24,761,193 122,129
Adult $3,295,108 21,248

TOTAL OTHER EXPENDITURES/RECIPIENTS* $511,255,345 464,054

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

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


National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-2
C. ADMINISTRATION
Ohio Department of Job and Family Services, Bureau
of Health Plan Policy.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
most drugs including prescribed insulin; total
parenteral nutrition products; and interdialytic
parenteral nutrition products. Products not covered:
cosmetics; fertility drugs; obesity drugs; experimental
drugs. Prior authorization required for some drugs
including these examples: Ceredase; Cerebyx;
Cerezyme; Clorazepates; Depo-Provera; Enbrel;
immunoglobulins; Lioresal Intrathecal; Lodosyn;
Nascoral; Orgaran; Oxandrin Panretin; Periostat;
Priftin; Prolastin; Proleukin; Provigil; Psoralens;
Remicade; Rituxan; Stimate; Synagis; and Targretin.
Products covered under DME: disposable needles
and syringe combinations used for insulin; blood
glucose test strips; and urine ketone test strips.

OTC Coverage: Selected coverage for: allergy,
asthma, and sinus products; analgesics; feminine
products; smoking deterrent products; cough and cold
preparations; digestive products; topical products;
laxatives; antacids; and vitamins and minerals.

Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and
NSAIDS; anticoagulants; anticonvulsants; anti-
depressants; anti-psychotics; anxiolytics, sedatives
and hypnotics; chemotherapy agents; contraceptives;
estrogens; and thyroid agents. Prior authorization
required for: antibiotics; antidiabetic agents;
antihistamines; antilipemic agents; cardiac drugs;
prescribed cold medications; ENT-anti-inflammatory
agents; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; and sympathominetics
(adrenergic). Therapeutic categories not covered:
anbolic steroids; anorectics; growth hormones;
innovator multi-source drugs; selected high-risk
drugs (e.g., Accutane); and drugs used in special
settings (e.g., outpatient hospital).

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

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

Unit Dose: Unit dose packaging not reimbursable.
Approved Drug List (ADL)/Prior
Authorization
ADL: Closed ADL with approximately 28,000 NDC-
specific trade and generic drugs. Products excluded
include obesity, fertility, and experimental drugs.
ADL managed by excluding products based on
contracting issues, restrictions on use, and prior
authorization.
Prior Authorization: State currently has a formal
prior authorization procedure. Prior authorization is
needed for certain individual drugs (see examples
above) A beneficiary may appeal a prior
authorization decision and be granted an
administrative hearing.
Prescribing or Dispensing Limitations
State does not impose prescribing or dispensing
limits on prescriptions.
Drug Utilization Review
PRODUR system implemented through POS in Feb
2000. State currently has a DUR Board with quarterly
review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.70, effective 7/1/98. ($0.50 fee
for flu vaccine.)

Ingredient Reimbursement Basis: EAC = WAC + 9%
(eff. 5/1/02).

Prescription Reimbursement Formula:
Reimbursement for legend drugs and selected OTC
products based on the lowest of:
1. Provider’s submitted charge, which should
reflect usual and customary charge to the general
public;
2. WAC + 9% plus a dispensing fee.
3. Federal- or state-established Maximum
Allowable Cost (MAC), for specifically
designated generically equivalent drugs plus a
dispensing fee.
Non-legend drugs - reimbursement is based on WAC
+ 9% plus a dispensing fee, or MAC if applicable.
Special reimbursement for Blood Factors 8 and 9.

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

Incentive Fee: None.

Patient Cost Sharing: No copayment.
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-3
E. USE OF MANAGED CARE
Approximately 400,000 Medicaid recipients were
enrolled in managed care in 2002. All received
pharmacy services through managed care plans.
Managed Care Organizations
Buckeye Community health Plan
175 South Third Street
Suite 520
Columbus, OH 43215
866/246-4356

Dayton Area Health Plan
One South Main Street
One Dayton Center
Dayton, OH 45402
937/224-3300

PrimeTime Medical Insurance Company
P.O. Box 6907
Canton, OH 44706
330/451-0934

Paramount Care, Inc.
P.O. Box 928
Toledo, OH 43697-0928
419/887-2550

QualChoice Health Plan
6000 Parkland Boulevard
Cleveland, OH 44124
440/460-0093

SummaCare
P.O. Box 3620
Akron, OH 44309
330/996-8410
F. STATE CONTACT
State Program Drug Administrator
Robert P. Reid, R.Ph.
Administrator, Pharmacy Services Unit
Ohio Department of Job and Family Services
Bureau of Health Plan Policy
30 East Broad Street, 27th Floor
Columbus, OH 43215-3414
T: 614/466-6420
F: 614/466-2908
E-mail: reidr@odjfs.state.oh.us
New Brand Name Products Contact
Robert P. Reid, R.Ph.
614/466-6420

Prior Authorization Contacts
Drugs: Robert P. Reid, R.Ph.
614/466-6420

DME/Nutritions: Bonnie Brownlee
614/466-6065
DUR Contact
Jan Lawson
DUR Administrator
255 East Main Street
Columbus, OH 43215
T: 614/466-9698
F: 614/-466-2866
DUR Board
Thomas E. Gretter, M.D.
Timothy Garner, M.D.
Jacob F. Palomaki, M.D.
Beth T. Tranen, D.O.
Rob Kubasak, R.Ph.
Sue Eastman, R.Ph.
Jill Orn, R.Ph.
Donald Sullivan, Ph.D., R.Ph.
Prescription Price Updating
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/827-4578
Medicaid Drug Rebate Contacts
Robert P. Reid, R.Ph.
614/466-6420
Claims Submission Contact
First Health Services Corp.
4300 Cox Road
Glen Allen, VA 23060
T: 800/884-2822
F: 800/884-7696
Medicaid Managed Care Contact
Cynthia Burnell, Chief
Bureau of Managed Health Care
Ohio Department of Job and Family Services
255 E. Main Street
Columbus, OH 43215
614/466-4693
Mail Order Pharmacy Benefit
State has mail order providers.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-4
Pharmacy and Therapeutics Committee
Robert P. Reid, R.Ph., Chairman
Bureau of Health Plan Policy
30 East Broad Street, 27th Floor
Columbus, OH 43266-0423

Suzanne Eastman, R.Ph., M.S.
3922 North Cliff Lane
Cincinnati, OH 43220

Michael Alexander, D.O.
3219 Sullivant Avenue
Columbus, OH 43204

Ruth E. Purdy, D.O.
4830 Slate Run Court
Columbus, OH 43220

Susan Baker, APN
2288 Kings Corners East
Lexington, OH 44904

Mary Jo Welker, M.D.
2231 North High Street
Columbus, OH 43201

Jennifer Christner, M.D.
2262 Parkwood
Toledo, OH 43620

Sandra Hrometz, R.Ph, Ph.D.
740 E. College Avenue
Bluffton, OH 43209

Tammie J. Stroup, R.Ph.
30 E. Broad Street, 27
th
Floor
Columbus, OH 43215-3414
Department of Job and Family Services
Officials
Thomas Hayes, Director
Ohio Department of Job and Family Services
30 East Broad Street, 32nd Floor
Columbus, OH 43215-3414
T: 614/466-6282
F: 614/466-2815
E-mail: hayest@odjfs.state.oh.us

Barbara C. Edwards, Deputy Director
Ohio Health Plans
Ohio Department of Job and Family Services
30 East Broad Street, 31st Floor
Columbus, OH 43215-3414
T: 614/466-0140
F: 614/752-3986
E-mail: Medicaid@odhs.state.oh.us


Robyn Colby, Chief
Bureau of Health Plan Policy
614/466-6420

Sheila Fujii, Chief
Bureau of Medical Assistance
255 E. Main Street
Columbus, OH 43215
614/466-2365
Medical Care Advisory Committee
Jerry Friedman, Chair
Cindy Norwood
Ed Lentz
Hubert Wirtz
Robert Logan
Eugene King, J.D.
Pamela Morris
Frank Giganti
Walter Clark, M.D.
Eileen Cooper Reed
Robert Staib
Jack Cera
Art Schlesinger
Randall Garland
William Sawyer, M.D.
Virginia Haller, M.D.
Maureen Mitchell, R.N., Ed.D.
Richard Tuck, M.D.
Christopher Moore
Nancy Lee
Kathleen Anderson
Katherine Kuck
Donna Skoda, M.S., R.D., L.D.
T. Clifford Deveny, M.D.
Randy Runyon
Brian Tilow
Executive Officers of State Medical and
Pharmaceutical Societies
Ohio State Medical Association
Brent Mulgrew
Executive Director
3401 Mill Run Drive
Hilliard, OH 43026
T: 800/766-6762
F: 614/527-6763
E-mail: brentm@osma.org
Internet address: www.osma.org









National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-5
Ohio Pharmacists Association
Ernest “Ernie” Boyd
Executive Director
6037 Frantz Road, Suite 106
Dublin, OH 43017
T: 614/798-0037
F: 614/798-0978
E-mail: eboyd@ohiopharmacists.org
Internet address: www.ohiopharmacists.org

Osteopathic Association
Jon F. Wills
Executive Director
53 W. 3rd Avenue
P.O. Box 8130
Columbus, OH 43201
T: 614/299-2107
F: 614/294-0457
E-mail: execdir@ooanet.org
Internet address: www.ooanet.org

State Board of Pharmacy
William T. Winsley
Executive Director
77 S. High Street, Room 1702
Columbus, OH 43215-6126
T: 614/466-4143
F: 614/752-4836
E-mail: exec@bop.state.oh.us
Interent address: www.state.oh.us/pharmacy/

Ohio Hospital Association
James Castle, CEO
155 E. Broad Street, 15
th
Floor
Columbus, OH 43215-3620
T: 614/221-7614
F: 614/221-4771
E-mail: oha@ohanet.org
Internet address: www.ohanet.org




















































National Pharmaceutical Council Pharmaceutical Benefits 2003
Ohio-6











National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-1
OKLAHOMA
1


A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $215,717,760 249,678 $285,068,869

RECEIVING CASH ASSISTANCE, TOTAL $71,737,280 62,218
Aged $21,886,460 21,329
Blind/Disabled $48,377,145 35,113
Child $903,823 4,161
Adult $569,852 1,615

MEDICALLY NEEDY, TOTAL $296,233 562
Aged $13,911 31
Blind/Disabled $149,640 137
Child $61,257 210
Adult $71,425 184

POVERTY RELATED, TOTAL $26,864,537 129,023
Aged $85,695 170
Blind/Disabled $134,217 149
Child $24,942,717 114,054
Adult $1,701,908 14,650

TOTAL OTHER EXPENDITURES/RECIPIENTS* $116,819,710 57,875

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

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

1

Note: As of January 1, 2004, (after the survey was conducted) the Oklahoma Medicaid program, according to its website,
underwent changes regarding managed care. These changes will be reflected in the 2004 compilation. Please contact the State for
information on the changes in managed care.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-2
C. ADMINISTRATION
Oklahoma Health Care Authority.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered (DME benefit):
disposable needles and syringe combinations for
insulin; blood glucose test strips; and urine ketone
test strips. Products covered with restrictions: total
parenteral nutrition (reimburse single most costly
ingredient, not reimbursed through pharmacy
program). Products not covered: cosmetics; fertility
drugs; and experimental drugs.

Over-the-Counter Product Coverage: Products
covered: birth control products. Products covered
with restrictions: allergy, asthma, and sinus products
(Claritin OTC only for children < 21 years. PA
required for adults. Rx required for all ages.);
digestive products (non-H2 antagonists-Prilosec OTC
only, Rx required); smoking deterrent products (PA
and Rx required). Products not covered: analgesics;
cough and cold preparations; H2 antagonists;
feminine products; topical products.

Therapeutic Category Coverage: Therapeutic
categories covered: antibiotics; anticoagulants;
anticonvulsants; antidepressants; antidiabetic agents;
antilipemic agents; anti-psychotics; chemotherapy
agents; contraceptives; ENT anti-inflammatory
agents; estrogens; sympathominetics (adrenergic);
and thyroid agents. Prior authorization required for:
anoretics (partial coverage); analgesics, antipyretics,
NSAIDs; antihistamine drugs (partial coverage);
anxiolytics, sedatives, and hypnotics; cardiac drugs;
growth hormones; hypotensive agents; misc. GI
drugs; prescribed smoking deterrents (partial
coverage) stimulants for ADHD; clopidigrel; and
montelukast. Therapeutic categories not covered:
anabolic steroids; and prescribed cold medications.
OBRA ’90 drugs identified as "coverage optional."

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

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

Unit Dose: Unit dose packaging not reimbursable.



Formulary/Prior Authorization
Formulary: Open formulary with the preferred drug
list (PDL). PDL managed through restrictions on
use, prior authorization, therapeutic substitution, use
of preferred products, and step therapy.

Prior Authorization: State currently has a formal
prior authorization procedure and DUR Board.
Agency grievance process exists for appeal of prior
authorization decisions or coverage of an excluded
product.
Prescription or Dispensing Limitations
Prescription Refills: None

Monthly Quantity Limits: Three prescriptions per
month/recipient. ICF-MR, Medicaid children, and
nursing home recipients are allowed unlimited orders.
Clients on Home and Community Based Waivers
and DDSD Waivers are also allowed an unlimited
number of prescriptions each month.

Quantity Limit per Prescription: 34-day supply or
100 units.
Drug Utilization Review
PRODUR system implemented in 2000. State
currently has a DUR Board with a monthly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.15, effective 10/95.

Ingredient Reimbursement Basis: EAC = AWP –
12.0%.

Prescription Charge Formula: Estimated Acquisition
Cost (EAC) plus dispensing fee, or usual and
customary charge, whichever is lower. In no event
shall charges to the Welfare Department exceed
charges made to the general public for the same
prescription or item.

Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. Override requires “Brand Medically
Necessary.” Currently, 414 drugs on MAC list.

Incentive Fee: None.

Patient Cost Sharing: Copayment is $1.00 for
prescriptions up to $29.99, $2.00 for prescriptions
over $30.00.

Cognitive Services: Does not pay for cognitive
services.

National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-3
E. USE OF MANAGED CARE
Approximately 185,000 Medicaid recipients were
enrolled in MCOs in FY 2002. Recipients receive
benefits through both the State and managed care
plans. Effective 1/1/2004, there will be no fully
capitated managed care plans in Oklahoma. The
Primary Care/Care Management System will remain
in place.
F. STATE CONTACTS
State Drug Program Administrator
Nancy Nesser, D.Ph., J.D.
Pharmacy Director
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105-9901
T: 405/522-7325
F: 405/522-3240
E-mail: nessern@ohca.state.ok.us
Internet address: www.ohca.state.ok.us
Prior Authorization Contact
Ronald Graham, D.Ph.
Manager, Operations/DUR
University of Oklahoma, College of Pharmacy
P.O. Box 26901
Oklahoma City, OK 73109
T: 405/271-6614
F: 405/271-2615
E-mail: ronald-graham@ouhsc.edu
DUR Contact
Ronald Graham, D.Ph.
405/271-6614
Medicaid DUR Board
Rick Crensaw, D.O.
Dick Robinson, R.Ph. (Vice-Chair)
Dorothy Gourley, D.Ph.
Cliff Meece, D.Ph.
Greg Tarasoff, M.D.
Cathy E. Hollen, D.Ph.
Thomas Kuhls, M.D.
Thomas Whitsett, M.D. (Chair)
Dan McNeill, Ph.D., PA-C
James Swaim, D.Ph.
Prescription Price Updating
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
Internet address: www.firstdatabank.com
Medicaid Drug Rebate Contacts
Tom P. Simonson
Drug Rebate Manager
Oklahoma Healthcare Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105-9901
T: 405/522-7327
F: 405/530-3236
E-mail: simonsoT@ohca.state.ok.us
New Brand Name Products Contact
Rodney Ramsey
Pharmacy Claims Specialist
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
T: 405/522-7492
F: 405/530-3238
E-mail: ramseyr@ohca.state.ok.us
Claims Submission Contact
EDS
2401 N.W. 23rd Street, Suite 11
Oklahoma City, OK 73107
405/416-6794
Medicare Managed Care Contact
Melinda Jones
Senior Compliance Analyst
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105-9901
T: 405/522-7125
F: 405/530-3281
E-mail: jonesm@ohca.state.ok.us
Mail Order Pharmacy Program
Oklahoma does not sponsor a mail order pharmacy
benefit. However, mail order pharmacies are allowed
to contract with the Oklahoma Medicaid program to
provide prescription products to Oklahoma Medicaid
beneficiaries. Pharmacy must be a contracted
provider.
Disease Management Program/Initiative
Contact
Kathe Eastham, R.N
Nurse Case Manager III
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105-9901
T: 405/522-7155
F: 405/522-7378
E-mail: easthamk@ohca.state.ok.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oklahoma-4
Oklahoma Health Care Authority Officials
Michael Fogarty, J.D.
Chief Executive Officer
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
T: 405/522-7300
F: 405/522-7187
E-mail: fogartym@ohca.state.ok.us

Lynn Mitchell, M.D.
State Medicaid Director
Oklahoma Health Care Authority
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
T: 405/530-7365
F: 405/530-3218
E-mail: mitchell@ohca.state.ok.us
Advisory Committee on Medical Care for
Public Assistance Recipients
Frank Wilson, III, M.D., Chairman
4545 N. Lincoln, Suite 124
Oklahoma City, OK 73105
Executive Officers of State Medical,
Pharmaceutical, and Osteopathic Societies
Oklahoma State Medical Association
Brian O. Foy, Executive Director
601 NW Grand Boulevard
Oklahoma City, OK 73118
T: 405/843-9571 or 800/522-9452
F: 405/842-1834
E-mail: osma@osmaonline.org
Internet address: www.osmaonline.org

Oklahoma Pharmaceutical Association
Phil Woodward, Ph.D., Executive Director
P.O. Box 18731
Oklahoma City, OK 73154
T: 405/528-3338
F: 405/528-1417
E-mail: pwoodward@opha.com
Internet address: www.opha.com

Oklahoma Osteopathic Association
Lynette C. McLain
Executive Director
4848 N. Lincoln Boulevard
Oklahoma City, OK 73105-3321
T: 405/528-4848
F: 405/528-6102
E-mail: ooa@okosteo.org
Internet address: www.okosteo.org



State Board of Pharmacy
Janis K. McAllister
President
4545 N. Lincoln Boulevard, Suite 112
Oklahoma City, OK 73105-3488
T: 405/521-3815
F: 405/521-3758
E-mail: pharmacy@oklaosf.state.ok.us
Internet address: www.state.ok.us/~pharmacy

Oklahoma Hospital Association
Craig W. Jones
President
4000 Lincoln Boulevard
Oklahoma City, OK 73105
T: 405/427-9537
F: 405/424-4507
E-mail: jones@okoha.com
Internet address: www.okoha.com


National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-1
OREGON
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services

B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $222,018,784 220,711 $279,029,096

RECEIVING CASH ASSISTANCE TOTAL $81,943,856 59,881
Aged $8,775,572 7,674
Blind/Disabled $66,610,479 31,564
Child $1,293,366 10,333
Adult $5,264,439 10,310

MEDICALLY NEEDY, TOTAL $32,193,369 7,442
Aged $5,225,676 1,960
Blind/Disabled $26,967,693 5,482
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $5,834,456 37,267
Aged $446,133 404
Blind/Disabled $1,288,996 622
Child $3,452,072 31,426
Adult $647,255 4,815

TOTAL OTHER EXPENDITURES/RECIPIENTS* $102,047,103 116,121

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-2
C. ADMINISTRATION
Office of Medical Assistance Programs (OMAP),
Department of Human Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin. Products covered under DME:
disposable needles and syringe combinations used for
insulin; blood glucose test strips; and urine ketone
test strips. Prior authorization required for:
isotretinon; acute anti-ulcer drugs; cosmetics; total
parenteral nutrition; interdialytic parenteral nutrition;
retinoic acid; nasal inhalers; coal tar preparations;
and topical testosterone. Products not covered:
cosmetics; fertility drugs; experimental drugs.
Over-the-Counter Product Coverage: Products
requiring prior authorization and physician
prescription (limited to 3 claims per month in each
therapeutic class): allergy, asthma, and sinus
products; analgesics; cough and cold preparations;
digestive products; feminine products; topical
products; and smoking deterrent products.
Therapeutic Category Coverage: Therapeutic
categories covered: analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants; anti-
depressants; antidiabetic drugs; antilipemic agents;
antipsychotics; cardiac drugs; chemotherapy agents;
prescribed cold medications; contraceptives;
estrogens; hypotensive agents; prescribed smoking
deterrents; sympathominetics (andrenergic); and
thyroid agents. Therapeutic categories requiring prior
authorization: anabolic steroids; anticonvulsants;
antihistamine drugs; anxiolytics, sedatives, and
hypnotics; ENT anti-inflammatory agents; growth
hormones; misc. GI drugs; antifungals; legend
laxatives; oral nutrionals; topical antibiotics; topical
antivirals; weight reduction drugs; and any other drug
products for which the only indication is for a non-
funded condition. Therapeutic categories not
covered: anoretics. (The Oregon Health Plan
coverages are limited to conditions which appear on
the HSC prioritized list.)
Coverage of Injectables: Injectable medicines
reimbursable through physician payment when used
in physician offices, home health care, and extended
care facilities.
Vaccines: Vaccines reimbursable by Medicaid as part
of the Vaccines for Children Program.
Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary with a preferred drug list
(PDL). PDL managed through physician profiling.
Prior Authorization: State currently has a formal
prior authorization procedure. Client may request an
administrative hearing to appeal a prior authorization
decision or to appeal the coverage of excluded
products.
Prescribing or Dispensing Limitations
34 days for chronic drugs. (Limits on initial
prescription for chronic medications to 15 days to
prevent wasting if drug is changed due to intolerance,
side effects, etc.) Therapy duration limits on selected
drugs.
Drug Utilization Review
PRODUR system implemented in March 1994. State
currently has a DUR Board with a quarterly review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.50, $3.80, effective 10/01/01.

1) $3.50 (retail);

2) $3.90 (institutional/SNF: providers operating a
True or Modified Dose Delivery System).

Ingredient Reimbursement Basis: EAC = AWP-15%
(Retail), AWP-11% (Institutional)
Prescription Charge Formula: Estimated acquisition
cost (EAC) defined as the lesser of: (1) AWP-15%
(2) Federal Upper Limits for multiple source drugs or
(3) state MAC, or (4) the usual and customary charge
plus a dispensing fee.
Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
allowable cost (MAC) limits on generic drugs.
Override requires or “Brand Medically Necessary”
plus documentation of patient intolerance to generic.
Incentive Fee: None.
Patient Cost Sharing: $2.00 (generic); $3.00 (brand)
Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-3
E. USE OF MANAGED CARE
Approximately 265,000 Medicaid Recipients were
enrolled in MCOs in FY 2002. Recipients enrolled in
MCOs receive pharmaceutical benefits through
managed care plans. Mental health drugs are carved
out of managed care.

Care Oregon, Inc
522 SW Fifth Avenue, Suite 200
Portland, OR 97204
800/224-4840

Cascade Comprehensive Care, Inc.
900 Main Street, Suite A
P.O. Box 217
Klamath Falls, OR 97601-0368
541/883-2947

Central Oregon Independent Health Services, Inc.
2650 NE Courtney Drive
P.O. Box 5729
Bend, OR 97708-5729
800/431-4155

Doctors of The Oregon Coast South (DOCS)
750 Central, Suite 202
P.O. Box 1096
Coos Bay, OR 97420
541/269-7400

Douglas County IPA
500 SE Cass, Suite 210
Roseburg, OR 97470
541/677-3453

Family Care, Inc
2121 SW Broadway, Suite 300
Portland, OR 97201
800/335-3205

Intercommunity Health Network, Inc
3600 NW Samaritan Drive
Corvallis, OR 97330
800/757-5114

Kaiser Permanente
500 NE Multnomah, Suite 100
Portland, OR 97232-2099
800/813-2000

Lane Individual Practice Association, Inc. (LIPA)
1500 Valley Rive Drive, Suite 370
Eugene, OR 97401
541/485-2155




Marion Polk Community Health Plan
198 Commercial Street, SE, Suite 240
Salem, OR 97301
503/584-2150

Mid Rogue IPA Health Plan
820 NE 7
th
Street
Grants Pass, OR 97526
541/471-4106

ODS Health Plans
601 SW 2
nd
Ave
Portland, OR 97204
800/342-0526

Oregon Health Management Services
1051 NE 6
th
Street, Suite 2C
Grants Pass, OR 97526
541/ 471-4208

Providence Health Plan
1235 NE 47
th
, Suite 220
Portland, OR 97213-2196
800/ 898-8174

Tuality Health Alliance
335 SE 8
th
Avenue
P.O. Box 925
Hillsboro, OR 97123-0925
800/681-1901
F. STATE CONTACTS
State Drug Program Administrator
Thomas Drawbaugh
Pharmacy Program Manager
Office of Medical Assistance Programs (OMAP)
Department of Human Resources
500 Summer Street, NE, E-35
Salem, OR 97301-1077
T: 503/945-6492
F: 503/373-7689
E-mail: thomas.drawbaugh@state.or.us
Internet address: www.dhs.state.or.us/healthplan
Prior Authorization Contact
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
Medicaid Program Coordinator
Oregon State University College of Pharmacy
840 SW Gaines Road, MC 212
Portland, OR 97239-3098
T: 503/494-1589
F: 503/494-8797
E-mail: ketchumk@ohsu.edu


National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-4
DUR Contact
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
503/494-1589
Medicaid DUR Board
Rickland G. Asai, D.M.D.
Patrick Bowman, R.Ph.
Gerald D. Fairbanks, R.Ph.
Dean Haxby, Pharm.D.
Christina Heinrich, Pharm.D. (Vice-Chair)
Robert Ingle, Jr., M.D., M.P.H.
Gregory Johnson, M.D. (Chair)
Raymond S. Lee, D.O.
Sharon Leigh, Pharm.D.
John Muench, M.D., M.P.H.
Clifford Singer, M.D.
New Brand Name Products Contact
Kathy L. Ketchum, R.Ph., M.P.A.: H.A.
503/494-1589
Prescription Price Updating
Jim Rowland
Account Manager
First Health Services Corporation
925 Commercial Street
Salem, OR 97301-2460
T: 503/391-1980
F: 503/391-1979
E-mail: rowlanji@fhsc.com
Medicaid Drug Rebate Contacts
Jim Rowland
503/391-1980
Claims Submission Contact
Jim Rowland
503/391-1980
Medicaid Managed Care Contact
Joyce Riggi
Delivery Systems Manager
Office of Medical Assistance Programs
500 Summer Street, NE
Salem, OR 97310
T: 503/945-6497
F: 503/947-5221





Disease Management Program/Initiative
Contact
Chris Barber
Case Management Coordinator
Office of Medical Assistance Programs
500 Summer Street, NE
Salem, OR 97301
503/945-6588
E-mail: chris.barber@state.or.us
Disease Management/Patient Education
Programs
Disease States/Medical Conditions: asthma,
cardiovascular disease, diabetes
Program Name: Care Enhance
Program Manager: McKesson
Mail Order Pharmacy Program
State has a Mail Order Pharmacy Program. All non-
institutionalized beneficiaries are entitled to
participate.
Office of Medical Assistance Officials
Jean Thorne
Director
Department of Human Services
500 Summer Street, NE, E-15
Salem, OR 97301
T: 503/945-5944
F: 503/378-2897
E-mail: jean.i.thorne@state.org.us

Lynn Read
Director
Office of Medical Assistance Programs
Department of Human Services
500 Summer Street, NE
Salem, OR 97301
T: 503/945-5772
F: 503/373-7689
E-mail: lynn.read@state.or.us
Title XIX Medical Care Advisory Committees
Elizabeth Byers
Bruce Bliatout
Donna Crawford
Rosemari Davis
Michael Garland
John Hogan
Kelley Kaiser
Noel Larson, D.M.D.
Amy Malone
Rick Wopat, M.D.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-5
Consultants to Health and Social Services
Section
Thomas Turek, M.D.
Medical Director
Office of Medical Assistance Programs
Department of Human Resources
500 Summer Street, NE
Salem, OR 97301
Pharmacy Advisory Task Force
Tom Holt, Chairman
Mike Dardis, R.Ph.
Jim Waletich, R.Ph.
Ed Hughes, R.Ph.
Ron Dulwick, R.Ph.
Jenny Kudna, R.Ph.
Dennis Perry, R.Ph.
Larry Cartier, R.Ph.
Richard Hartmann, R.Ph.
Chris Vorrath, R.Ph.
Susie Morris, R.Ph.
Tom Hornsby, R.Ph.
Kathy Ketchum, R.Ph.
John Mansfield, R.Ph.
Dave Lewis, R.Ph.
Dave Walden, R.Ph.
Cynthia Wong, R.Ph.
Executive Officers of State Medical and
Pharmaceutical Associations
Oregon Medical Association
Stephanie Munoz
Director of Operations
5210 SW Corbett Street
Portland, OR 97239-3897
T: 503/226-1555
F: 503/241-7148
E-mail: stephanie@theoma.org
Internet address: www.ormedassoc.org

Oregon State Pharmacists Association
Tom Holt
Executive Director
29702-B Town Center Loop West
Wilsonville, OR 97070-6481
T: 503/582-9055
F: 503/582-9046
E-mail: tomh@oregonpharmacists.com
Internet address: www.oregonpharmacists.com








Osteopathic Physicians and Surgeons of Oregon
Jeff Heatherington
Executive Director
2121 SW Broadway, Suite 300
Portland, OR 97201
T: 503/222-2779
F: 503/222-2392
E-mail: jeffh@opso.org
Internet address: www.opso.com

State Board of Pharmacy
Gary Schnabel
Executive Director
State Office Bldg., Room 425
800 NE Oregon Street, #9
Portland, OR 97232
T: 503/731-4032
F: 503/731-4067
E-mail: gary.a.schnabel@state.or.us
Internet address: www.pharmacy.state.or.us

Oregon Association of Hospitals and Health Systems
Ken Ballantyne
Senior Vice President
4000 Kruse Way Place
Building 2, Suite 100
Lake Oswego, OR 97035-2543
T: 503/636-2204
F: 503/636-8310
E-mail: kenb@oahhs.org
Internet address: www.oahhs.org




























National Pharmaceutical Council Pharmaceutical Benefits 2003
Oregon-6












National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-1
PENNSYLVANIA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS

2001 2002**
Expenditures Recipients Expenditures Recipients
TOTAL $690,558,773 461,114 $718,210,352

RECEIVING CASH ASSISTANCE, TOTAL $295,061,741 162,880
Aged $63,115,582 25,318
Blind / Disabled $210,975,578 76,006
Child $8,864,185 39,509
Adult $12,106,396 22,047

MEDICALLY NEEDY, TOTAL $68,796,845 36,604
Aged $60,348,380 23,250
Blind / Disabled $4,759,422 1,278
Child $2,469,233 7,645
Adult $1,219,810 4,431

POVERTY RELATED, TOTAL $146,089,558 155,466
Aged $47,997,255 19,730
Blind / Disabled $79,066,222 33,769
Child $17,670,812 92,287
Adult $1,355,269 9,680

TOTAL OTHER EXPENDITURES/RECIPIENTS* $180,610,629 106,164


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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-2
C. ADMINISTRATION
Office of Medical Assistance Programs, Department
of Public Welfare.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; urine ketone test strips; interdialytic parenteral
nutrition; and total parenteral nutrition. Products not
covered: cosmetics; fertility drugs; and experimental
drugs.

Over-the-Counter Product Coverage: Products
covered: analgesics; feminine products; topical
products; laxatives; scabicides containing permethrin;
oral electrolytes; and smoking deterrent products.
Products covered with restrictions: allergy, asthma,
and sinus (indication or prescribed); cough and cold
preparations (indication other than C+C on Rx);
digestive products (not including H2 antagonists)
(legend products only); and digestive products (H2
antagonists) (PA > 90 days at acute dose). Products
not covered: emollients and digestive products (non
H2 antagonists).

Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; analgesics,
antipyretics, NSAIDs; antibiotics; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti-
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; contraceptives;
ENT anti-inflammatory agents; estrogens; growth
hormones; hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); thyroid agents; and
prescribed smoking deterrent products; and
prescribed cold medications. Therapeutic categories
not covered: anorectics (unless for treatment of
hyperkinesis or narcolepsy); hair restoration drugs,
vitamins (with some exceptions); and products from
companies not participating in the rebate program.

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

Vaccines: Vaccines reimbursable at AWP – 10% as
part of the Medical Assistance, Children Health
Insurance Program, the Vaccines for Children
Program, and EPSDT Program.

Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.

Prior Authorization: State currently has a prior
authorization procedure screening for drug classes
and individual drugs. Products that require PA
include BMN brand name drugs that have A-rated
generics, H2 antagonists used >90 days, and drugs
for erectile dysfunction. Also, Oxycontin
prescriptions with doses in excess of 3 tablets per
day, or being on more than 2 different strengths
concurrently and COX-2 drugs if the patient is taking
another NSAID, the prescribed dose is higher than
the FDA recommended dose, or the patient is under
70 years of age and is not taking an anticoagulant.
Prescribing or Dispensing Limitations
Quantity Limit: 34-day supply or 100 units,
whichever is greater.

Refill Limit: Up to 5 within 6 months.

Monthly Prescription Limit: 6
Drug Utilization Review
PRODUR system implemented in June 1993. DUR
Board has 10 members and meets quarterly.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.00 ($5.00 for compounds),
effective 10/1/95.

Ingredient Reimbursement Basis: EAC = AWP-10%.

Prescription Charge Formula:
1. Payment for single source drugs and those
multisource brand name drugs certified as
medically necessary will be the lower of the
EAC plus dispensing fee or the pharmacy's usual
and customary charge.
2. State MAC for the drug plus dispensing fee or
the pharmacy's usual and customary charge.
3. For compound prescriptions, an additional fee of
$1.00 is allowed to a pharmacy, bringing the
total dispensing fee to $5.00.

Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. 465 drugs are listed on the State-
specific MAC list. Override requires “Brand
Medically Necessary” or “Brand Necessary,” plus
prior authorization.

Incentive Fee: None.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-3
Patient Cost Sharing: Copayment is $1.00; $2.00 for
General Assistance. The copayment will not apply to
those recipients who are federally exempt, under 21
years of age, pregnancy cases and long-term care
patients, plus patients receiving drugs in the
following categories:
− Anticonvulsants
− Antidiabetic agents
− Antiglaucoma agents
− Antihypertensive agents
− Antineoplastic agents
− Antiparkinson agents
− Cardiovascular preparations
− HIV/AIDS specific drugs
− Psychotherapeutic agents

Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 936,000 unduplicated Medicaid
recipients were enrolled in managed care in 2002.
All receive pharmacy services, depending on their
category of assistance, through managed care.
Managed Care Organizations
AmeriHealth HMO/Mercy Health Plan 65,312
1901 Market Street, 45
th
Floor
Philadelphia, PA 19103

Keystone Mercy Healthplan 246,609
200 Stevens Drive, Suite 900
Philadelphia, PA 19113-1570

Americhoice of PA 103,240
The Wanamaker Building
100 Penn Square East, Suite 900
Philadelphia, PA 19107

Health Partners of Philadelphia 126,060
841 Chestnut Street, Suite 900
Philadelphia, PA 19107

Three Rivers Health Plans/MedPlus+ 135,525
300 Oxford Drive
Monroeville, PA 15146

UPMC Health Plan, Inc./Best 63,823
Healthcare of Western PA
One Chatam Center
112 Washington Place
Pittsburgh, PA 15219

Gateway Health Plan 195,723
Two Chatam Center, Suite 500
Pittsburgh, PA 15219
F. STATE CONTACTS
State Drug Program Administrator
Joseph E. Concino, R.Ph., Chief
Office of Medical Assistance Programs
Pharmacy Services Section
P.O. Box 8046
Harrisburg, PA 17105
T: 717/772-6341
F: 717/772-6366
E-mail: jconcino@state.pa.us
Internet address: www.dpw.state.pa.us/omap
Welfare Department Officials
Estelle B. Richman
Secretary
Department of Public Welfare
Health and Welfare Building
P.O. Box 2675
Harrisburg, PA 17105-2675
T: 717/787-2600
F: 717/772-2062
E-mail: ra-dpwsecretarynet@state.pa.us

David S. Feinberg
Deputy Secretary for Medical Assistance Programs
Department of Public Welfare
Health and Welfare Building
P.O. Box 2675
Harrisburg, PA 17105-2675
T: 717/787-1870
F: 717/787-4639
E-mail: pamedicaid@state.pa.us

Gwendolyn A. Poles, D.O.
Clinical Management Consultant

Teresa Shuchart
Director
Division of Data and Claims Management

Richard M. Wallace
Acting Director
Bureau of Program Integrity

Donald R. Yearsley
Acting Director
Bureau of Policy, Budget, and Planning

Patricia S. Jacobs
Acting Director
Bureau of Fee-for-Service Programs

Michael Jacobs
Acting Director
Bureau of Managed Care Operations

National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-4
Andrew Major
Director
Bureau of Long Term Care Programs

Louis J. Cappello, R.Ph.
Pharmacy Consultant
Pharmacy Services Section

John Ferrara, R.Ph.
Director
Division of Program Integrity
DUR Board
Richard D. Baltz, M.D.
3028 Market Street
Camp Hill, PA 17011

Richard T. Bell, M.D.
Chairman
2016 Redwood Avenue
Wyomissing, PA 19610

Richard W. Sloan, M.D.
Thomas Hart Family Practice Center
York Hospital
1001 South George Street
York, PA 17405

Otto F. Wolke, R.Ph.
Geisinger Health Plan
Geisinger Office Building
Danville, PA 17822

Patricia A. Keys, Pharm.D., R.Ph.
1514 Scenery Ridge Drive
Pittsburgh, PA 15241

Marshall P. Burnside, R.Ph.
6000 Bell Road
Harrisburg, PA 17111

Michael A. Zemaitis, Ph.D., R.Ph.
133 Shadowlawn Drive
Pittsburgh, PA 15261

Robert L. Mayer, Jr., Pharm.D., R.Ph.
5814 Elmer Street
Pittsburgh, PA 15232

Keith Burkhart, M.D.
206 Mine Road
Hershey, PA 17033

Jeffrey P. Staab, M.D., M.S.
5 Heritage Lane
Phoenixville, PA 19460-4607
New Brand Name Products Contact
Joseph E. Concino, R.Ph.
717/772-6341
Prescription Price Updating
First DataBank
1111 Bayhill Drive
San Bruno, CA 94066
800/633-3453
Medicaid Drug Rebate Contacts
Technical: David Ehrhart, 717/772-6305
Policy: Donald Yearsley, 717/772-6341
Disputes: Louis Cappello, 610/447-5385
Claims Submission Contact
EDS
275 Grandview Avenue
Camp Hill, PA 17011
(Calls with contractor must be made through state
agency.)
Medicaid Managed Care Contact
Michael Jacobs
Acting Director, Division of MCO Monitoring and
Compliance
Office of Medical Assistance Programs
Cherrywood Bldg, DPW Complex #2
Harrisburg, PA 17105
T: 717/772-6300
F: 717/772-2730
E-mail: mjacobs@state.pa.us
Mail Order Pharmacy Program
None
Expanded Drug Coverage Program Contact
Thomas M. Snedden, Director
PACE Program
PA Department of Aging
555 Walnut Street, 5
th
Floor.
Harrisburg, PA 17101
717/787-7313
Medical Assistance Advisory Committee
Christine Allen
PACE/LTCCAP c/o LIFE
University of Pennsylvania School of Nursing
4101 Woodland Avenue
Philadelphia, PA 19104-4510

National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-5
Shirley Beer
Armstrong County Low Income Rights Organization
RD #8, Box 134
Kittanning, PA 16201

Shelley Bishop
Pennsylvania Mental Health Consumers Association
4105 Derry Street
Harrisburg, PA 17111

Kent D. W. Bream, M.D.
Department of Family Practice
University of Pennsylvania
2 Gates, HUP, 3400 Spruce Street
Philadelphia, PA 19104

Louise Brookins
Philadelphia State Welfare Rights Organization
1231 N. Franklin Street
Philadelphia, PA 19122

Kevin Casey
Pennsylvania Protection and Advocacy
1414 Cameron Street, Suite C
Harrisburg, PA 17103

Michael D. Chambers
County Commissioners Association of Pennsylvania
17 North Front Street
Harrisburg, PA 17101

Barbara Coffin
Pennsylvania Association of Area Agencies on Aging
Berks County Office of Aging
County Services Center
633 Court Street
Reading, PA 19601-4303

Dona Dmitrovic
Executive Director
Pennsylvania Recovery Organization Alliance, Inc.
900 South Arlington Avenue, Suite 119
Harrisburg, PA 17109

Henry R. Fiumelli
Executive Director
Pennsylvania Forum for Primary Health Care
1035 Mumma Road, Suite 1
Wormleysburg, PA 17043


Vickie Hoak (Vice-Chair)
Pennsylvania Homecare Association
20 Erford Road, Suite 115
Lemoyne, PA 17043




Dolores Hodgkiss
Managed Care Association of Pennsylvania
240 North Third Street, Suite 501
Harrisburg, PA 17101

Kathy Hubert
Pennsylvania County Drug and Alcohol
Program Administrators
17 North Front Street
Harrisburg, PA 17101

Michelle Jones
Healthy Start, Inc.
400 North Lexington Street
Pittsburgh, PA 15208

George Kimes
Pennsylvania Community Providers Association
2400 Park Drive
Harrisburg, PA 17110

Christine Klejbuk
PA Assn. Non-Profit Homes for the Aging
Dir. of Public Policy
1100 Bent Creek Boulevard
Mechanicsburg, PA 17050

Ms. Carol Lavoritano
AmeriChoice
The Wanamaker Building
100 Penn Square East, Suite 900
Philadelphia, PA 19107

Yvette Long
Philadelphia Welfare Rights Organization
1231 North Franklin Street
Philadelphia, PA 19122

Donald McCoy (Chair)
Pennsylvania Medical Society
777 East Park Drive
P.O. Box 8820
Harrisburg, PA 17105-8820

Anne R. McHugh
Hospital and Healthsystem Association of
Pennsylvania
4750 Lindle Road
P.O. Box 8600
Harrisburg, PA 17105-8600

Donna McNonagle
Philadelphia Coordinated Health Care
123 South Broad Street, 22
nd
Floor
Philadelphia, PA 19109
717/546-7643, Ext. 3652

National Pharmaceutical Council Pharmaceutical Benefits 2003
Pennsylvania-6
Jonna Miller
Delaware County Office of Behavior Health
20 South 69
th
Street, 3
rd
Floor
Upper Darby, PA 19082

Richard R. Orlandi
Pennsylvania Medical Society
777 East Park Drive
P.O. Box 8820
Harrisburg, PA 17105-8820

Mary Ellen Rehrman
10 Bertolet School Road
Spring City, PA 19475

Dale Laninga - Ex-Officio Member
Department of Aging
Intra Governmental Council on Long Term Care
555 Walnut Street, 5th Floor
Harrisburg, PA 17101-1919

Michael A. Yantis, Jr. - Ex-Officio Member
Pennsylvania Department of Health Office of Policy
Room 808, Health and Welfare Building
Harrisburg, PA 17120
Executive Officers of State Medical and
Pharmaceutical Associations
Pennsylvania Medical Society
Roger F. Mecum
Executive Vice President
777 E. Park Drive
P.O. Box 8820
Harrisburg, PA 17105-8820
T: 717/558-7750
F: 717/558-7840
E-mail: rmecum@pamedsoc.org
Internet address: www.pamedsoc.org

Pennsylvania Pharmacists Association
Patricia A. Epple, CAE
Executive Director
508 North Third Street
Harrisburg, PA 17101-1199
T: 717/234-6151
F: 717/236-1618
E-mail: pepple@papharmacists.com
Internet address: www.papharmacists.com

Pennsylvania Osteopathic Medical Association
Mario E.J. Lanni
Executive Director
1330 Eisenhower Boulevard
Harrisburg, PA 17111-2395
T: 717/939-9318
F: 717/939-7255
E-mail: poma@poma.org
Internet address: www.poma.org
Pennsylvania Podiatry Association
Michael Q. Davis
Executive Director
757 Poplar Church Road
Camp Hill, PA 17011
717/763-7665

State Board of Pharmacy
Melanie Zimmerman
Executive Secretary
124 Pine Street
P.O. Box 2649
Harrisburg, PA 17105-2649
T: 717/783-7156
F: 717/787-7769
E-mail: pharmacy@pados.dos.state.pa.us
Internet address:
www.dos.state.pa.us/bpoa/phabd/mainpage.htm

The Hospital and Healthsystem Association of
Pennsylvania
Carolyn F. Scanlan
President/CEO
4750 Lindle Road
P.O. Box 8600
Harrisburg, PA 17105-8600
T: 717/561-5314
F: 717/561-5334
E-mail: cscanlan@haponline.org
Internet address: www.haponline.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Rhode Island-1
RHODE ISLAND
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001 2002**

Expended Recipients Expended Recipients

TOTAL $104,912,603 50,379 $120,952,122 50,155

RECEIVING CASH ASSISTANCE TOTAL $63,036,440 28,257
Aged $7,362,321 4,417
Blind/Disabled $55,530,351 22,501
Child $49,522 595
Adult $94,246 744

MEDICALLY NEEDY, TOTAL $8,948,203 3,671
Aged $6,099,170 2,960
Blind/Disabled $2,848,698 709
Child $0 -
Adult $335 2

POVERTY RELATED, TOTAL $333,172 911
Aged $94,162 97
Blind/Disabled $152,155 111
Child $61,352 523
Adult $25,503 180

TOTAL OTHER EXPENDITURES/RECIPIENTS* $32,594,788 17,540

*Total Other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and
unknown.
**2002 data on expenditures and number of recipients by maintenance assistance status and basis of eligibility are unavailable.
2002 data provided by the Rhode Island Department of Human Services.

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

Note: Rhode Island estimates 2003 drug expenditures to be $139 million and the number of Medicaid drug recipients to be 52,000.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Rhode Island-2
C. ADMINISTRATION
Rhode Island Department Human Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; urine ketone test
strips. Products covered under DME: blood glucose
test strips; total parenteral nutrition (prior
authorization required); and interdialytic parenteral
nutrition (prior authorization required). Products not
covered: cosmetics; fertility drugs; experimental
drugs; DESI drugs.

Over-the-Counter Product Coverage: Products
covered: allergy, asthma, and sinus products;
analgesics (acetaminophen); cough and cold
preparations (guifenisin, diphenhydramine,
chlorpheniramine); digestive products (non-H2
antagonists); topical products; (antibiotics only);
antacids; and laxatives. Products not covered:
allergy, asthma, and sinus products; digestive
products (H2 antagonists); feminine products; and
smoking deterrent products.

Therapeutic Category Coverage: Products covered:
anabolic steroids; analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
anti-depressants; antidiabetic agents, antilipemic
agents; anti-psychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents,
prescribed cold medications; contraceptives; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); and thyroid
agents. Prior authorization required for: anoretics;
antihistamines; growth hormones; misc. GI drugs;
PPIs; Provigil; CNS stimulants; Tracleer; Remodulin;
Flolan; Xolair; erectile dysfunction products; and
Cox 2 inhibitors; Therapeutic categories not covered:
prescribed smoking deterrents; products for hair
growth.

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

Vaccines: Limited coverage under the Vaccines for
Children Program and through the physician payment
program for adults.

Unit Dose: Unit dose packaging not reimbursable.
Formulary/Prior Authorization
Formulary: State has a formulary. Prior
authorization is used to manage the formulary. Fair
hearing process to appeal prior authorization
decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Refills to a maximum of 5
are allowed.

Monthly Quantity Limit: One month’s supply for
non-maintenance drugs. One inhaler per fill. 8 tablets
per month for erectile dysfunctions medication.

Maintenance Medication: The attending physician
may prescribe certain maintenance drugs of 100
tablets, capsules or pint of liquid or a 30-day supply
of these drugs - whichever is greater.

Monthly Dollar Limits: None
Drug Utilization Review
PRODUR system implemented in December 1994.
State has a DUR Board that meets quarterly.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $3.40 (ambulatory) and $2.85
(nursing homes), effective 1987.

Ingredient Reimbursement Basis: EAC = WAC +
5%.

Prescription Charge Formula:
1. In accordance with Federal regulation the upper
limit for payment for prescribed drugs will be
based upon the amount allowed by the Medical
Assistance Program or the usual and customary
charge to the general public, whichever is lower.
2. Payment for over-the-counter drugs (non-legend
drugs) will be based upon the lower of either the
allowable cost of the drug plus 5 percent, the
usual and customary charge to the general
public, or the allowable cost plus the
professional fee for service.

Maximum Allowable Cost: State imposes Federal
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” with a documented
medical reason why a generic cannot be used.

Incentive Fee: None.

Patient Cost Sharing: No copayment.

Cognitive Services: Does not pay for cognitive
services.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Rhode Island-3
E. USE OF MANAGED CARE
Approximated 135,000 Medicaid recipients were
enrolled in managed care in 2003. Managed care
recipients receive pharmaceutical benefits through
managed care plans.
Managed Care Organizations
− United Healthcare of New England
− Coordinated Health Partners, Inc.
− Neighborhood Health Plan of Rhode Island

F. STATE CONTACTS
State Drug Program Administrator
Paula J. Avarista, R.Ph.
Chief of Pharmacy
Department of Human Services
600 New London Avenue
Cranston, RI 02919
T: 401/462-6390
F: 401/462-6336
E-mail: pavarista@dhs.state.ri.us
Internet address: www.dhs.state.ri.us
DUR Contact
Paula J. Avarista, R.Ph.
401/462-6390
Rhode Island DUR Board
Raymond Maxim, M.D.
Edward Westlake, M.D.
Richard Wagner, M.D.
Steve Kogurt, Ph.D.
Craig Bowen, Pharm.D.
John Zevzavadjian R.Ph.
Ellen Mauro, R.N, M.P.H.
New Brand Name Products Contact
Paula J. Avarista, R.Ph.
401/462-6390
Prescription Price Updating
Paula J. Avarista, R.Ph.
401/462-6390
Medicaid Drug Rebate Contacts
Technical: Helen Vaughn (EDS), 401/784-3879
Policy: Paula J. Avarista, 401/462-6390
Claims Submission Contact
EDS
401/784-3879
Medicaid Managed Care Contact
Tricia Leddy, Administrator
Department of Human Services
600 New London Avenue
Cranston, RI 02919
401/462-2127
E-mail: tleddy@dhs.ri.gov
Mail Order Pharmacy Program
None
Department of Human Services Officials
Jane Hayward
Director
Department of Human Services
600 New London Avenue
Cranston, RI 02920
T: 401/462-2121
F: 401/462-3677
E-mail: jhayward@gw.dhs.state.ri.us

John Young
Associate Director
Medical Services
Department of Human Services
600 New London Avenue
Cranston, RI 02920
T: 401/462-3575
F: 401/462-6338
E-mail: jyoung@gw.dhs.state.ri.us
Executive Officers of State Medical and
Pharmaceutical Societies
Rhode Island Medical Society
Newell E. Warde, Executive Director
235 Promenade Street, Suite 500
Providence, RI 02908
T: 401/331-3207
F: 401/751-8050
E-mail: nwarde@rimed.org
Internet address: www.rimed.org

Rhode Island Society of Osteopathic Physicians and
Surgeons/Northeast Osteopathic Consortion
Donald J. Halpin, Executive Director
P.O. Box 487
Winchester, MA 01800
781/721-9900
E-mail: nocdos@shore.net
Internet address: www.northeastosteo.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
Rhode Island-4
Rhode Island Pharmacists Association
James Hutson
Executive Director
1643 Warwick Avenue
PMB 113
Warwick, RI 02889
T: 401/737-2600
F: 401/737-0959
E-mail: jhutson@ripharmacists.org
Internet address: www.ripharmacists.org

State Board of Pharmacy
Catherine A. Cordy
Chief of The Board
3 Capitol Hill, Room 205
Providence, RI 02908-5097
T: 401/277-2837
F: 401/222-2158
E-mail: cathyc@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: 401/274-1647
F: 401/274-1838
E-mail: edwardq@hari.org
Internet address: www.hari.org



National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-1
SOUTH CAROLINA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged
Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $438,498,935 542,764 $456,972,236 576,065

RECEIVING CASH ASSISTANCE, TOTAL $217,671,240 201,137 $219,601,046 214,691
Aged $54,051,659 30,510 $49,524,373 29,073
Blind/Disabled $133,255,085 73,126 $131,756,715 72,534
Child $11,428,870 53,959 $14,462,664 62,082
Adult $18,935,626 43,542 $23,857,294 51,002

MEDICALLY NEEDY, TOTAL $0 - $0 -
Aged $0 - $0 -
Blind/Disabled $0 - $0 -
Child $0 - $0 -
Adult $0 - $0 -

POVERTY RELATED, TOTAL $135,326,028 239,631 $145,484,844 255,443
Aged $41,923,282 24,199 $42,051,488 24,724
Blind/Disabled $51,608,068 21,735 $53,686,398 23,236
Child $39,949,877 179,897 $47,894,525 194,168
Adult $1,844,801 13,800 $1,852,433 13,315

TOTAL OTHER EXPENDITURES/RECIPIENTS* $85,501,667 101,996 $91,886,346 105,931


*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
**2002 data provided by the South Carolina Department of Health and Human Services.

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

National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-2
C. ADMINISTRATION
South Carolina Department of Health & Human
Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin, and disposable needles and
syringe combinations used for insulin. Products
covered as DME: blood glucose test strips; urine
ketone test strips; total parenteral nutrition; and
interdialytic nutrition. Products not covered:
cosmetics; fertility drugs; DESI drugs; and
experimental drugs.

Over-the-Counter Product Coverage: Within
program guidelines and limitations, the Medicaid
program covers all rebated OTC medications and
their generic equivalents. Products not covered:
smoking deterrent products.

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

Coverage of Injectables: Injectable medicines
reimbursable through the Physician Services Program
when used in physicians’ offices. Injectables
reimbursable through the Prescription Drug Program
when used at home, through home health care, or in
long-term care facilities.

Vaccines: Vaccines reimbursable based on CDC
price as part of the Vaccines for Children Program
(age under 21).

Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary; certain drug
classifications excluded.
General Exclusions:
1. Weight control products.
2. Investigational pharmaceuticals or products.
3. Immunizing agents.
4. Pharmaceuticals determined by the FDA to be
less than effective and identical, related, or
similar drugs.
5. Injectable pharmaceuticals administered by the
practitioner in the office in a clinic, or in a
mental health center (Synagis is reimbursable
through the Physician Services Program and is
non-covered through Pharmacy Services).
6. Products used as flushes to maintain patency of
devices.
7. Devices and supplies (e.g., diabetic supplies,
infusion supplies, etc.)
8. Fertility products.
9. Smoking cessation products, whether legend or
OTC.
10. Pharmaceuticals which are not rebated.
11. Nutritional supplements
12. Oral hydration therapies for adults.
13. Pharmaceuticals used for cosmetic purposes or
hair growth.

Prior Authorization: State currently has a prior
authorization program. Beneficiaries can request a
fair hearing and exception to policy to appeal a prior
authorization decision. The prescriber must obtain
prior authorization for Medicaid coverage of the
following products:
1. Brand name products (excluding certain
narrow, therapeutic index drugs) for which
there are A-rated, therapeutically equivalent,
less costly generics available.
2. COX-2 inhibitors for patients < age 60.
3. Erectile dysfunction products.
4. OxyContin® (when maximum quantity
limitation is exceeded).
5. Panretin®.
6. Proton pump inhibitors for patients > age
21.
7. Serostim®.
8. Targretin®.
9. Xenical®.
Prescribing or Dispensing Limitations
Prescription Refill Limit: The prescriber authorizes
the number of refills.

Monthly Quantity Limit: Children (birth to age 21)
are allowed unlimited prescriptions per month.
Beneficiaries over the age of 21 are limited to a
maximum of four prescriptions per month; however,
pharmacists may override the monthly prescription
limit for adult Medicaid beneficiaries if the
prescription meets certain specified override criteria.

Quantity Limit per Prescription: 34 days’ supply per
prescription.

Monthly Dollar Limit: None.
National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-3
Drug Utilization Review
PRODUR system implemented November 2000.
State currently has a DUR Board with a monthly
review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.05, effective 7/1/89.

Ingredient Reimbursement Basis: EAC = AWP-10%.

Prescription Charge Formula: Medicaid
reimbursement for pharmacy services will be based
on the lowest of: the Estimated Acquisition Cost
(EAC); Federal or State maximum allowable cost
(MAC); or the provider's submitted usual and
customary charge.

Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific maximum
allowable costs (MAC) on additional drugs.
Override requires “Brand Medically Necessary” with
handwritten certification by the prescriber and prior
authorization.

Incentive Fee: None.

Patient Cost Sharing: $3.00 copayment per
prescription.

Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Approximately 74,000 Medicaid recipients were
enrolled in MCOs in FY 2003. Recipients receive
pharmaceutical benefits through managed care plans.
Managed Care Organizations
Select Health of South Carolina, Inc.
Patricia Marquis, Chief Operating Officer
P.O. Box 40024
Charleston, SC 29403
843/569-1759











F. STATE CONTACTS
State Drug Program Administrator
James M. Assey, R.Ph., Division Director
Division of Pharmaceutical Services and DME
S.C. Department of Health & Human Services
P.O. Box 8206
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/255-8353
E-mail: asseyj@dhhs.state.sc.us
Internet address: www.dhhs.state.sc.us
Prior Authorization Contact
Caroline Y. Sojourner, R.Ph., Dept. Head
Department of Pharmacy Services
S.C. Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206
T: 803/898-2876
F: 803/255-8353
E-mail: sojourne@dhhs.state.sc.us
DUR Contact
Caroline Y. Sojourner, R.Ph.
803/898-2876
DUR Committee
Gwendolyn C. Galphin, M.D.
F. Joseph Hodge, R.Ph.
Henry Rose, R.Ph.
Leslie M. Stuck, M.D.
Caroline Sojourner, R.Ph.
Michele Burnett, R.Ph.
New Brand Name Products Contact
James M. Assey, R.Ph.
803/898-2876
Prescription Price Updating
First DataBank,
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/588-4003
Medicaid Drug Rebate Contacts
Technical: Rod Davis, 803/898-2610
Policy: James Assey, 803/898-2876
DUR & PA: Caroline Sojourner, 803/898-2876
Disputes: Laurel Kennerly, 803/898-2954

National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-4
Claims Submission Contact
Rod Davis
Deputy Director of Information Technology
S.C. Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206
803/898-2610
E-mail: davisr@dhhs.state.sc.us
Medicare Managed Care Contact
Bruce Harbaugh
Department of Primary Care & Alternative
Reimbursement Programs
S.C. Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206
803/898-2818
Mail Order Drug Program
None, however, mail order pharmacies may enroll.
Disease Management Program/Initiative
Contact
Kathie Reed
Division of Client Education and Outreach Services
S.C. Department of Health and Human Services
P.O. Box 8206
Columbia, SC 29202-8206
803/898-2638
E-mail: reed@dhhs.state.sc.us
South Carolina Department of Health and
Human Services Officials
Robert Kerr, Director
S. C. Department of Health & Human Services
1801 Main Street
P.O. Box 8206
Columbia, SC 29202-8206
T: 803/898-2504
F: 803/898-4515
E-mail: kerr@gov.sc.gov

Melanie Giese, Chief
Bureau of Health Services
803/898-2870

Caroline Y. Sojourner, R.Ph., Department Head
Department of Pharmacy Services
803/898-2876







Medical Care Advisory Council
Ms. Valerie Aiken
Mr. John P. Barber
Ms. Susan B. Berkowitz
Ms. Lesly A. Bowers
Dr. Gloria Bonali
Mr. Bruce Carlson
Mr. Tommy Cockrell
Charles P. Darby, M.D.
C. Warren Derrick, M.D.
Ana DeFede, Ph.D
James M. DuRant, Jr., M.D.
C. Morrison Farish, M.D.
Mr. Ron Fitzwater
Ms. Laura Fowler
Ms. Connie Ginsberg
Dr. Barbara Haight
Jerome E. Kurent, M.D.
Mr. Rudy Long
Ms. Amy McDonald
Mr. J.J. McLawhorn
Albert D. Mims, M.D.
Dr. Linda S. Moore
Mr. John A. Morris
J. Michael Ross, R.Ph.
Sabra Slaughter, Ph.D.
Mr. Lewis Stephens
Ms. Cindy White
Ms. Deborah Williamson
Dr. Constance Yearling
Dr. Foster H. Young, Jr.
Mr. Hal Zorn
Executive Officers of State Medical and
Pharmaceutical Societies
South Carolina Medical Association
Todd K. Atwater, Chief Executive Officer
132 West Park Boulevard
P.O. Box 11188
Columbia, SC 29210
T: 803/798-6207
F: 803/772-6783
E-mail: todd@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





National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-5
South Carolina Pharmacy Association
James R. Bracewell, Executive Vice President
1350 Browning Road
Columbia, SC 29210-6903
T: 803/354-9977
F: 803/354-9207
E-mail: jbracewell@scrx.org
Internet address: www.scrx.org/scrx

State Board of Pharmacy
Lee Ann F. Bundrick, Administrator
South Carolina Board of Pharmacy
Kingstree Building
110 Centerview Drive, Suite 306
Columbia, SC 29210
T: 803/898-4700
F: 803/896-4596
E-mail: bundricl@mail.llr.state.sc.us
Internet address: www.llr.state.sc.us/pol/pharmacy

South Carolina Hospital Association
Kenneth A. Shull, President
101 Medical Circle
P.O. Box 6009
West Columbia, SC 29171-6009
T: 803/796-3080
F: 803/796-2938
E-mail: kshull@scha.org
Internet address: www.scha.org

National Pharmaceutical Council Pharmaceutical Benefits 2003
South Carolina-6
National Pharmaceutical Council Pharmaceutical Benefits 2003
South Dakota-1
SOUTH DAKOTA
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult

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



B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients

TOTAL $52,608,524 58,203 $62,382,937

RECEIVING CASH ASSISTANCE, TOTAL $27,648,344 20,993
Aged $3,255,890 1,849
Blind/Disabled $21,559,128 8,701
Child $1,147,090 6,450
Adult $1,686,236 3,993

MEDICALLY NEEDY, TOTAL $0 -
Aged $0 -
Blind/Disabled $0 -
Child $0 -
Adult $0 -

POVERTY RELATED, TOTAL $4,526,417 21,497
Aged $39,540 49
Blind/Disabled $66,140 61
Child $4,065,705 19,072
Adult $355,032 2,315

TOTAL OTHER EXPENDITURES/RECIPIENTS* $20,433,763 15,713

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
South Dakota-2
C. ADMINISTRATION
Department of Social Services, Office of Medical
Services.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe
combinations used for insulin; blood glucose test
strips; and urine ketone test strips. Products not
covered: cosmetics; DESI drugs; fertility drugs;
experimental drugs; total parental nutrition; drugs for
impotence; and interdialytic parenteral nutrition.

Over-the-Counter Product Coverage: Products not
covered: allergy, asthma and sinus products;
analgesics; cough and cold preparations; digestive
products; feminine products; topical products; and
smoking deterrents.

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

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

Vaccines: Vaccines reimbursable with HCPC code as
part of the Vaccines for Children Program.

Unit Dose: Unit dose packaging reimbursable.
Formulary/Prior Authorization
Formulary: Open formulary.

Prior Authorization: State currently has a formal
prior authorization procedure. Request for fair
hearing required for appealing coverage of an
excluded product or a prior authorization decision.

Prescribing or Dispensing Limitations
Prescription Dollar Limit: None.
Monthly Quantity Limit: None.
Drug Utilization Review
PRODUR system implemented in 1996. State has a
DUR Board with annual review.
Pharmacy Payment and Patient Cost Sharing
Dispensing Fee: $4.75 to $5.55 (with unit dose fee
applied), effective 7/1/1991

Ingredient Reimbursement Basis: EAC = AWP-
10.5%.

Prescription Charge Formula: Payment is the lower
of:
1. FUL, State MAC plus a dispensing fee, or
2. EAC plus a dispensing fee, or usual and
customary charge to the general public.

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

Incentive Fee: $10.00

Patient Cost Sharing: Copayment is $2.00.

Cognitive Services: Does not pay for cognitive
services.
E. USE OF MANAGED CARE
Does not use MCOs to deliver pharmacy services to
Medicaid recipients.
F. STATE CONTACTS
State Drug Program Administrator
Mark Petersen, R.Ph.
Pharmacy Consultant
Department of Social Services
Office of Medical Services
700 Governors Drive
Pierre, SD 57501
T: 605/773-3495
F: 605/773-5246
E-mail: markp@state.sd.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
South Dakota-3
Prior Authorization Contact
Mark Petersen, R.Ph.
605/773-3495
DUR Contact
Michael Jockheck, R.Ph.
Pharmacy Consultant
SD Dept of Social Services
700 Governors Drive
Pierre, SD 57501
605/773-6439
E-mail: mike.jockheck@state.sd.us
Steering Committee (Medicaid DUR Board)
Damian Prunty (Program Administrator)
Tom Carlson, R.Ph.
Richard Holm, M.D.
Pam Jones, R.Ph.
Bruce Lushbough, M.D.
New Brand Name Products Contact
Mark Petersen, R.Ph.
605/773-3495
Prescription Price Updating
Mark Petersen, R.Ph.
605/773-3495
Medicaid Drug Rebate Contacts
Helen Rokusek
Rebate Coordinator
Dept. of Social Services
700 Governors Drive
Pierre, SD 57501
605/773-3653
Claims Submission Contact
Meredith Heerman
Dept. of Social Services
700 Governors Drive
Pierre, SD 57501
T: 605/773-3495
F: 605/773-5246
E-mail: meredith_heerman@state.sd.us
Disease Management Program/Initiative
Contact
Mark Petersen, R.Ph., 605/773-3495
South Dakota Medicaid Agency Officials
James Ellenbecker
Secretary
Department of Social Services
700 Governors Drive
Pierre, SD 57501-2291
T: 605/773-3165
F: 605/773-4855
E-mail: info@dss.state.sd.us

Damian Prunty
Program Administrator
Medical Services
Department of Social Services
700 Governors Drive
Pierre, SD 57501-2291
T: 605/773-3495
F: 605/773-5246
E-mail: Medicaid@dss.state.sd.us
Medical Advisory Committee
Paul Engbrecht, Chairman
Tieszen Memorial Home
437 State Street
Marion, SD 57043
605/648-3384

John Jones, Vice Chairman
Division of Health, Medical & Laboratory Services
Health Laboratory Building
615 E. 4th Street
c/o 500 E. Capitol Avenue
Pierre, SD 57501
605/773-3737

Jud Bergan, O.D.
103 South Eagan
Madison, SD 57042

Sheryl Petersen
218 W. Third Street
Pierre, SD 57501

James D. M. Russell
Hospital Admin.
St. Mary's Hospital
803 E. Dakota
Pierre, SD 57501
605/224-3100

Herb McClellan, Jr., D.D.S.
Box 189
Mobridge, SD 57601-0189

National Pharmaceutical Council Pharmaceutical Benefits 2003
South Dakota-4
Lynn Greff
Apothecary Shop at Medical Arts
719 St. Francis Street
Rapid City, SD 57701

Stephen Schroeder, M.D.
Hand Co. Clinic
P.O. Box 287
Miller, SD 57362

Michelle Miller
McKennan Home Health
800 E. 21st Street
Sioux Falls, SD 57105-1016

A.A. Lampert, M.D.
13075 Bogus Jim Road
Rapid City, SD 57702-9720
Evaluation Committee
V. R. Brandenburg, M.D.
Dennis Hodge, Pharm.D.
Helen Fiechtner, Pharm.D.
Jane Mort, Pharm.D.
James Clem, Pharm.D.
Marc Aldrich (Physician)
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
E-mail: pjensen@sdsma.org
Internet address: www.sdsma.org

South Dakota Osteopathic Association
David A. Lauer, D.O.
Secretary-Treasurer
P.O. Box 247
Sturgis, SD 57785
T: 605/347-3616
F: 605/347-4713

South Dakota Pharmacists Association
Robert Overturf
Executive Director
215 W. Sioux Avenue
P.O. Box 518
Pierre, SD 57501-0518
T: 605/224-2338
F: 605/224-1280
E-mail: sdpha@midconetwork.com
Internet address: www.sdpha.org

State Board of Pharmacy
Dennis M. Jones
Executive Secretary
4305 S. Louise Avenue, Suite 104
Sioux Falls, SD 57106
T: 605/362-2737
F: 605/361-2738
E-mail: 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, Suite 1
Sioux Falls, SD 57106
T: 605/361-2281
F: 605/361-5175
E-mail: hewett@sdaho.org
Internet address: www.sdaho.org


National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-1
TENNESSEE -- TennCare
On January 1, 1994, Tennessee made history by
withdrawing from the Medicaid Program and
implementing an innovative new health care reform
plan called TennCare. In order to implement
TennCare, Tennessee was granted a Section 1115
demonstration waiver by the Federal government.
TennCare replaced the existing Medicaid Program
with a program of managed health care. TennCare
receives about 66 percent of its annual budget from
the Federal government. Approximately one-third
of the TennCare budget consists of State funds.
TennCare required no new taxes and extended
health coverage not only to the nearly 800,000
Tennesseans in the Medicaid population, but also to
an approximately 400,000 uninsured or uninsurable
persons using a system of managed care.
Enrollment was open in 1994 to eligible persons in
the uninsured, uninsurable, and Medicaid-eligible
categories.

On January 1, 1995, TennCare reached 90% of its
target enrollment and closed enrollment in the
uninsured category. However, on April 1, 1997,
enrollment in the uninsured category re-opened to
children under the age of 18 who do not have
access to health insurance through a parent or
guardian. On May 21, 1997, TennCare enrollment
became available for eligible dislocated workers. In
an effort to expand coverage to more of Tennessee's
uninsured children, the Bureau of TennCare opened
enrollment on January 1, 1998 to uninsured
Tennesseans under the age of nineteen (19) with
access to health insurance whose individual family
incomes are below 200% of the poverty level.
Effective January 1, 1998, uninsured children under
age nineteen (19) who meet the TennCare criteria
for uninsured are being allowed to enroll in
TennCare indefinitely. The Bureau of TennCare
eliminated deductibles and limited co-payments to
$5 and $10 for these new eligibility populations and
all uninsured children under eighteen (18) years of
age who enrolled in TennCare during previous open
enrollment periods. Enrollment remains open to
persons who are Medicaid-eligible or who are
uninsurable. Current enrollment (1/23/04) is
approximately 1.3 million of which 1 million are
Medicaid eligibles and 300,000 are in the
uninsured/uninsurable categories.

The State of Tennessee was granted approval by the
Health Care Financing Administration for a five-
year demonstration project under Section 1115 of
the Social Security Act. State rules were
promulgated to assist in administering the statewide
program (TSOP). The initial five-year
demonstration project ended December 31, 1998.
HCFA approved a waiver extension for three years
beginning January 1, 1999 through December 31,
2001. On July 1, 2002, Tennessee reached a new
five-year agreement with the federal government to
continue TennCare.

TennCare services are offered through managed
care organizations (MCOs) and behavioral health
organizations (BHOs) under contract with the State.
These MCOs, spread out over the twelve regions of
Tennessee, are paid a fixed amount. The MCOs and
BHOs negotiate payment rates with individual
providers. Enrollees have a choice of MCOs (and
their corresponding BHO partner plan) from those
available in their geographic area. Effective January
1, 1997, all services are delivered within a strict
"gatekeeper" model system requiring primary care
providers to manage enrollees' health care.

TennCare services, as determined medically
necessary by the MCO, cover inpatient and
outpatient hospital care, physician services,
prescription drugs, lab and x-ray services, medical
supplies, home health care, hospice care, and
ambulance transportation. Excluded from TennCare
managed care services are long-term care services
and Medicare cross-over payments which are
continuing as they were under the former Medicaid
system.

TennCare is financed by pooling current Federal,
State, and local expenditures for indigent health
care. Pooled resources totaled $5.5 billion in FY
2001. In the future, competition among managed
care networks, combined with the enrollment cap,
should enable TennCare to grow at a predictable
rate not exceeding the annual rate of growth in
State spending.

ELIGIBILITY FOR TENNCARE COVERAGE
The current federal waiver separates TennCare into
Two products: TennCare Medicaid and TennCare
Standard. Tenncare Medicaid is a continuation of
the basic TennCare Medicaid program with a few
minor changes in benefits. TennCare Medicaid adds
a new eligibility category: woman under 65 who
have been screened by The Centers for Disease
Control and are in need of treatment for breast or
cervical cancer.




National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-2
TennCare Standard is similar to a commercial
HMO package. People eligible for TennCare
standard are adults below the 100 percent of the
federal poverty level, children below 200 percent of
the poverty level, and people who are “medically
eligible” a new term to describe what the state
previously referred to as “uninsurables.” The
difference is that “Medical eligibility” will be
determined by a State-appointed health insurance
underwriter. Under the previous TennCare system,
a denial letter from an insurance company defined
“uninsurability.”

The five-year waiver that TennCare began on July
1, 2002 also includes an annual “open enrollment”
period, which would allow people who are
uninsured or medically eligible above poverty to
enroll in TennCare. The current fiscal year’s budget
does not allow for an open enrollment period, at
least through the end of the current fiscal year, June
30, 2003. However, if an applicant is both below
100 percent of the poverty level and medically
eligible, enrollment will be allowed at any time
during the year.

Persons wanting to apply for TennCare must visit
the local Tennessee Department of Human Services
(DHS) office. There is a local DHS office in every
Tennessee County. For the applicants' convenience,
DHS will make a copy of the application, date
stamp it, and process the application.
A. ADMINISTRATION
Tennessee Department of Finance and
Administration, Bureau of TennCare
B. PROVISIONS RELATING TO DRUGS
Benefit Design
Pharmacy services are provided by the managed
care organizations. Within Federal and State
guidelines, each individual managed care and
pharmacy benefit management organization makes
formulary/drug decisions. Pharmacy services are
to be covered as medically necessary, excluding
DESI, less than effective and IRS drugs and some
drugs for which TennCare does not mandate
coverage (e.g., drugs for infertility, weight
reduction, cosmetic purposes, hair growth products,
products for symptomatic relief of cough and colds,
experimental drugs; smoking cessation products,
and OTCs). Starting in July 1, 2003 all eligible
products dispensed through ambulatory
pharmacies are invoiced through the CMS rebate
program.
Formulary: Preferred Drug List (PDL) was phased
in from October 15
th
through December 15
th
in 3
phases (see http://tennessee.fhsc.com).

Prior Authorization: Prior authorization procedures
are administered by Consultec (through 12/31/03)
and First Health starting on 1/1/04.

Copayment: Deductibles and copayments apply to
services other than preventive services (e.g.,
immunizations) based on a sliding scale according
to income. Medicaid recipients and persons or
families with income under 100% of the Federal
poverty level are not required to pay premiums,
deductibles, or copayments in order to participate in
the TennCare program.

C. USE OF MANAGED CARE
Medicaid recipients and the uninsured/uninsurable
are enrolled in MCOs through the TennCare
program. All receive pharmacy benefits through
managed care.
Managed Care Organizations
Better Health Plans
890 Willow Tree Circle
Cordova, TN 38018

BlueCare
801 Pine Street
Chattanooga, TN 37402-2555

John Deere Health Plan
Executive Tower I, Suite 400
408 N. Cedar Bluff Road
Knoxville, TN 37923

TLC Family Care Healthplan
P.O. Box 49
Memphis, TN 38101

OmniCare Health Plan, Inc.
1991 Corporate Avenue, 5th Floor
Memphis, TN 38132

PHP TennCare
1420 Centerpoint Boulevard
Knoxville, TN 37932

TennCare Select
801 Pine Street
Chattanooga, TN 37402-2555

VHP Community Care
215 Centerview Drive, Suite 300
Brentwood, TN 37027
National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-3
MCO/Behavioral Health Organization
Better Health Plans
Blue Care
John Deere Health Plan
OmniCare Health Plan
Preferred Health Partnership (PHP)
Premier Behavioral Systems
Tennessee Behavioral Health, Inc.
TLC Family Health Care Health Plan
VHP Community Care
D. STATE CONTACTS
State Drug Program Administrator
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
TennCare Officials
Manny Martins, Deputy Commissioner
Bureau of TennCare
Department of Finance and Administration
729 Church Street
Nashville, TN 37247-6501
T: 615/741-0213
F: 615/741-0882
E-mail: manny.martins@state.tn.us

TennCare Information Line
800/669-1851
Prior Authorization Contact
Jeffrey G. Stockard, D.Ph.
615/532-3107
DUR Contact
Jeffrey G. Stockard, D.Ph.
615/532-3107
TennCare DUR Advisory Board
Butch Benson, D.Ph.
1310 Mulberry Court
Murfreesboro, TN 37130

Christi Capers, Pharm.D.
Clin. Edu. Consultant, Pfizer Inc.
4043 Farmingham Woods Drive
Hermitage, TN 37076-4405


Diane Crutchfield, D.Ph.
1223 Eaglenest Lane
Knoxville, TN 37922

Martha Drannon, Pharm.D.
Frayser Family Counseling Center Pharmacy
2150 Whitney Avenue
Memphis, TN 38127

Don Hazelwood, D.Ph.
E.W. James Pharmacy
3100 S. First Street
Milan, TN 38358

Connie J. Holladay, M.D.
6432 River Tide Drive
Memphis, TN 38120

Mack A. Land, M.D.
5210 Poplar Avenue, Suite 200
Memphis, TN 38119

David Shepard, Pharm.D., B.C.P.P.
Dickson Apothecary East
104 Highway 70 East
Dickson, TN 37055

Daniel D. Sumrok, M.D.
Family Practice
22700 Highway 22
McKenzie, TN 38201
TennCare Pharmacy Advisory Board
James Powers, M.D. (Chairman)
7155 Vanderbilt
Medical Center East
Nashville, TN 37232

Alan Corley, D.Ph. (Vice Chairman)
P.O. Box 874
Greenville, TN 37744

Dianne Todd Pace, Ph.D., R.N., FNP
886 Wood Cairn Cove
Cordova , TN 38018

Edward Capparelli, M.D.
121 Moore Street
Newport, TN 37821

James King, M.D.
1 Prime Care Drive
Selmer, TN 38375

Lisa D’Souza, J.D.
301 Charlotte Avenue
Nashville, TN 37201

National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-4
Peter Frizzell, M.D.
1 Roundtree Court
Johnson City, TN 37604

Lynn Knott, Pharm.D., CGP, FASCP
1744 Stillwater Circle
Brentwood, TN 37027

Stanley Dowell, M.D.
Eastmoreland Internal Medicine
1325 Eastmoreland Avenue, Suite 245
Memphis, TN 38104

Sheila Spates, Pharm.D.
809 Tree Trunk Road
Knoxville, TN 37922

Terry Shea, Pharm.D.
3 Chamblee Court
Signal Mountain, TN 37377

William Terrell, M.D.
1444 E. Shelby Drive, Suite 317
Memphis, TN 38116

Tracy Purcell (ex-officio)
Bureau of TennCare
729 Church Street
Nashville, TN 37247-6501

David Hollis, M.D. (ex-officio)
Bureau of TennCare
729 Church Street
Nashville, TN 37247-6501
TennCare Bureau
Jeffrey G. Stockard, D.Ph.
615/532-3107
TennCare Medical Care Advisory
Committee
Iris Snider, M.D.
TN Chapter of American Academy of Pediatrics
111 Epperson Avenue
Athens, TN 37303

Lloyd A. Walwyn, M.D., J.D.
601 Due West Avenue
Madison, TN 37115

Deb Murph, R.N.
Cherokee Health Systems
6350 West Andrew Johnson Highway
Talbott, TN 37877

Jeannie Beauchamp, D.D.S.
1833 Memorial Drive
Clarksville, TN 37043
Don Hazelwood, D.Ph.
3100 S. First Street
Milan, TN 38358

Cato Johnson
Methodist Healthcare
1211 Union Street, Suite 700
Memphis, TN 38104

Joe Brown
Hardin County Nursing Home
2006 Wayne Road
Savannah, TN 38372

Sheryl McCormick
Region 2 Mental Health Council
7208 Merriwood Drive
Knoxville, TN 37919

Don Redden
Developmental Services of Dickson County
P.O. Box 628
Dickson, TN 37056

Tony Halton
National Health Care for the Homeless Council
P.O. Box 60427
Nashville, TN 37206

Osbie Howard
OmniCare Health Plan, Inc.
1991 Corporate Avenue, 5
th
Floor
Memphis, TN 38132

Nancy Reykdal
Blue Cross/Blue Shield of Tennessee
801 Pine Street
Chattanooga, TN 37402

Yolanda McClain
The Salvation Army
611 Stockell Street
Nashville, TN 37207

Effie Candis Pelfrey
Tennessee Health Care Campaign
1103 Foothill Court
Nashville, TN 37217

Virginia T. Lodge, Commissioner
Department of Human Services
400 Deaderick Street, 15
th
Floor
Nashville, TN 37248
National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-5
Prescription Price Updating
First DataBank
1111 Bayhill Drive, Suite 350
San Bruno, CA 94066
T: 650/588-5454
F: 650/588-6867
Medicaid Drug Rebate Contacts
Audits: Sybil Creekmore, 615/741-0213
Disputes: Jeff Stockard, D.Ph., 615/532-3107
Claims Submission Contact
Carmen Gilbert Menser
First Health
4300 Cox Road
Glen Allen, VA 23060
T: 804/965-7513
F: 804/290-4831
E-mail: cngilbert@fhsc.com
Medicaid Managed Care Contact
Michael Drescher, Public Information Officer
Bureau of TennCare
729 Church Street
Nashville, TN 37247-6501
T: 615/741-0213
F: 615/741-0882
E-mail: michael.drescher@state.tn.us
Mail Order Pharmacy Program
Tennessee has a mail order pharmacy option in its
Medical Assistance Program. All beneficiaries are
entitled to participate.
Disease Management Patient Education
Programs
Program Name: TennCare Centers for Excellence
Disease/Medical States: Asthma, Cardiovascular
Disease, and Diabetes
Program Manager: Applied Health Outcomes
Disease Management Patient Education
Contact
Judy Black
Director of Disease Management
Bureau of TennCare
729 Church Street
Nashville, TN 37247-6501
T: 615/532-6705
F: 615/741-0882





Executive Officers of State Medical and
Pharmaceutical Societies
Tennessee Medical Association
Donald H. Alexander, CEO
P.O. Box 120909
2301 21
st
Avenue South
Nashville, TN 37212-0909
T: 615/385-2100
F: 615/385-3319
E-mail: dona@tma.medwire.org
Internet address: www.medwire.org

Tennessee Osteopathic Medical Association
Dee Ann Walker, CAE
Executive Director
200 4
TH
Avenue North, Suite 900
Nashville, TN 37219
T: 615/301-3048
F: 615/254-7047
E-mail: dawalker@walkermgt.com
Internet address: www.tomanet.org

Tennessee Pharmacists Association
Baeteena M. Black, Ph.D.
Executive Director
226 Capitol Boulevard, Suite 840
Nashville, TN 37219-1893
T: 615/256-3023
F: 615/255-3528
E-mail: tpa@tnpharm.org
Internet address: www.tnpharm.org

State Board of Pharmacy
Kendall M. Lynch, Director
Davy Crocket Tower
500 James Robertson Parkway, 2
nd
Floor
Nashville, TN 37243-1149
T: 615/741-2718
F: 615/741-2722
E-mail: kendall.lynch@state.tn.us
Internet address:
http://www.state.tn.us/commerce/boards/
pharmacy/index.htm

Tennessee Hospital Association
Craig A. Becker
President
500 Interstate Boulevard South
Nashville, TN 37210-4634
T: 615/256-8240
F: 615/242-4803
Internet address: www.tha.com

National Pharmaceutical Council Pharmaceutical Benefits 2003
Tennessee-6
Hospital Alliance of Tennessee
Adrienna Knestrick
President
211 Seventh Avenue North, Suite 400
Nashville, TN 37219
T: 615/254-1941
F: 615/254-1942
E-mail: adrienna@hospitalalliancetn.com
Internet address: www.hospitalalliance.com

National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas-1
TEXAS
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**
Expenditures Recipients Expenditures Recipients
TOTAL $1,327,222,456 1,917,351 $1,591,064,713

RECEIVING CASH ASSISTANCE, TOTAL $757,087,849 713,254
Aged $225,287,571 155,312
Blind / Disabled $439,674,579 240,642
Child $50,653,592 221,789
Adult $41,472,107 95,511

MEDICALLY NEEDY, TOTAL $13,645,641 30,183
Aged $0 -
Blind / Disabled $0 -
Child $56,065 264
Adult $13,589,576 29,919

POVERTY RELATED, TOTAL $171,959,460 810,157
Aged $812,066 930
Blind / Disabled $821,022 815
Child $149,515,656 665,651
Adult $20,810,716 142,761

TOTAL OTHER EXPENDITURES/RECIPIENTS* $384,529,506 363,757

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

Source: CMS, MSIS Report, FY 2001 and CMS-64 Report, FY 2002.
National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas-2
C. ADMINISTRATION
Texas Health and Human Services Commission.
Vendor drug program was implemented September
1, 1971.
D. PROVISIONS RELATING TO DRUGS
Benefit Design
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles (pen needles
only) and syringe combinations used for insulin.
Products not covered: cosmetics; fertility drugs;
experimental drugs; total parenteral nutrition; and
interdialytic parenteral nutrition; blood glucose test
strips; urine ketone test strips.

Over-the-Counter Product Coverage: Products
covered: feminine products; topical products;
allergy, asthma, and sinus products; analgesics;
cough and cold preparations; digestive products;
smoking deterrent products. Products not covered:
Certain OTC drugs are covered on a prescription
basis except as otherwise provided in the
reimbursement formula and vendor payment to
hospitals, nursing homes and institutions.

Therapeutic Category Coverage: Therapeutic
categories covered: anabolic steroids; antibiotics;
analgesics; antipyretics, NSAIDs; anticoagulants;
anticonvulsants; anti-depressants; antidiabetic
drugs; antihistamine drugs; antilipemic agents;
antipsychotics; anxiolytics, sedatives, and
hypnotics; cardiac drugs; chemotherapy agents;
contraceptives; prescribed cold medications; ENT
anti-inflammatory agents; estrogens; hypotensive
agents; misc. GI drugs; thyroid agents; prescribed
smoking deterrents; and sympathominetics
(adrenergic). Prior authorization required for:
growth hormones; dextroamphetamines (>21 years
of age); xenical (hyperlipidemia only). Therapeutic
categories not covered: anti-obesity agents;
vitamins (except prenatal); children’s vitamins with
fluoride; and DESI drugs.

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

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

Unit Dose: Unit dose packaging reimbursable if
there is not an added expense for the packaging.
Formulary/Prior Authorization
Formulary: Open formulary; however, products
must be listed in the Texas Drug Code Index.
Formulary managed through exclusions based on
contracting issues, restrictions on use, and prior
authorization. General exclusions (diseases, drug
categories, etc.) include: amphetamines, appliances,
durable medical equipment (bedpans, etc. - either
rental or purchase), elastic stockings, first aid
supplies, medical supplies, oxygen, supports and
suspensories, and trusses.

Prior Authorization: State currently has a prior
authorization procedure screening for drug classes
and individual drugs. Prior Authorization
pharmacist may be contacted to appeal a prior
authorization decision.
Prescribing or Dispensing Limitations
Prescription Refill Limit: Five refills, but total
amount may not exceed 6-month supply.

Monthly Quantity Limit: Prescribed quantity cannot
exceed 6-month supply.

Monthly Prescription Limit: Limited to 3 per month
except for recipients under age 21 and nursing
home recipients.

Other Limit: Recipients in managed care pilots
receive unlimited prescription coverage.
Drug Utilization Review
PRODUR system implemented in February 1995.
State currently has a DUR board with a quarterly
review.
Pharmacy Payment and Patient Cost
Sharing
Dispensing Fee: . $5.14. ($5.27 was reduced for
cost containment purposes in October 2003). The
dispensing fee, including all costs of filling a
prescription, was established by cost accounting
and service evaluation of the expenses involved in
dispensing a prescription.

Ingredient Reimbursement Basis: EAC = AWP-
15% or WAC + 12%, whichever is lower, AAC for
hospitals and public health providers.

Prescription Charge Formula: Average dispensing
expense (ADE) formula for payment:

1. (EAC + 5.14) divided by 0.9805 = amount paid
+ $0.15 delivery service.
2. DEAC only for Wyeth-Ayerst and Abbott.

National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas-3
Insulin and approved non-legend drugs on
prescription: pharmacists and dispensing physicians
will be reimbursed on the basis of usual charges to
the general public or cost plus 50% of cost,
whichever is lower; 50% of cost not to exceed
assigned variable dispensing fee.

Maximum Allowable Cost: State imposes Federal
Upper Limits as well as State-specific limits on
generic drugs. 1,317 therapeutic classes and 8,169
NDC numbers are listed on the State-specific MAC
list. Override requires “Dispense as Written”,
“Medically Necessary”, “Brand Necessary”, or
“Brand Medically Necessary.”

Incentive Fee: None.

Cognitive Services: Does not pay for cognitive
services.

Patient Cost Sharing: No copayment.
E. USE OF MANAGED CARE
Approximately 530,000 Medicaid recipients were
enrolled in MCOs in 2002 (all of whom are
AFDC/AFDC- related). Recipients in managed
care receive pharmaceutical benefits through the
State. (Pharmacy program is “carved out.”)
Managed Care Organizations
AMERIGROUP, Inc.
1200 East Copeland Road, Suite 200
Arlington, TX 76011

Community First Health Plan
4801 NW Loop 410, Suite 1000
San Antonio, TX 78229

El Paso First Health Plans
2501 North Mesa
El Paso, TX 79902

HMO Blue-Medicaid
901 S. Central Expressway
Richardson, TX 75080

Texas Children’s Health Plan
1919 Braeswood
Houston, TX 77230

Superior Health Plan
2100 S. IH35, Suite 202
Auston, TX 78704

Community Health Choice
2636 South Loop, Suite 700
Houston, TX 77054
First Care Health Plan
12940 N. Highway 183
Austin, TX 78750

JPS/MetroWest Health Plan
1617 Hemphill
Fortworth, TX 76104

Parkland Health First
2777 N. Stemmons Breeway, Suite 1750
Dallas, TX 75207
F. STATE CONTACTS
State Drug Program Administrator
Barbara Dean, R.Ph.
Acting Director, Vendor Drug Program
Texas Health and Human Services Commission
1100 W. 49th Street
Austin, TX 78756-3174
T: 512/491-1101
F: 512/491-1959
E-mail: barbara.dean@hhsc.state.tx.us
Internet address: www.hhsc.state.tx.us
Health and Human Services Commission
Officials
Albert Hawkins
Executive Commissioner
Texas Health and Human Service Commission
4900 N. Lamar Boulevard
Austin, TX 78751
T: 512/424-6502
F: 512/424-6587
E-mail: albert.hawkins@hhsc.state.tx.us

Jason Cooke
Associate Commissioner for Medicaid
Texas Health and Human Services Commission
4900 N. Lamar Boulevard
Austin, TX 78751
T: 512/424-6517
F: 512/424-6587
E-mail: Medicaid@hhsc.state.tx.us
Prior Authorization Contact
Don Valdes, R.Ph.
Pharmacist II
Vendor Drug Program
Texas Health and Human Services Commission
1100 W. 49th Street
Austin, TX 78756
T: 512/491-1172
F: 512/491-1962
E-mail: Don.Valdes@hhsc.state.tx.us
National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas-4
DUR Contact
Barbara Dean, R.Ph.
Manager, DUR Program
Texas Health and Human Services Commission
1100 W. 49th Street
Austin, TX 78756-3174
T: 512/491-1101
F: 512/491-1959
E-mail: barbara.dean@hhsc.state.tx.us
DUR Board
Leroy Knodel, Pharm.D., Vice Chairman
Drug Information Service
Department of Pharmacology
The University of Texas Health Science Center
7703 Floyd Curl Drive
San Antonio, TX 78284-7766

Thomas Lee Kurt, M.D., M.P.H.
8600 Thackery, Suite 162
Dallas, TX 75225

Mark S. Gittings, D.O., R.Ph.
12340 Almeda Trace Circle, Suite 2302
Austin, TX 78727

Robert L. Hogue, M.D.
101 A South Park Drive
Brownwood, TX 76801

Daniel Saylak, D.O., Chairman
841 N. Rosemary Drive
Bryan, TX 77802

Mary Spies Maxwell, M.D.
4526 Burnet Road
Austin, TX 78731

Adelina Barbosa, R.Ph.
#10 Casa De Palmas
Brownsville, TX 78521

Anita Martinez, R.Ph., CDE
2819 Burning Hill
San Antonio, TX 78247

James B. Hills, R.Ph.
9100 South West Freeway
Houston, TX 77054

Robert T. Reilly, Pharm.D.
Thomason Hospital
Department of Pharmacy
4815 Alameda Avenue, P. O. Box 2009
El Paso, TX 79905
New Brand Name Products Contact
Martha McNeill, R.Ph.
Product and Prescriber Manager
Texas Health and Human Services Commission
11209 Metric Boulevard, Building H
Austin, TX 78758
T: 512/491-1157
F: 512/491-1961
E-mail: Martha.mcneill@hhsc.state.tx.us
Prescription Price Updating
Martha McNeill, R.Ph.
512/491-1157
Medicaid Drug Rebates Contact
Heather Murphy
Manager, Pharmacy Rebates
Vendor Drug Program
Texas Health and Human Services Commission
1100 W. 49
th
Street
Austin, TX 78745
T: 512/491-1163
F: 512/491-1960
E-mail: heather.murphy@hhsc.state.tx.us
Claims Submission Contact
Laura Bagheri
Manager, Pharmacy Resolutions
Vendor Drug Program
Texas Health and Human Services Commission
1100 West 49
th
Street
Austin, TX 78745
T: 512/491-1741
F: 512/491-1958
E-mail: laura.bagheri@hhsc.state.tx
Medicaid Managed Care Contact
Pamela Coleman
Director, Health Plan Operations
Texas Health and Human Services Commission
1100 W. 49
th
Street
Austin, TX 78756
512/491-1302
E-mail: pam.coleman@hhsc.state.tx.us
Mail Order Pharmacy Program
None
National Pharmaceutical Council Pharmaceutical Benefits 2003
Texas-5
Executive Officers of State Medical and
Pharmaceutical Societies
Texas Medical Association
Louis J. Goodman, Ph.D., CAE
Executive Vice President/CEO
401 W. 15
th
Street
Austin, TX 78701-1680
T: 800/880-1300
F: 512/370-1632
E-mail: lou.goodman@texmed.org
Internet address: www.texmed.org

Texas Pharmacy Association
Jim Martin, R.Ph.
Executive Director/CEO
P. O. Box 14709
1624 E. Anderson Lane
Austin, TX 78761-4709
T: 512/836-8350
F: 512/836-8308
E-mail: jmartin@txpharmacy.com
Internet address: www.txpharmacy.com

Texas Osteopathic Medical Association
Terry Boucher, M.P.H.
Executive Director, Secretary/Treasurer
1415 Lavaca Street
Austin, TX 78701-1634
T: 512/708-8662
F: 512/708-1415
E-mail: 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 Street, Suite 3-600
Austin, TX 78701-3942
T: 512/305-8000
F: 512/305-8082
E-mail: gay.dodson@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 Pharmaceutical Benefits 2003
Texas-6


















































National Pharmaceutical Council Pharmaceutical Benefits 2003
Utah-1
UTAH
A. BENEFITS PROVIDED AND GROUPS ELIGIBLE
Type of Benefit Categorically Needy Medically Needy (MN)
Aged
Blind/
Disabled
Child Adult Aged Blind/
Disabled
Child Adult
Prescribed Drugs
Inpatient Hospital Care
Outpatient Hospital Care
Laboratory & X-ray Service
Nursing Facility Services
Physician Services
Dental Services


B. EXPENDITURES FOR DRUGS
2001

2002**

Expenditures Recipients Expenditures Recipients

TOTAL $117,101,302 136,682 $140,275,267

RECEIVING CASH ASSISTANCE TOTAL $48,529,173 33,260
Aged $5,275,146 2,848
Blind/Disabled $37,273,244 12,442
Child $1,949,135 11,105 <