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Pharmaceutical Benefits

Under State Medical


Assistance Programs

2007

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

©2007
by the National Pharmaceutical Council
This compilation of data on State Medical Assistance Programs (Title XIX) presents a general
overview of the characteristics of State programs, together with detailed information on the
pharmaceutical benefits provided. The data collection effort covers all States with Medicaid programs
and the District of Columbia.

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

The data in this compilation were compiled under the direction of David Goldenberg, Ph.D., with
assistance from Errica Philpott, Steven Heath, Stanley Weintraub, Edward Steinhouse, J.D., Elizabeth
Segall, Vishal Gupta, and Michael Sanky of United BioSource Corporation. Paul Gavejian, Michael
Steele, and Matthew Leach of Total Compensation Solutions prepared and conducted the 2007 survey.
George Chalissery and Hmetrix were responsible for aggregating the data on number of prescriptions
and drug expenditures by therapeutic category. David Schulz at StateScape provided updated
information on State officials, State professional societies, and State pharmaceutical assistance
programs. As always, Gary Persinger and Kimberly Westrich of the National Pharmaceutical Council
provided valuable input and support.
National Pharmaceutical Council Pharmaceutical Benefits 2007

TABLE OF CONTENTS

SECTION 1: INTRODUCTION .......................................................................................................... 1-1

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


Medicaid Program Overview .................................................................................................... 2-3
- Total Medicaid Eligibles by Maintenance Assistance Status, 2004 ........................ 2-11
- Total Medicaid Eligibles by Age Group, 2004........................................................ 2-12
- Total Medicaid Eligibles by Gender, 2004.............................................................. 2-13
- Total Medicaid Eligibles by Race/Ethnicity 2004................................................... 2-14
- Total Medicaid Eligibles by Basis of Eligibility, 2004 ........................................... 2-15
- Total Medicaid Eligibles per 1000 Population, 2004 .............................................. 2-16
- Total Net U.S. Medical Assistance Expenditures by Type of Service,
FY 2004 and FY 2005 ............................................................................................. 2-17
- Federal Medical Assistance Percentages (FMAP), FY 2007 and FY 2008 ............ 2-18
- Medicaid Total Net Expenditures and Eligibles, 2004 ............................................ 2-19
- Total Medicaid Program Expenditures, 2005 .......................................................... 2-20
- Total SCHIP Enrollment, 2005 ............................................................................... 2-21
- Total SCHIP Enrollment, 2006 ............................................................................... 2-22
- Total SCHIP Expenditures, 2005 ............................................................................ 2-23
- Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2004 .............. 2-24
- Total Medicaid Medical Vendor Payments and Dual Eligibility Status, 2004 ....... 2-26
Medicaid Managed Care Enrollment ................................................................................... 2-29
- Medicaid Managed Care Enrollment, As of June 30, 2006..................................... 2-31
- Pharmaceutical Benefits Under Managed Care Plans ............................................. 2-32
- Medicaid Managed Care Enrollment Trends, 2001-2006 ....................................... 2-33
- Medicaid Managed Care Plan Type, As of June 30, 2006 ...................................... 2-34
- Medicaid Managed Enrollment by Plan Type, As of June 30, 2006 ....................... 2-35
- Medicaid Managed Care Enrollment by Payment Arrangement,
As of June 30, 2006 ................................................................................................. 2-36
Medicaid Managed Care Waivers .......................................................................................... 2-37
- Section 1915(b) and 1115 Waivers ......................................................................... 2-39

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


- Age Demographics, 2006 .......................................................................................... 3-5
- Race Demographics, 2006 ......................................................................................... 3-6
- Hispanic Demographics, 2006 ................................................................................... 3-7
- Insurance Status-Populations, 2006........................................................................... 3-8
- Insurance Status-Percentages, 2006 .......................................................................... 3-9
- Poverty Status-Populations, 2006 ............................................................................ 3-10
- Poverty Status-Percentages, 2006............................................................................ 3-11
- Employment Status, 2006 ........................................................................................ 3-12
- Medicaid/Medicare Certified Facilities, 2006 ......................................................... 3-13
- Licensed Pharmacies, As of June 30, 2006 ............................................................. 3-14
- Physicians, 2005 ...................................................................................................... 3-16
- Other Providers, 2004/2006 ..................................................................................... 3-17

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


The Medicaid Drug Program.................................................................................................... 4-3
- Drug Expenditures Trends, 2004-2005 ..................................................................... 4-5
- Ranking Based on Drug Expenditures, 2004-2005 ................................................... 4-6
- Drugs as a Percentage of Total Net Expenditures, 2005 ........................................... 4-7
- Drugs as a Percentage of Total Net Expenditures, 2003-2005 .................................. 4-8
- Drug Expenditures by Category, 2004 ...................................................................... 4-9
- Prescriptions Processed by Category, 2004............................................................. 4-11
- Medicaid Average Cost per Prescription, 2004 ....................................................... 4-13
- Drug Expenditures by Category, 2005 .................................................................... 4-14
- Prescriptions Processed by Category, 2005............................................................. 4-16
- Medicaid Average Cost per Prescription, 2005 ....................................................... 4-18
- Drug Expenditures by Category, 2006 .................................................................... 4-19
- Prescriptions Processed by Category, 2006............................................................. 4-21
- Medicaid Average Cost per Prescription, 2006 ....................................................... 4-23
Medicaid Drug Rebates ........................................................................................................... 4-24
- Medicaid Drug Rebates, 2005 ................................................................................. 4-25
- Medicaid Drug Rebate Trends, 2001-2005 ............................................................. 4-26
- Medicaid Drug Rebate Trends, Annual Percent Change, 2000-2005 ..................... 4-27
- Rebates as a Percent of Drug Expenditures, 2005 ................................................... 4-28
Medicaid Drug Coverage ........................................................................................................ 4-29
- Pharmacy Advisory Committees ............................................................................. 4-31
- Pharmacy Benefit Design – Coverage ..................................................................... 4-32
- Coverage of Injectables ........................................................................................... 4-35
- Coverage of Vaccines and Unit Dose ...................................................................... 4-36
- Coverage of Over-the-Counter Medications ........................................................... 4-37
- Prior Authorization Process and Procedures ........................................................... 4-39
- Prior Authorization .................................................................................................. 4-42
- Drug Utilization Review .......................................................................................... 4-45
- Prescribing/Dispensing Limits ................................................................................ 4-46
Pharmacy Payment and Patient Cost Sharing ...................................................................... 4-47
- Pharmacy Payment and Patient Cost Sharing.......................................................... 4-48
- Maximum Allowable Cost (MAC) Programs.......................................................... 4-49
- Mandatory Substitution ........................................................................................... 4-50
- Counseling Requirements and Payment for Cognitive Services ............................. 4-51
- Prescription Price Updating ..................................................................................... 4-52

SECTION 5: STATE PHARMACY PROGRAM 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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Section 1:
Introduction

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INTRODUCTION
The 2007 edition of Pharmaceutical Benefits Under State Medical Assistance Programs marks the 41st
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 2: Contains an overview of the Medicaid program (which is current at press time and
has not been revised to reflect any future changes that may result from the Deficit Reduction
Act), 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. 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 2007
NPC annual survey of State pharmacy program administrators. In addition, this section
provides Medicaid eligibility statistics from CMS for fiscal year 2004 and program
expenditure data for fiscal year 2005. 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 State pharmaceutical assistance programs.


The book also contains a series of appendices. Appendix A features a list of State contacts and CMS
Medicaid program personnel. Appendix B provides a national level summary on total Medicaid
program recipients by type of service for FY 2004 and data on total number of drug recipients for each
State and the nation as a whole for the period 1998-2004. Appendix C provides the current Medicaid
drug rebate law (which is current at press time and has not been revised to reflect any future
changes that may result from the Deficit Reduction Act). 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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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:

! Data on Medicaid eligibles by gender and race/ethnicity;


! Total SCHIP enrollment by State;
! Information on the number of Medicaid/Medicare dual eligibles and Medicaid medical vendor
payments for dual eligibles by State.

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 2007 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 United BioSource Corporation and their subcontractors, Total
Compensation Solutions, Hmetrix, and StateScape, for administering the survey and compiling
important parts of the information on State pharmacy programs. We hope you continue to find the
information contained in this compilation useful and, as always, we welcome your suggestions and
comments.

Gary Persinger
Vice President, Health Care Systems
National Pharmaceutical Council

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Section 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 (FQHC) services and any other ambulatory services
offered by an FQHC 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;
! 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; and
! 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 the Department of Health
and Human Services (DHHS) has determined has a shortage of home health agencies, the services are

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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;
! Provided by a laboratory that meets the requirements for participation in Medicare; and
! 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; and
! 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, 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.
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 2004, the Medicaid program enrolled 57.6 million eligible individuals with vendor payments for
medical care services totaling $257.7 billion. The vendor payments reported in the 2004 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 2004 of over $280 billion. When
administrative costs are added to total net expenditures, total Medicaid program expenditures in 2004
were $295.3 billion. For FY 2005, total program expenditures, including those for administration,
were $314.7 billion.

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Total Medicaid Eligibles by Maintenance Assistance Status, 20041

Receiving
Total Cash Medically Poverty 1115 MAS
State Eligibles Assistance Needy Related Other Demonstration Unknown
National Total 57,575,692 20,559,445 3,313,195 17,654,820 9,855,899 6,191,305 1,028
Alabama 918,304 274,597 0 473,394 37,592 132,721 0
Alaska 127,779 50,610 0 66,090 11,079 0 0
Arizona 1,394,378 550,709 0 362,701 269,001 211,967 0
Arkansas 700,038 155,522 12,329 300,605 51,721 179,861 0
California 10,619,361 4,724,483 788,296 609,272 2,133,527 2,363,781 2
Colorado 524,760 315,452 0 150,395 58,911 0 2
Connecticut 508,387 82,602 26,014 105,479 294,292 0 0
Delaware 166,604 79,976 0 15,415 43,402 27,811 0
District of Columbia 160,304 86,349 36,611 28,192 9,152 0 0
Florida 2,867,361 1,224,666 106,007 1,080,601 450,243 5,843 1
Georgia 1,759,654 614,889 10,091 833,942 300,732 0 0
Hawaii 223,417 109,093 3,168 51,898 16,745 42,479 34
Idaho 220,535 58,719 0 127,270 34,546 0 0
Illinois 2,264,567 267,908 443,451 1,174,697 134,026 244,485 0
Indiana 982,131 383,104 0 362,910 236,117 0 0
Iowa 399,710 159,714 11,347 130,176 98,473 0 0
Kansas 344,006 131,391 7,356 144,451 60,808 0 0
Kentucky 833,511 389,105 31,828 334,449 78,129 0 0
Louisiana 1,112,345 357,850 13,564 627,371 113,560 0 0
Maine 306,397 58,110 4,171 134,809 79,104 30,203 0
Maryland 845,145 217,098 97,901 350,903 48,168 131,075 0
Massachusetts 1,156,690 314,997 20,511 454,852 135,831 230,499 0
Michigan 1,770,258 466,725 119,909 559,893 524,071 99,621 39
Minnesota 736,476 415,749 26,565 76,547 102,361 115,254 0
Mississippi 785,105 336,988 0 388,839 31,443 27,758 77
Missouri 1,205,751 721,856 0 155,389 198,035 130,471 0
Montana 113,073 48,927 8,897 31,172 24,075 0 2
Nebraska 260,865 67,774 25,254 129,813 37,411 0 613
Nevada 256,841 151,831 0 57,208 47,802 0 0
New Hampshire 134,216 25,945 12,390 66,034 29,847 0 0
New Jersey 988,602 387,466 5,472 381,705 144,339 69,620 0
New Mexico 511,778 199,408 0 199,847 96,967 15,555 1
New York 4,888,941 2,015,032 947,008 677,568 115,119 1,134,214 0
North Carolina 1,526,268 587,054 45,245 779,887 114,082 0 0
North Dakota 74,996 31,543 12,437 13,706 17,310 0 0
Ohio 1,996,065 433,986 0 418,532 1,143,547 0 0
Oklahoma 683,702 184,415 1 444,337 54,949 0 0
Oregon 590,236 178,155 0 168,164 142,621 101,043 253
Pennsylvania 1,890,061 789,183 107,058 637,420 356,400 0 0
Rhode Island 216,052 79,077 4,309 35,939 53,129 43,598 0
South Carolina 990,658 298,965 0 437,149 195,881 58,663 0
South Dakota 124,032 42,396 0 54,045 27,591 0 0
Tennessee 1,619,941 620,026 206,875 294,071 190,654 308,311 4
Texas 3,878,183 853,265 80,981 2,293,200 650,737 0 0
Utah 295,299 98,214 6,292 105,088 62,486 23,219 0
Vermont 163,595 28,197 14,418 50,260 16,350 54,370 0
Virginia 821,256 148,124 10,190 512,062 143,818 7,062 0
Washington 1,195,703 292,146 20,155 382,563 379,282 121,557 0
West Virginia 373,373 121,122 7,504 200,322 44,425 0 0
Wisconsin 971,210 309,474 39,590 145,519 196,363 280,264 0
Wyoming 77,772 19,458 0 38,669 19,645 0 0

1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Eligibles by Age Group, 20041

65 Years and
State Total Eligibles <20 Years 21-64 Years Older Age Unknown
National Total 57,575,692 31,265,163 20,283,550 5,917,484 109,495
Alabama 918,304 486,702 308,866 122,736 0
Alaska 127,779 86,867 33,310 7,602 0
Arizona 1,394,378 715,813 591,870 86,694 1
Arkansas 700,038 420,164 216,520 63,354 0
California 10,619,361 4,952,527 4,764,288 902,525 21
Colorado 524,760 318,605 154,316 51,243 596
Connecticut 508,387 270,566 173,412 64,409 0
Delaware 166,604 82,813 71,492 12,299 0
District of Columbia 160,304 86,818 59,313 14,172 1
Florida 2,867,361 1,644,182 849,036 373,858 285
Georgia 1,759,654 1,114,125 477,959 167,568 2
Hawaii 223,417 110,593 90,064 22,760 0
Idaho 220,535 153,818 53,317 13,400 0
Illinois 2,264,567 1,264,313 627,877 372,369 8
Indiana 982,131 615,708 286,060 80,363 0
Iowa 399,710 228,781 129,581 41,347 1
Kansas 344,006 213,480 97,034 33,492 0
Kentucky 833,511 458,162 282,237 93,085 27
Louisiana 1,112,345 745,594 257,619 109,132 0
Maine 306,397 127,609 144,358 34,428 2
Maryland 845,145 491,203 273,958 79,966 18
Massachusetts 1,156,690 515,616 500,166 140,908 0
Michigan 1,770,258 1,015,405 621,511 133,155 187
Minnesota 736,476 398,610 247,866 89,998 2
Mississippi 785,105 464,734 224,639 95,732 0
Missouri 1,205,751 685,309 419,250 101,188 4
Montana 113,073 65,145 37,477 10,449 2
Nebraska 260,865 164,407 66,519 23,798 6,141
Nevada 256,841 153,307 79,591 23,840 103
New Hampshire 134,216 83,667 36,429 14,115 5
New Jersey 988,602 550,025 295,518 143,059 0
New Mexico 511,778 327,093 151,993 32,692 0
New York 4,888,941 2,112,705 2,174,386 499,842 102,008
North Carolina 1,526,268 860,015 486,217 180,034 2
North Dakota 74,996 39,981 25,360 9,655 0
Ohio 1,996,065 1,139,998 696,688 159,379 0
Oklahoma 683,702 461,685 156,642 65,375 0
Oregon 590,236 289,485 250,518 50,226 7
Pennsylvania 1,890,061 1,013,149 655,551 221,360 1
Rhode Island 216,052 108,448 82,724 24,880 0
South Carolina 990,658 543,494 305,375 141,789 0
South Dakota 124,032 81,288 30,439 12,305 0
Tennessee 1,619,941 747,263 696,060 176,618 0
Texas 3,878,183 2,672,469 801,061 404,632 21
Utah 295,299 175,777 105,137 14,382 3
Vermont 163,595 73,901 68,340 21,354 0
Virginia 821,256 496,821 222,230 102,188 17
Washington 1,195,703 712,093 399,316 84,293 1
West Virginia 373,373 200,481 138,974 33,918 0
Wisconsin 971,210 472,173 344,956 154,054 27
Wyoming 77,772 52,176 20,130 5,464 2

1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Eligibles by Gender, 20041


State Total Eligibles Female Male Gender Uknown
National Total 57,575,692 34,103,950 23,358,176 113,566
Alabama 918,304 583,874 328,483 5,947
Alaska 127,779 70,590 57,186 3
Arizona 1,394,378 776,189 618,187 2
Arkansas 700,038 438,854 259,490 1,694
California 10,619,361 6,717,525 3,901,818 18
Colorado 524,760 311,442 213,318 0
Connecticut 508,387 302,193 206,194 0
Delaware 166,604 99,238 67,366 0
District of Columbia 160,304 95,541 64,763 0
Florida 2,867,361 1,667,537 1,198,228 1,596
Georgia 1,759,654 1,047,589 712,045 20
Hawaii 223,417 120,313 103,104 0
Idaho 220,535 124,512 96,023 0
Illinois 2,264,567 1,369,106 895,461 0
Indiana 982,131 579,693 402,438 0
Iowa 399,710 231,250 168,460 0
Kansas 344,006 198,114 145,875 17
Kentucky 833,511 482,166 351,341 4
Louisiana 1,112,345 638,257 473,953 135
Maine 306,397 168,041 138,128 228
Maryland 845,145 504,615 340,530 0
Massachusetts 1,156,690 670,140 486,550 0
Michigan 1,770,258 990,908 779,350 0
Minnesota 736,476 423,705 312,771 0
Mississippi 785,105 459,776 303,168 22,161
Missouri 1,205,751 699,762 505,986 3
Montana 113,073 65,006 48,067 0
Nebraska 260,865 144,612 109,958 6,295
Nevada 256,841 149,663 106,502 676
New Hampshire 134,216 77,792 56,424 0
New Jersey 988,602 590,954 397,648 0
New Mexico 511,778 302,577 209,183 18
New York 4,888,941 2,737,167 2,077,827 73,947
North Carolina 1,526,268 918,374 607,894 0
North Dakota 74,996 44,346 30,649 1
Ohio 1,996,065 1,158,583 837,480 2
Oklahoma 683,702 396,931 286,771 0
Oregon 590,236 333,855 256,381 0
Pennsylvania 1,890,061 1,098,948 791,113 0
Rhode Island 216,052 126,918 89,134 0
South Carolina 990,658 618,978 371,558 122
South Dakota 124,032 70,279 53,753 0
Tennessee 1,619,941 940,866 679,075 0
Texas 3,878,183 2,231,241 1,646,853 89
Utah 295,299 170,827 124,024 448
Vermont 163,595 90,456 73,139 0
Virginia 821,256 484,984 336,234 38
Washington 1,195,703 722,913 472,741 49
West Virginia 373,373 213,109 160,264 0
Wisconsin 971,210 599,461 371,749 0
Wyoming 77,772 44,180 33,539 53
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Eligibles by Race/Ethnicity, 20041

American
Indian/
Total Black/African Alaska Hispanic or
State Eligibles White American Native Asian Latino Other
National Total 57,575,692 24,963,746 13,320,983 833,800 1,502,416 12,533,000 4,421,747
Alabama 918,304 428,801 436,679 2,577 4,240 20,835 25,172
Alaska 127,779 54,040 6,635 47,359 6,523 4,699 8,523
Arizona 1,394,378 485,844 80,073 153,888 17,422 623,427 33,724
Arkansas 700,038 438,290 209,923 5,599 6,669 33,852 5,705
California 10,619,361 2,249,008 976,625 45,748 515,864 5,787,987 1,044,129
Colorado 524,760 243,850 41,584 4,881 6,779 197,336 30,330
Connecticut 508,387 236,498 110,945 986 11,860 147,891 207
Delaware 166,604 72,159 70,292 344 2,521 21,285 3
District of Columbia 160,304 2,697 139,053 47 1,375 12,765 4,367
Florida 2,867,361 1,054,831 844,911 2,904 23,431 714,828 226,456
Georgia 1,759,654 749,052 855,834 1,492 22,350 26,314 104,612
Hawaii 223,417 52,040 3,555 662 68,483 8,157 90,520
Idaho 220,535 196,567 2,086 5,521 1,181 14,841 339
Illinois 2,264,567 963,463 810,940 4,355 54,523 402,105 29,181
Indiana 982,131 669,291 218,553 620 4,009 79,022 10,636
Iowa 399,710 263,799 28,786 1,874 3,559 14,385 87,307
Kansas 344,006 219,138 54,265 4,665 4,454 34 61,450
Kentucky 833,511 672,499 103,601 432 2,920 17,859 36,200
Louisiana 1,112,345 407,018 619,087 2,915 6,173 8,984 68,168
Maine 306,397 291,537 7,123 3,924 2,761 1,052 0
Maryland 845,145 279,384 442,491 1,575 24,435 65,393 31,867
Massachusetts 1,156,690 590,847 126,942 2,895 38,633 188,707 208,666
Michigan 1,770,258 1,016,738 601,030 9,332 26,120 97,695 19,343
Minnesota 736,476 441,501 118,215 28,246 46,631 702 101,181
Mississippi 785,105 263,644 436,995 2,961 3,972 6,636 70,897
Missouri 1,205,751 849,802 298,472 4,006 8,483 62 44,926
Montana 113,073 81,551 1,005 26,408 472 3,629 8
Nebraska 260,865 172,392 33,260 9,073 2,825 97 43,218
Nevada 256,841 120,628 48,411 3,722 8,269 57,862 17,949
New Hampshire 134,216 121,971 2,678 160 1,048 4,691 3,668
New Jersey 988,602 371,025 307,191 3,700 20,609 175,870 110,207
New Mexico 511,778 126,902 10,899 96,357 2,889 264,030 10,701
New York 4,888,941 1,753,381 1,154,965 82,849 286,679 663,942 947,125
North Carolina 1,526,268 668,841 609,834 25,149 14,506 77,777 130,161
North Dakota 74,996 52,578 1,419 16,389 270 0 4,340
Ohio 1,996,065 1,329,951 589,261 2,113 13,587 60,185 968
Oklahoma 683,702 422,119 107,827 87,102 6,837 0 59,817
Oregon 590,236 415,236 25,900 14,440 17,272 109,713 7,675
Pennsylvania 1,890,061 1,126,287 500,438 2,364 36,286 138,164 86,522
Rhode Island 216,052 89,736 18,433 415 5,073 39,218 63,177
South Carolina 990,658 405,429 483,878 1,589 3,126 25,604 71,032
South Dakota 124,032 75,349 2,994 41,959 714 2,660 356
Tennessee 1,619,941 1,060,363 450,537 2,623 3,938 41,376 61,104
Texas 3,878,183 1,012,711 709,856 14,497 56,696 2,045,169 39,254
Utah 295,299 214,958 5,969 10,629 8,844 52,331 2,568
Vermont 163,595 93,595 1,300 245 406 303 67,746
Virginia 821,256 368,434 366,039 1,349 21,394 59,191 4,849
Washington 1,195,703 728,888 71,648 30,407 49,394 162,553 152,813
West Virginia 373,373 352,864 19,798 132 541 30 8
Wisconsin 971,210 544,950 151,348 14,461 25,093 50,166 185,192
Wyoming 77,772 61,269 1,400 5,860 277 1,586 7,380

1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Eligibles by Basis of Eligibility, 20041

Blind/ Foster Care BCCA BOE


State Total Eligibles Aged Disabled Children Adults Children Women Unknown
National Total 57,575,692 5,193,457 8,607,606 27,822,746 14,996,502 933,167 21,095 1,119
Alabama 918,304 101,352 200,452 440,345 168,436 7,329 390 0
Alaska 127,779 6,922 13,512 76,972 27,667 2,582 124 0
Arizona 1,394,378 72,649 122,720 629,761 559,106 10,142 0 0
Arkansas 700,038 62,814 104,425 353,398 172,705 6,290 405 1
California 10,619,361 728,023 1,077,016 4,197,060 4,459,060 151,411 6,719 72
Colorado 524,760 50,337 75,675 268,565 111,221 18,795 145 22
Connecticut 508,387 63,877 62,120 267,669 108,622 5,923 176 0
Delaware 166,604 11,767 19,583 70,818 62,502 1,887 47 0
District of Columbia 160,304 10,182 31,484 74,527 39,378 4,733 0 0
Florida 2,867,361 317,508 523,045 1,443,986 535,405 47,208 209 0
Georgia 1,759,654 139,709 286,385 999,537 307,160 24,095 2,768 0
Hawaii 223,417 21,895 24,652 95,465 74,509 6,829 33 34
Idaho 220,535 13,308 29,872 140,678 34,084 2,593 0 0
Illinois 2,264,567 327,080 318,285 1,136,989 406,351 75,383 479 0
Indiana 982,131 79,895 137,907 568,530 181,330 14,194 275 0
Iowa 399,710 40,769 65,980 200,711 80,485 11,765 0 0
Kansas 344,006 33,335 56,935 180,665 59,598 13,366 107 0
Kentucky 833,511 69,892 224,670 398,929 128,504 11,154 362 0
Louisiana 1,112,345 108,627 186,351 675,676 131,361 9,671 659 0
Maine 306,397 33,718 48,646 117,347 102,894 3,649 143 0
Maryland 845,145 69,551 130,721 447,242 179,869 17,762 0 0
Massachusetts 1,156,690 112,075 259,840 465,839 318,230 706 0 0
Michigan 1,770,258 106,402 312,142 884,365 426,113 41,197 0 39
Minnesota 736,476 70,095 102,786 366,718 187,411 9,112 354 0
Mississippi 785,105 87,741 162,816 411,035 119,450 3,830 156 77
Missouri 1,205,751 99,152 177,494 626,072 275,730 26,787 516 0
Montana 113,073 9,473 18,402 57,569 23,537 3,939 151 2
Nebraska 260,865 23,242 31,834 144,091 49,216 11,546 323 613
Nevada 256,841 22,583 37,674 135,058 54,477 6,884 165 0
New Hampshire 134,216 14,012 17,985 80,561 19,016 2,642 0 0
New Jersey 988,602 112,082 185,698 473,060 191,757 25,807 198 0
New Mexico 511,778 24,675 57,173 305,869 119,484 4,267 309 1
New York 4,888,941 397,538 709,473 2,040,128 1,675,009 66,076 717 0
North Carolina 1,526,268 179,264 259,130 775,630 294,293 17,951 0 0
North Dakota 74,996 9,584 10,035 35,795 17,593 1,989 0 0
Ohio 1,996,065 149,438 319,238 1,035,824 456,477 35,088 0 0
Oklahoma 683,702 61,009 92,692 424,017 90,375 15,609 0 0
Oregon 590,236 48,243 73,796 248,776 202,172 16,779 217 253
Pennsylvania 1,890,061 220,305 433,865 853,680 329,213 51,908 1,090 0
Rhode Island 216,052 21,087 41,471 92,598 55,180 5,413 303 0
South Carolina 990,658 135,935 140,610 473,857 229,827 10,267 162 0
South Dakota 124,032 10,157 17,190 74,201 20,296 2,144 44 0
Tennessee 1,619,941 129,763 356,551 686,560 428,684 17,678 700 5
Texas 3,878,183 400,780 434,149 2,450,210 552,169 40,029 846 0
Utah 295,299 13,497 31,962 156,407 85,648 7,503 282 0
Vermont 163,595 19,737 20,397 66,487 54,179 2,722 73 0
Virginia 821,256 99,048 147,556 447,154 112,523 14,639 336 0
Washington 1,195,703 83,989 158,555 609,444 325,868 17,847 0 0
West Virginia 373,373 30,492 99,269 174,862 61,337 6,704 709 0
Wisconsin 971,210 133,435 148,475 395,235 277,098 16,698 269 0
Wyoming 77,772 5,414 8,912 46,774 13,893 2,645 134 0

1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Eligibles Per 1000 Population, 20041

Total State Total Eligibles per


State Population Eligibles 1000 Population
National Total 293,655,404 57,575,692 196.1
Alabama 4,530,182 918,304 202.7
Alaska 655,435 127,779 195.0
Arizona 5,743,834 1,394,378 242.8
Arkansas 2,752,629 700,038 254.3
California 35,893,799 10,619,361 295.9
Colorado 4,601,403 524,760 114.0
Connecticut 3,503,604 508,387 145.1
Delaware 830,364 166,604 200.6
District of Columbia 553,523 160,304 289.6
Florida 17,397,161 2,867,361 164.8
Georgia 8,829,383 1,759,654 199.3
Hawaii 1,262,840 223,417 176.9
Idaho 1,393,262 220,535 158.3
Illinois 12,713,634 2,264,567 178.1
Indiana 6,237,569 982,131 157.5
Iowa 2,954,451 399,710 135.3
Kansas 2,735,502 344,006 125.8
Kentucky 4,145,922 833,511 201.0
Louisiana 4,515,770 1,112,345 246.3
Maine 1,317,253 306,397 232.6
Maryland 5,558,058 845,145 152.1
Massachusetts 6,416,505 1,156,690 180.3
Michigan 10,112,620 1,770,258 175.1
Minnesota 5,100,958 736,476 144.4
Mississippi 2,902,966 785,105 270.4
Missouri 5,754,618 1,205,751 209.5
Montana 926,865 113,073 122.0
Nebraska 1,747,214 260,865 149.3
Nevada 2,334,771 256,841 110.0
New Hampshire 1,299,500 134,216 103.3
New Jersey 8,698,879 988,602 113.6
New Mexico 1,903,289 511,778 268.9
New York 19,227,088 4,888,941 254.3
North Carolina 8,541,221 1,526,268 178.7
North Dakota 634,366 74,996 118.2
Ohio 11,459,011 1,996,065 174.2
Oklahoma 3,523,553 683,702 194.0
Oregon 3,594,586 590,236 164.2
Pennsylvania 12,406,292 1,890,061 152.3
Rhode Island 1,080,632 216,052 199.9
South Carolina 4,198,068 990,658 236.0
South Dakota 770,883 124,032 160.9
Tennessee 5,900,962 1,619,941 274.5
Texas 22,490,022 3,878,183 172.4
Utah 2,389,039 295,299 123.6
Vermont 621,394 163,595 263.3
Virginia 7,459,827 821,256 110.1
Washington 6,203,788 1,195,703 192.7
West Virginia 1,815,354 373,373 205.7
Wisconsin 5,509,026 971,210 176.3
Wyoming 506,529 77,772 153.5
1
Eligibles are defined as individuals who were on the Medicaid rolls at least one month during the year.

Source: U.S. Department of Commerce, Bureau of the Census, 2004; CMS, MSIS Report, FY 2004.

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National Pharmaceutical Council Pharmaceutical Benefits 2007
Total Net U.S. Medical Assistance Expenditures
by Type of Service, FY 2004 & FY 2005

Percent Percent Percent


Service FY 2005 FY 2004
of Total of Total Change

Inpatient Acute Care Hospital $55,502,233,756 18.52% $53,369,218,290 19.01% 4.00%

Nursing Facility $46,361,761,383 15.47% $46,500,694,515 16.56% -0.30%

Pharmaceuticals $43,077,457,835 14.38% $40,065,314,592 14.27% 7.52%

HCBS Waivers $23,354,604,979 7.79% $21,765,416,501 7.75% 7.30%

ICF-Mentally Retarded $12,524,696,098 4.18% $12,132,969,504 4.32% 3.23%

Hospital Outpatient $12,337,463,061 4.12% $11,615,651,583 4.14% 6.21%

Physicians $10,141,677,696 3.38% $9,689,801,589 3.45% 4.66%

Personal Care Services $9,439,267,997 3.15% $8,237,712,957 2.93% 14.59%

Clinic* $9,015,530,077 3.01% $8,141,919,807 2.90% 10.73%

Inpatient Mental Health Hospital $8,216,467,960 2.74% $7,658,041,454 2.73% 7.29%

Home Health Care $3,569,443,730 1.19% $3,445,105,331 1.23% 3.61%

Dental $3,384,483,853 1.13% $3,112,152,041 1.11% 8.75%

Other Practitioners $2,217,963,102 0.74% $2,001,837,788 0.71% 10.80%

Lab/X-ray $1,273,909,924 0.43% $1,170,828,366 0.42% 8.80%

EPSDT $1,075,932,247 0.36% $1,045,523,675 0.37% 2.91%

Other** $58,166,915,121 19.41% $50,819,666,983 18.10% 14.46%

Total Expenditures $299,659,808,819 100%‡ $280,771,854,976 100% ‡ 6.73%

‡ 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 2004 and FY 2005.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Federal Medical Assistance Percentage (FMAP),


FY 2007 and FY 2008
2007 Enhanced 2008 Enhanced
State 2007 FMAP FMAP* 2008 FMAP FMAP*
Alabama 68.85% 78.20% 67.62% 77.33%
Alaska 57.58% 70.31% 52.48% 66.74%
Arizona 66.47% 76.53% 66.20% 76.34%
Arkansas 73.37% 81.36% 72.94% 81.06%
California 50.00% 65.00% 50.00% 65.00%
Colorado 50.00% 65.00% 50.00% 65.00%
Connecticut 50.00% 65.00% 50.00% 65.00%
Delaware 50.00% 65.00% 50.00% 65.00%
District of Columbia** 70.00% 79.00% 70.00% 79.00%
Florida 58.76% 71.13% 56.83% 69.78%
Georgia 61.97% 73.38% 63.10% 74.17%
Hawaii 57.55% 70.29% 56.50% 69.55%
Idaho 70.36% 79.25% 69.87% 78.91%
Illinois 50.00% 65.00% 50.00% 65.00%
Indiana 62.61% 73.83% 62.69% 73.88%
Iowa 61.98% 73.39% 61.73% 73.21%
Kansas 60.25% 72.18% 59.43% 71.60%
Kentucky 69.58% 78.71% 69.78% 78.85%
Louisiana 69.69% 78.78% 72.47% 80.73%
Maine 63.27% 74.29% 63.31% 74.32%
Maryland 50.00% 65.00% 50.00% 65.00%
Massachusetts 50.00% 65.00% 50.00% 65.00%
Michigan 56.38% 69.47% 58.10% 70.67%
Minnesota 50.00% 65.00% 50.00% 65.00%
Mississippi 75.89% 83.12% 76.29% 83.40%
Missouri 61.60% 73.12% 62.42% 73.69%
Montana 69.11% 78.38% 68.53% 77.97%
Nebraska 57.93% 70.55% 58.02% 70.61%
Nevada 53.93% 67.75% 52.64% 66.85%
New Hampshire 50.00% 65.00% 50.00% 65.00%
New Jersey 50.00% 65.00% 50.00% 65.00%
New Mexico 71.93% 80.35% 71.04% 79.73%
New York 50.00% 65.00% 50.00% 65.00%
North Carolina 64.52% 75.16% 64.05% 74.84%
North Dakota 64.72% 75.30% 63.75% 74.63%
Ohio 59.66% 71.76% 60.79% 72.55%
Oklahoma 68.14% 77.70% 67.10% 76.97%
Oregon 61.07% 72.75% 60.86% 72.60%
Pennsylvania 54.39% 68.07% 54.08% 67.86%
Rhode Island 52.35% 66.65% 52.51% 66.76%
South Carolina 69.54% 78.68% 69.79% 78.85%
South Dakota 62.92% 74.04% 60.03% 72.02%
Tennessee 63.65% 74.56% 63.71% 74.60%
Texas 60.78% 72.55% 60.53% 72.37%
Utah 70.14% 79.10% 71.63% 80.14%
Vermont 58.93% 71.25% 59.03% 71.32%
Virginia 50.00% 65.00% 50.00% 65.00%
Washington 50.12% 65.08% 51.52% 66.06%
West Virginia 72.82% 80.97% 74.25% 81.98%
Wisconsin 57.47% 70.23% 57.62% 70.33%
Wyoming 52.91% 67.04% 50.00% 65.00%

* The “Enhanced Federal Medical Assistance Percentages” are for use in State Children’s Health Insurance Program under Title XXI, and for some or all
of children’s medical assistance under Medicaid sections 1905(u)(2) and 1905(u)(3).
** The values for the District of Columbia in the table were set for the state plan under titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, including programs remaining in Title IV of the Act the Percentage for the District of Columbia is
50.00%.
Source: Federal Register, May 15, 2006, Vol. 71, No. 93, pages 28041-28042, and November 30, 2006, Vol. 71, No. 230, pages 69209-69211.

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Medicaid Total Net Expenditures and Eligibles, 2004

Total Net Medical Total Average


1
State Assistance Expenditures Eligibles Per Eligible
National Total 280,771,854,976 57,575,692 $4,877
Alabama 3,636,777,895 918,304 $3,960
Alaska 884,037,863 127,779 $6,918
Arizona 4,933,111,255 1,394,378 $3,538
Arkansas 2,585,068,063 700,038 $3,693
California 30,677,337,285 10,619,361 $2,889
Colorado 2,648,577,338 524,760 $5,047
Connecticut 3,875,748,955 508,387 $7,624
Delaware 792,028,808 166,604 $4,754
District of Columbia 1,116,037,028 160,304 $6,962
Florida 12,789,934,905 2,867,361 $4,461
Georgia 7,044,051,167 1,759,654 $4,003
Hawaii 907,974,098 223,417 $4,064
Idaho 938,680,696 220,535 $4,256
Illinois 9,991,310,983 2,264,567 $4,412
Indiana 4,889,329,727 982,131 $4,978
Iowa 2,239,281,593 399,710 $5,602
Kansas 1,782,435,217 344,006 $5,181
Kentucky 4,086,404,587 833,511 $4,903
Louisiana 4,933,031,400 1,112,345 $4,435
Maine 2,021,194,249 306,397 $6,597
Maryland 4,586,430,658 845,145 $5,427
Massachusetts 8,725,068,052 1,156,690 $7,543
Michigan 8,224,940,371 1,770,258 $4,646
Minnesota 5,550,210,439 736,476 $7,536
Mississippi 3,284,724,191 785,105 $4,184
Missouri 6,082,476,995 1,205,751 $5,045
Montana 666,602,722 113,073 $5,895
Nebraska 1,430,800,678 260,865 $5,485
Nevada 1,037,927,527 256,841 $4,041
New Hampshire 1,148,626,371 134,216 $8,558
New Jersey 7,928,423,533 988,602 $8,020
New Mexico 2,212,810,008 511,778 $4,324
New York 40,978,466,799 4,888,941 $8,382
North Carolina 7,945,585,983 1,526,268 $5,206
North Dakota 479,677,381 74,996 $6,396
Ohio 11,550,492,206 1,996,065 $5,787
Oklahoma 2,500,517,344 683,702 $3,657
Oregon 2,596,299,977 590,236 $4,399
Pennsylvania 14,088,449,923 1,890,061 $7,454
Rhode Island 1,646,343,632 216,052 $7,620
South Carolina 3,848,423,641 990,658 $3,885
South Dakota 561,562,642 124,032 $4,528
Tennessee 7,029,807,190 1,619,941 $4,340
Texas 16,077,695,030 3,878,183 $4,146
Utah 1,235,552,901 295,299 $4,184
Vermont 798,758,992 163,595 $4,883
Virginia 3,825,216,022 821,256 $4,658
Washington 5,243,560,705 1,195,703 $4,385
West Virginia 1,937,298,997 373,373 $5,189
Wisconsin 4,410,918,293 971,210 $4,542
Wyoming 365,832,661 77,772 $4,704

1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.

Source: CMS, CMS-64 Report, FY 2004 and CMS-MSIS Report, FY 2004.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Total Medicaid Program Expenditures, 2005

Total Net Medical Administrative Total Program


State Assistance Expenditures Expenditures Expenditures
National Total $299,659,808,819 $15,068,079,406 $314,727,888,225
Alabama $3,837,473,614 $87,376,814 $3,924,850,428
Alaska $983,488,511 $70,733,046 $1,054,221,557
Arizona $5,725,919,558 $183,453,394 $5,909,372,952
Arkansas $2,809,920,508 $110,188,017 $2,920,108,525
California $33,662,911,379 $3,103,635,656 $36,766,547,035
Colorado $2,796,729,720 $120,319,778 $2,917,049,498
Connecticut $4,027,599,803 $148,734,067 $4,176,333,870
Delaware $868,667,588 $54,603,382 $923,270,970
District of Columbia $1,254,159,659 $63,312,168 $1,317,471,827
Florida $13,218,246,322 $658,687,998 $13,876,934,320
Georgia $7,333,266,041 $407,426,231 $7,740,692,272
Hawaii $1,033,126,200 $65,725,548 $1,098,851,748
Idaho $1,008,634,738 $63,181,574 $1,071,816,312
Illinois $10,785,542,795 $590,108,980 $11,375,651,775
Indiana $5,234,229,575 $246,067,710 $5,480,297,285
Iowa $2,376,772,384 $103,762,462 $2,480,534,846
Kansas $1,967,790,699 $122,828,846 $2,090,619,545
Kentucky $4,253,083,096 $125,336,656 $4,378,419,752
Louisiana $5,313,395,456 $161,949,822 $5,475,345,278
Maine $2,242,388,876 $80,066,998 $2,322,455,874
Maryland $5,136,302,340 $297,871,779 $5,434,174,119
Massachusetts $9,556,863,877 $403,706,704 $9,960,570,581
Michigan $8,656,266,850 $389,937,793 $9,046,204,643
Minnesota $5,528,371,422 $319,075,173 $5,847,446,595
Mississippi $3,342,615,012 $95,654,946 $3,438,269,958
Missouri $6,528,988,350 $298,709,983 $6,827,698,333
Montana $696,069,297 $40,452,839 $736,522,136
Nebraska $1,377,175,781 $93,856,052 $1,471,031,833
Nevada $1,184,065,213 $66,180,415 $1,250,245,628
New Hampshire $1,244,582,951 $57,418,911 $1,302,001,862
New Jersey $7,508,874,058 $461,298,321 $7,970,172,379
New Mexico $2,363,669,655 $82,478,622 $2,446,148,277
New York $42,752,347,265 $1,299,681,010 $44,052,028,275
North Carolina $8,844,879,833 $464,447,476 $9,309,327,309
North Dakota $508,464,760 $21,344,898 $529,809,658
Ohio $11,572,449,325 $342,550,662 $11,914,999,987
Oklahoma $2,712,779,961 $161,029,370 $2,873,809,331
Oregon $2,810,667,717 $252,091,973 $3,062,759,690
Pennsylvania $15,786,514,016 $702,907,573 $16,489,421,589
Rhode Island $1,671,398,242 $82,385,970 $1,753,784,212
South Carolina $4,068,509,449 $129,160,005 $4,197,669,454
South Dakota $608,250,647 $24,507,634 $632,758,281
Tennessee $7,557,403,733 $501,249,768 $8,058,653,501
Texas $17,264,066,130 $662,460,980 $17,926,527,110
Utah $1,341,242,046 $105,012,245 $1,446,254,291
Vermont $859,483,644 $58,665,386 $918,149,030
Virginia $4,425,080,633 $259,286,946 $4,684,367,579
Washington $5,700,850,706 $505,104,188 $6,205,954,894
West Virginia $2,161,356,254 $87,988,910 $2,249,345,164
Wisconsin $4,751,656,671 $204,535,435 $4,956,192,106
Wyoming $405,216,459 $29,528,292 $434,744,751
Source: CMS, CMS-64 Report, FY 2005.

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Total SCHIP Enrollment, 2005*


Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP Adults Enrolled in SCHIP
State Enrollment Enrollment Enrollment Demonstrations
National Total 1,738,270 4,412,945 6,151,215 644,569
Alabama - 81,856 81,856 -
Alaska 22,322 - 22,322 -
Arizona - 88,005 88,005 113,621
Arkansas - 1,214 1,214 -
California** 181,017 1,042,458 1,223,475 -
Colorado - 59,530 59,530 1,575
Connecticut - 22,289 22,289 -
Delaware 150 10,204 10,354 -
District of Columbia 6,631 - 6,631 -
Florida 1,942 382,859 384,801 -
Georgia - 306,733 306,733 -
Hawaii 20,602 - 20,602 -
Idaho 18,639 3,200 21,839 135
Illinois 120,582 160,850 281,432 175,994
Indiana 93,666 35,878 129,544 -
Iowa 16,453 30,109 46,562 -
Kansas - 47,323 47,323 -
Kentucky 41,180 22,548 63,728 -
Louisiana 146,347 - 146,347 -
Maine 21,806 8,848 30,654 -
Maryland 106,471 13,845 120,316 -
Massachusetts 119,268 43,411 162,679 -
Michigan 33,965 55,292 89,257 101,283
Minnesota 107 4,969 5,076 35,011
Mississippi - 79,352 79,352 -
Missouri 115,355 - 115,355 -
Montana - 15,841 15,841 -
Nebraska 44,706 - 44,706 -
Nevada - 39,316 39,316 -
New Hampshire 707 11,185 11,892 -
New Jersey 43,435 86,156 129,591 66,827
New Mexico 24,310 - 24,310 5,780
New York NR 618,973 618,973 -
North Carolina - 196,181 196,181 -
North Dakota 1,936 3,789 5,725 -
Ohio 216,495 - 216,495 -
Oklahoma 108,100 - 108,100 -
Oregon - 52,722 52,722 11,366
Pennsylvania - 179,807 179,807 -
Rhode Island 25,609 1,535 27,144 24,169
South Carolina 80,646 - 80,646 -
South Dakota 10,843 3,195 14,038 -
Tennessee - - - -
Texas - 526,406 526,406 -
Utah - 43,931 43,931 -
Vermont - 6,614 6,614 -
Virginia 57,815 66,240 124,055 -
Washington - 15,547 15,547 -
West Virginia - 38,614 38,614 -
Wisconsin 57,165 - 57,165 108,808
Wyoming - 6,120 6,120 -

*The data displayed in this table were compiled from the CMS website at
http://www.cms.hhs.gov/NationalSCHIPPolicy/downloads/FY2005AnnualEnrollmentReport.pdf.
Column and row values do not always sum to totals.
** California reported aggregate enrollment for unborn children via email.
NR- State has not reported data via the Statistical Enrollment Data System (SEDS).
Source: CMS, SCHIP Annual Enrollment Report 2005.

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Total SCHIP Enrollment, 2006*


Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP Adults Enrolled in SCHIP
State Enrollment Enrollment Enrollment Demonstrations
National Total 1,932,667 4,691,485 6,624,152 700,596
Alabama - 84,257 84,257 -
Alaska 22,227 - 22,227 -
Arizona - 96,669 96,669 109,738
Arkansas - 3,440 3,440 -
California 214,216 1,177,189 1,391,405 -
Colorado - 69,997 69,997 2,625
Connecticut - 23,110 23,110 -
Delaware 172 10,579 10,751 -
District of Columbia 6,332 - 6,332 -
Florida 1,877 301,718 303,595 -
Georgia - 343,690 343,690 -
Hawaii 22,031 - 22,031 -
Idaho 17,858 6,869 24,727 382
Illinois 139,565 177,216 316,781 211,114
Indiana 97,213 36,483 133,696 -
Iowa 17,756 31,819 49,575 -
Kansas - 48,934 48,934 -
Kentucky 41,943 22,918 64,861 -
Louisiana 142,389 - 142,389 -
Maine 22,167 8,947 31,114 -
Maryland 112,123 23,911 136,034 -
Massachusetts 126,120 64,520 190,640 -
Michigan 61,214 57,287 118,501 101,919
Minnesota 97 5,246 5,343 34,313
Mississippi - 83,359 83,359 -
Missouri 106,577 - 106,577 -
Montana - 17,304 17,304 -
Nebraska 44,981 - 44,981 -
Nevada - 39,317 39,317 -
New Hampshire 671 11,722 12,393 -
New Jersey 42,482 78,402 120,884 88,606
New Mexico 25,155 - 25,155 5,787
New York 51,576 636,786 688,362 -
North Carolina 53,180 194,811 247,991 -
North Dakota 1,889 4,429 6,318 -
Ohio 218,529 - 218,529 -
Oklahoma 116,012 - 116,012 -
Oregon - 59,039 59,039 13,750
Pennsylvania - 188,765 188,765 -
Rhode Island 24,028 1,464 25,492 21,125
South Carolina 68,870 - 68,870 -
South Dakota 11,254 3,330 14,584 -
Tennessee - - - -
Texas - 585,461 585,461 -
Utah - 51,967 51,967 -
Vermont - 6,314 6,314 -
Virginia 65,536 71,646 137,182 939
Washington - 15,000 15,000 -
West Virginia - 39,855 39,855 -
Wisconsin 56,627 - 56,627 110,298
Wyoming - 7,715 7,715 -

*The data displayed in this table were compiled from the CMS website at http://www.cms.hhs.gov/NationalSCHIPPolicy/
SCHIPER/list.asp.
Column and row values do not always sum to totals.
Source: CMS, SCHIP Annual Enrollment Report 2006 (Revised March 2007).

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Total SCHIP Expenditures, 2005

Medicaid SCHIP Non-Medicaid SCHIP Total SCHIP


State Expenditures Expenditures Expenditures
National Total $1,957,501,616 $5,274,003,241 $7,231,504,857
Alabama $0 $100,725,496 $100,725,496
Alaska $32,720,132 $2,003,640 $34,723,772
Arizona $0 $256,444,257 $256,444,257
Arkansas $63,137,114 $13,530,687 $76,667,801
California $235,868,466 $965,714,137 $1,201,582,603
Colorado $0 $59,499,505 $59,499,505
Connecticut $487 $31,568,327 $31,568,814
Delaware $254,987 $9,569,305 $9,824,292
District of Columbia $8,915,304 $512,014 $9,427,318
Florida $5,225,829 $337,355,275 $342,581,104
Georgia $0 $278,810,644 $278,810,644
Hawaii $17,074,156 $1,287,336 $18,361,492
Idaho $16,700,064 $4,196,828 $20,896,892
Illinois $52,747,363 $441,330,244 $494,077,607
Indiana $73,979,126 $28,865,771 $102,844,897
Iowa $17,071,268 $37,644,726 $54,715,994
Kansas $0 $59,331,747 $59,331,747
Kentucky $63,321,377 $26,622,400 $89,943,777
Louisiana $125,937,574 $11,921,047 $137,858,621
Maine $19,272,547 $8,001,526 $27,274,073
Maryland $160,616,680 $27,633,244 $188,249,924
Massachusetts $116,585,007 $71,264,347 $187,849,354
Michigan $30,507,986 $216,526,269 $247,034,255
Minnesota $0 $110,072,609 $110,072,609
Mississippi $0 $133,948,150 $133,948,150
Missouri $118,305,367 $3,504,111 $121,809,478
Montana $0 $15,919,915 $15,919,915
Nebraska $46,497,218 $964,276 $47,461,494
Nevada $0 $38,439,249 $38,439,249
New Hampshire $577,504 $9,253,754 $9,831,258
New Jersey $53,751,037 $261,552,917 $315,303,954
New Mexico $24,153,109 $538,391 $24,691,500
New York $165,754,958 $392,007,001 $557,761,959
North Carolina $0 $283,039,101 $283,039,101
North Dakota $5,379,032 $5,302,888 $10,681,920
Ohio $234,450,124 $5,653,230 $240,103,354
Oklahoma $78,138,283 $1,749,250 $79,887,533
Oregon $0 $53,025,345 $53,025,345
Pennsylvania $0 $208,143,654 $208,143,654
Rhode Island $34,991,476 $46,875,741 $81,867,217
South Carolina $68,047,065 $4,596,131 $72,643,196
South Dakota $11,264,792 $4,323,769 $15,588,561
Tennessee $0 $0 $0
Texas $0 $396,131,832 $396,131,832
Utah $0 $35,638,694 $35,638,694
Vermont $0 $5,083,497 $5,083,497
Virginia $47,020,947 $75,760,728 $122,781,675
Washington $0 $50,982,193 $50,982,193
West Virginia $0 $40,421,152 $40,421,152
Wisconsin $29,235,237 $92,585,572 $121,820,809
Wyoming $0 $8,131,319 $8,131,319
Source: CMS, CMS-64 Report, 2005.

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Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 20041

Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total 57,575,692 49,361,011 523,829 4,530,864 422,973
Alabama 918,304 728,680 47,835 85,461 24,539
Alaska 127,779 116,512 3 8,170 148
Arizona 1,394,378 1,269,306 1,218 65,203 11,268
Arkansas 700,038 596,512 23,518 73,501 1,880
California 10,619,361 9,541,090 8,175 954,783 5,224
Colorado 524,760 450,709 8,157 9,125 4,142
Connecticut 508,387 413,315 7,523 44,610 4,071
Delaware 166,604 146,445 4,953 6,404 4,241
District of Columbia 160,304 140,933 69 13,361 962
Florida 2,867,361 2,347,199 34,756 333,640 44,766
Georgia 1,759,654 1,505,647 58,508 14,974 27,953
Hawaii 223,417 194,383 83 24,032 1,874
Idaho 220,535 197,631 3,363 11,105 0
Illinois 2,264,567 1,918,663 10,696 145,179 2,724
Indiana 982,131 845,259 9,807 73,969 7,190
Iowa 399,710 326,949 4,723 31,242 3,573
Kansas 344,006 286,012 5,343 29,169 3,303
Kentucky 833,511 676,706 30,554 85,767 11,446
Louisiana 1,112,345 948,819 30,737 106,564 16,851
Maine 306,397 246,169 1,205 28,966 5,509
Maryland 845,145 710,870 16,373 47,416 6,330
Massachusetts 1,156,690 928,406 194 92,740 16,809
Michigan 1,770,258 1,563,692 1,516 52,670 7,120
Minnesota 736,476 616,061 2,289 63,342 5,460
Mississippi 785,105 634,520 1,267 42,979 2,079
Missouri 1,205,751 1,033,623 5,183 71,830 3,841
Montana 113,073 94,901 536 11,057 0
Nebraska 260,865 221,958 0 23,823 2,296
Nevada 256,841 219,552 9,532 19,578 4,648
New Hampshire 134,216 111,012 2,118 5,773 1,353
New Jersey 988,602 805,847 0 138,578 20,062
New Mexico 511,778 465,072 12,660 29,225 0
New York 4,888,941 4,249,119 2,690 330,088 1,231
North Carolina 1,526,268 1,234,899 602 201,784 29,149
North Dakota 74,996 60,174 1,176 1,216 818
Ohio 1,996,065 1,739,767 26,484 123,336 13,209
Oklahoma 683,702 586,738 0 81,155 9,734
Oregon 590,236 510,214 11,052 32,249 6,462
Pennsylvania 1,890,061 1,551,971 692 218,444 24,471
Rhode Island 216,052 177,531 609 18,815 2,223
South Carolina 990,658 856,853 0 76,944 6,238
South Dakota 124,032 105,696 2,958 9,724 1,506
Tennessee 1,619,941 1,311,747 13,332 132,679 11,220
Texas 3,878,183 3,391,054 71,506 275,155 36,114
Utah 295,299 270,361 317 14,353 927
Vermont 163,595 133,320 189 10,003 497
Virginia 821,256 666,656 20,455 91,721 14,559
Washington 1,195,703 1,068,860 10,380 87,970 7,598
West Virginia 373,373 312,397 12,948 0 0
Wisconsin 971,210 762,708 3,938 78,127 4,595
Wyoming 77,772 68,493 1,607 2,865 760
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid/Medicare Dual Eligibles by Dual Eligibility Type, 2004


(Con’t)1

SLMB/
State Medicaid QDWI QI(1) QI(2) Other
National Total 225,355 78 218,908 570 2,292,104
Alabama 4,074 0 14,239 2 13,474
Alaska 0 0 0 0 2,946
Arizona 0 0 9,439 0 37,944
Arkansas 0 31 4,593 3 0
California 0 5 3,376 0 106,708
Colorado 5 0 1,789 1 50,832
Connecticut 6,249 0 6,993 0 25,626
Delaware 0 0 1 0 4,560
District of Columbia 744 0 376 7 3,852
Florida 20,765 0 27,691 0 58,544
Georgia 2,623 3 13,774 0 136,172
Hawaii 0 0 0 0 3,045
Idaho 0 0 0 0 8,436
Illinois 22,529 0 13,474 0 151,302
Indiana 13,577 2 4,115 0 28,212
Iowa 7,600 0 1,766 0 23,857
Kansas 1,528 0 1,314 0 17,337
Kentucky 4,322 1 5,038 0 19,677
Louisiana 100 1 9,245 14 14
Maine 1,792 2 2,788 484 19,482
Maryland 0 0 2,430 0 61,726
Massachusetts 0 0 0 0 118,541
Michigan 8,216 3 3,073 10 133,958
Minnesota 11,291 0 2,465 0 35,568
Mississippi 14,612 1 801 0 88,846
Missouri 11,258 0 266 0 79,750
Montana 0 0 0 0 6,579
Nebraska 0 1 0 0 12,787
Nevada 1,398 0 2,098 3 32
New Hampshire 902 3 565 0 12,490
New Jersey 0 0 8,660 0 15,455
New Mexico 0 0 0 0 4,821
New York 5,550 0 1,657 1 298,605
North Carolina 6,134 0 13,199 0 40,501
North Dakota 190 0 322 0 11,100
Ohio 38 0 6,101 0 87,130
Oklahoma 1,246 0 4,788 41 0
Oregon 5,377 0 3,303 0 21,579
Pennsylvania 16,962 0 14,169 0 63,352
Rhode Island 0 0 1,459 0 15,415
South Carolina 0 1 3,980 2 46,640
South Dakota 1,044 0 655 2 2,447
Tennessee 24,412 0 0 0 126,551
Texas 14,966 0 18,387 0 71,001
Utah 1,551 0 496 0 7,294
Vermont 854 0 0 0 18,732
Virginia 0 24 5,359 0 22,482
Washington 1,852 0 3,557 0 15,486
West Virginia 0 0 0 0 48,028
Wisconsin 7,911 0 747 0 113,184
Wyoming 3,683 0 360 0 4
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Medical Vendor Payments and Dual Eligibility Status,


20041
Not a QMB/
State All Eligibles Dual Eligible QMB Only Medicaid SLMB Only
National Total $257,748,435,309 $144,060,399,677 $674,272,018 $56,786,668,933 $206,068,714
Alabama $3,856,624,429 $1,583,302,687 $36,749,661 $929,411,242 $1,573,886
Alaska $904,557,756 $663,584,562 $50 $149,413,298 $50,137
Arizona $3,888,008,156 $2,909,704,375 $1,584,011 $534,628,409 $4,780
Arkansas $2,358,152,529 $1,350,469,421 $57,154,274 $915,494,564 $725,502
California $27,443,631,984 $16,304,359,930 $21,496,160 $7,740,241,914 $13,682,863
Colorado $2,398,974,577 $1,286,651,222 $4,283,211 $142,693,310 $741,802
Connecticut $3,695,687,112 $1,469,760,511 $7,250,195 $1,264,098,742 $1,680,201
Delaware $800,099,395 $501,603,593 $6,803,439 $116,053,504 $1,713,717
District of Columbia $1,269,371,462 $829,880,668 $113,203 $227,411,616 $683,302
Florida $12,834,434,692 $6,641,965,601 $35,492,107 $3,225,433,405 $32,372,233
Georgia $6,944,469,214 $4,098,833,748 $214,976,658 $441,370,014 $29,692,794
Hawaii $861,761,796 $518,366,411 $88,437 $230,605,032 $648,386
Idaho $990,209,718 $619,521,602 $3,076,663 $168,770,815 $0
Illinois $10,796,139,208 $5,303,760,742 $13,232,916 $1,966,589,869 $1,259,504
Indiana $4,342,598,411 $2,402,498,613 $2,744,506 $1,122,154,376 $889,850
Iowa $2,205,524,237 $1,091,095,702 $5,193,230 $607,709,124 $1,269,105
Kansas $1,860,136,019 $924,679,742 $2,276,944 $496,868,464 $622,265
Kentucky $3,923,759,382 $2,528,984,869 $17,532,058 $919,880,290 $2,522,976
Louisiana $4,039,097,496 $2,545,291,686 $22,136,367 $1,354,365,543 $2,775,625
Maine $2,366,282,600 $1,528,843,247 $1,160,637 $396,767,238 $2,099,865
Maryland $4,594,329,962 $3,033,677,426 $66,508,717 $657,797,458 $11,835,875
Massachusetts $7,776,024,456 $4,061,810,608 $663,361 $1,400,612,956 $10,560,083
Michigan $7,696,785,150 $4,297,053,142 $3,973,840 $635,854,939 $5,884,410
Minnesota $4,575,111,805 $2,448,893,343 $2,340,154 $1,226,049,464 $1,905,268
Mississippi $3,312,060,122 $1,583,259,507 $1,963,380 $189,216,764 $1,966,640
Missouri $4,886,664,657 $2,770,860,385 $2,320,950 $892,257,766 $1,021,268
Montana $584,752,191 $318,938,763 $155,884 $140,284,879 $0
Nebraska $1,345,629,686 $641,628,543 $0 $159,993,203 $714,427
Nevada $805,569,471 $528,799,835 $5,868,888 $222,445,442 $938,586
New Hampshire $822,246,561 $399,394,534 $5,972,314 $93,798,742 $238,693
New Jersey $6,622,936,246 $3,181,378,756 $0 $3,073,182,618 $4,199,969
New Mexico $2,277,653,128 $1,482,024,017 $11,886,973 $444,946,387 $0
New York $37,273,255,429 $19,968,508,658 $430,297 $7,347,226,694 $462,361
North Carolina $7,388,008,367 $4,298,480,752 $395,516 $2,286,938,831 $13,442,116
North Dakota $477,445,701 $186,722,991 $848,147 $12,779,336 $208,728
Ohio $11,374,733,796 $6,206,561,478 $41,391,910 $2,626,016,848 $19,396,257
Oklahoma $2,335,120,746 $1,388,345,408 $0 $909,763,650 $5,344,419
Oregon $2,152,757,267 $1,353,044,525 $6,574,936 $367,790,027 $1,314,492
Pennsylvania $10,055,362,936 $5,575,969,238 $966,185 $2,188,796,043 $7,151,983
Rhode Island $1,530,945,956 $829,656,968 $116,863 $206,084,602 $851,843
South Carolina $4,014,695,264 $2,003,846,419 $0 $674,288,402 $1,167,982
South Dakota $579,796,034 $332,820,680 $3,800,749 $159,328,824 $327,405
Tennessee $6,971,053,079 $4,340,458,251 $7,006,782 $1,323,392,378 $5,293,080
Texas $13,214,404,197 $8,735,684,016 $16,400,930 $2,757,643,652 $3,637,188
Utah $1,355,982,016 $701,877,088 $140,906 $180,264,103 $267,120
Vermont $744,334,990 $437,944,801 $600,107 $98,598,023 $1,695,821
Virginia $3,574,171,786 $1,995,983,802 $13,611,074 $1,058,514,158 $2,750,176
Washington $4,930,041,261 $2,698,245,965 $10,910,399 $1,293,379,059 $3,759,628
West Virginia $2,019,557,347 $982,282,005 $9,001,749 $0 $0
Wisconsin $4,314,127,932 $1,959,115,766 $5,646,769 $1,175,320,659 $4,696,389
Wyoming $363,357,597 $213,973,075 $1,429,511 $34,142,257 $27,714
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
QMB Only = Qualified Medicare Beneficiaries Without Other Medicaid
QMB/ Medicaid = QMBs With Full Medicaid
SLMB Only = Specified Low-Income Beneficiaries Without Other Medicaid

Source: CMS, MSIS Report, FY 2004.

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Total Medicaid Medical Vendor Payments and Dual Eligibility Status,


2004 (Con’t)1

SLMB/
State Medicaid QDWI QI (1) QI (2) Other
National Total $4,307,421,421 $243,359 $217,035,370 $153,285 $51,496,172,532
Alabama $122,139,141 $0 $5,661,187 $79,664 $1,177,706,961
Alaska $0 $0 $0 $0 $91,509,709
Arizona $0 $0 $0 $0 $442,086,581
Arkansas $0 $219,793 $946,387 $0 $33,142,588
California $0 $68 $1,963,877 $0 $3,361,887,172
Colorado $5,963 $0 $203,923 $0 $964,395,146
Connecticut $225,520,619 $0 $540,863 $0 $726,835,981
Delaware $0 $0 $0 $0 $173,925,142
District of Columbia $10,852,595 $0 $980,889 $0 $199,449,189
Florida $451,995,102 $0 $49,787,717 $0 $2,397,388,527
Georgia $58,121,538 $0 $4,848,443 $0 $2,096,626,019
Hawaii $0 $0 $0 $0 $112,053,530
Idaho $0 $0 $0 $0 $198,840,638
Illinois $363,664,994 $0 $86,368,096 $0 $3,061,263,087
Indiana $220,274,012 $0 $832,418 $0 $593,204,636
Iowa $141,284,567 $0 $535,775 $0 $358,436,734
Kansas $16,654,868 $0 $264,421 $0 $418,769,315
Kentucky $111,728,632 $6 $871,349 $0 $342,239,202
Louisiana $1,475,519 $0 $784,091 $0 $112,268,665
Maine $38,238,724 $1,006 $1,324,604 $2,035 $397,845,244
Maryland $0 $0 $1,801,891 $0 $822,708,595
Massachusetts $0 $0 $0 $0 $2,302,377,448
Michigan $167,773,217 $12,517 $4,973,315 $65,437 $2,581,194,333
Minnesota $223,013,200 $0 $806,762 $0 $672,103,614
Mississippi $61,632,145 $887 $528,046 $0 $1,473,492,753
Missouri $144,113,748 $0 $185,166 $0 $1,075,905,374
Montana $0 $0 $0 $0 $125,372,665
Nebraska $0 $0 $0 $0 $543,293,513
Nevada $29,887,741 $0 $492,586 $0 $17,136,393
New Hampshire $16,311,953 $0 $87,587 $0 $306,442,738
New Jersey $0 $0 $1,488,796 $0 $362,686,107
New Mexico $0 $0 $0 $0 $338,795,751
New York $174,249,724 $0 $27,250,325 $3,820 $9,755,123,550
North Carolina $168,238,567 $0 $4,773,427 $0 $615,739,158
North Dakota $2,401,884 $0 $28,722 $0 $274,455,893
Ohio $308,828 $0 $8,773,647 $0 $2,472,284,828
Oklahoma $17,184,163 $0 $590,267 $2,209 $13,890,630
Oregon $93,177,180 $0 $423,435 $0 $330,432,672
Pennsylvania $474,498,156 $0 $3,469,894 $0 $1,804,511,437
Rhode Island $0 $0 $289,060 $0 $493,946,620
South Carolina $0 $292 $798,598 $0 $1,334,593,571
South Dakota $26,692,103 $0 $133,490 $120 $56,692,663
Tennessee $233,115,834 $0 $0 $0 $1,061,786,754
Texas $374,700,130 $0 $1,280,943 $0 $1,325,057,338
Utah $31,409,379 $0 $229,963 $0 $441,793,457
Vermont $5,002,198 $0 $0 $0 $200,494,040
Virginia $0 $8,790 $1,618,639 $0 $501,685,147
Washington $12,335,080 $0 $847,399 $0 $910,563,731
West Virginia $0 $0 $0 $0 $1,028,273,593
Wisconsin $177,580,212 $0 $206,046 $0 $991,562,091
Wyoming $111,839,705 $0 $43,326 $0 $1,902,009
1
Eligibles are defined as individuals who were on the Medicaid roles at least one month during the year.
SLMB/Medicaid = SLMBs with full Medicaid
QDWI = Qualified Disabled and Working Individuals
QI 1 = Qualifying Individuals (1)
QI 2 = Qualifying Individuals (2)
Other = Other Dual Eligibles, Dual Category Unknown, and Dual Status Unknown

Source: CMS, MSIS Report, FY 2004

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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. Since 1993, managed care enrollment has increased from 14.4% to over
65% of total Medicaid enrollment. In 2006, 65.3% of all Medicaid beneficiaries were enrolled in
some type of managed care program. As of June 30, 2006, all but two States (Alaska 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, 2006. DHHS, CMS, Center for Medicaid
& State Operations. *Includes data for Puerto Rico. **Approximated numbers for 1995. Total Medicaid population was
provided by the Office of the Actuary, which used CMS 2082 data to calculate average Medicaid enrollees over 1995. The
managed care population differs from the 11,619,929 reported in the 1995 report as the number represented enrollment of some
beneficiaries in more than one plan.

TYPES OF MEDICAID MANAGED CARE PLANS

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

! Health Insuring Organization (HIO): an entity that provides for or arranges for the
provision of care and contracts on a prepaid capitated risk basis to provide a
comprehensive set of services.
! Commercial Managed Care Organization (Com-MCO): a Com-MCO is a health
maintenance organization with a contract under §1876 or a Medicare+Choice
organization, a provider sponsored organization or any other private or public
organization, which meets the requirements of §1902(w). They provide
comprehensive services to commercial and/or Medicare enrollees, as well as
Medicaid enrollees.
! Medicaid-only Managed Care Organization (Mcaid-MCO): an MCO that
provides comprehensive services to Medicaid beneficiaries, but not commercial or
Medicare enrollees.
! Prepaid Inpatient Health Plan (PIHP): an entity that provides less than
comprehensive services on an at-risk basis or one that provides any benefit package
on a non-risk or other than State reimbursement Plan basis; and provides, arranges
for or otherwise has responsibility for the provision of any inpatient hospital or
institutional services.
! Prepaid Ambulatory Health Plan (PAHP): a prepaid ambulatory health plan that
provides less than comprehensive services on an at-risk or other than State Plan
reimbursement basis, and does not provide, arranges for, or otherwise has
responsibility for the provision of any inpatient hospital or institutional services.
! 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

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primary care (and sometimes additional services). This category includes those
PIHPs that act as PCCMs.
! Program for All-Inclusive Care for the Elderly (PACE): a program that provides
prepaid, capitated comprehensive health care services to the frail elderly.
! “Other” Managed Care Arrangement: An entity where the plan is not considered
a PCCM, PIHP, PAHP, Comprehensive MCO, Medicaid-only MCO, HIO, or PACE.
The most utilized of these plans are Comprehensive MCOs and Prepaid Health Plans.

Table 2-1: Medicaid Managed Care Plans

Number of Number of Enrollees


Plans
Health Insuring Organization (HIO) 4 517,537
Commercial Managed Care Organization (COM-MCO) 177 9,936,268
Medicaid-Only Managed Care Organization (Mcaid-MCO) 133 9,362,928
Primary Care Case Management (PCCM) 33 6,467,252
Prepaid Inpatient Health Plan (PIHP) 109 8,244,584
Prepaid Ambulatory Health Plan (PAHP) 43 5,752,996
Program of All-Inclusive Care for the Elderly (PACE) 35 12,500
Other 11 2,509,586
Total 545 42,803,651*
*This table provides duplicated figures by plan type. The total number of enrollees includes 12,973,245 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, 2006. DHHS, CMS, Center for Medicaid
& State Operations.

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

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Medicaid Managed Care Enrollment, As of June 30, 2006

Rank Based on
Medicaid Medicaid Managed Percent in Percent in
State Enrollment Care Enrollment Managed Care Managed Care
National Total 45,652,642 29,830,406 65.34%
Alabama 785,949 497,539 63.30% 38
Alaska 100,720 0 0.00% 51
Arizona 977,094 875,492 89.60% 9
Arkansas 635,065 527,233 83.02% 16
California 6,508,528 3,276,440 50.34% 44
Colorado 391,227 372,046 95.10% 6
Connecticut 395,624 299,052 75.59% 22
Delaware 144,619 110,601 76.48% 21
District of Columbia 137,517 93,182 67.76% 29
Florida 2,276,597 1,491,020 65.49% 33
Georgia 1,321,564 1,290,814 97.67% 4
Hawaii 203,345 162,650 79.99% 20
Idaho 171,795 139,875 81.42% 18
Illinois 1,929,200 140,100 7.26% 50
Indiana 839,101 604,891 72.09% 24
Iowa 329,637 285,163 86.51% 12
Kansas 283,383 161,600 57.03% 42
Kentucky 706,903 652,935 92.37% 7
Louisiana 969,193 689,609 71.15% 25
Maine 243,487 162,397 66.70% 31
Maryland 700,431 489,988 69.96% 26
Massachusetts 1,037,978 627,241 60.43% 41
Michigan 1,523,390 1,292,524 84.85% 15
Minnesota 583,564 371,429 63.65% 37
Mississippi 570,178 58,189 10.21% 49
Missouri 830,262 826,394 99.53% 2
Montana 82,832 55,382 66.86% 30
Nebraska 210,235 169,982 80.85% 19
Nevada 172,274 141,936 82.39% 17
New Hampshire 111,559 83,529 74.87% 23
New Jersey 858,177 595,626 69.41% 27
New Mexico 400,835 261,318 65.19% 34
New York 4,208,629 2,572,242 61.12% 40
North Carolina 1,299,624 843,441 64.90% 35
North Dakota 54,063 30,069 55.62% 43
Ohio 1,749,120 698,049 39.91% 47
Oklahoma 556,068 477,677 85.90% 14
Oregon 408,932 369,447 90.34% 8
Pennsylvania 1,816,812 1,568,237 86.32% 13
Puerto Rico 930,989 907,236 97.45% 5
Rhode Island 181,483 119,483 65.84% 32
South Carolina 690,391 139,412 20.19% 48
South Dakota 101,006 99,240 98.25% 3
Tennessee 1,190,407 1,190,407 100.00% 1
Texas 2,767,930 1,897,394 68.55% 28
Utah 208,501 181,173 86.89% 10
Vermont 133,466 86,347 64.70% 36
Virgin Islands 5,262 0 0.00% 51
Virginia 704,739 445,560 63.22% 39
Washington 990,321 858,052 86.64% 11
West Virginia 296,831 137,457 46.31% 46
Wisconsin 863,145 403,306 46.73% 45
Wyoming 62,660 0 0.00% 51

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, 2006. DHHS, CMS, Center for Medicaid & State Operations.

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Pharmaceutical Benefits Under Managed Care Plans


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

“N/A” indicates Not Applicable.


Sources: As reported by State drug program administrators in the 2007 NPC Survey.

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Medicaid Managed Care Enrollment Trends, 2001-2006


State 2001 2002 2003 2004 2005 2006
National Total 20,773,813 23,117,668 25,262,873 26,913,570 28,575,585 29,830,406
Alabama 350,485 405,090 404,797 439,832 496,190 497,539
Alaska 0 0 0 0 0 0
Arizona 527,674 697,171 808,506 806,193 885,204 875,492
Arkansas 257,662 336,111 374,067 386,395 505,942 527,233
California 2,870,514 3,191,168 3,258,787 3,258,787 3,290,851 3,276,440
Colorado 247,181 278,095 262,263 369,270 389,769 372,046
Connecticut 239,829 280,106 294,331 303,404 302,427 299,052
Delaware 83,422 87,465 86,709 99,598 106,783 110,601
District of Columbia 79,673 80,300 85,370 88,452 91,217 93,182
Florida 1,184,506 1,267,998 1,354,025 1,450,117 1,487,991 1,491,020
Georgia 878,140 1,043,154 1,212,639 1,273,133 1,319,554 1,290,814
Hawaii 127,779 132,787 141,399 145,580 160,130 162,650
Idaho 37,913 58,284 101,257 131,693 142,512 139,875
Illinois 136,497 130,988 137,682 158,869 175,000 140,100
Indiana 433,014 484,116 502,401 509,732 555,642 604,891
Iowa 206,751 227,495 243,954 262,487 274,094 285,163
Kansas 118,209 130,162 141,119 153,395 154,184 161,600
Kentucky 489,711 500,987 611,878 625,807 636,465 652,935
Louisiana 56,542 206,992 505,434 723,837 761,468 689,609
Maine 96,051 110,922 148,151 154,785 164,774 162,397
Maryland 421,355 451,307 466,688 469,998 482,749 489,988
Massachusetts 616,241 628,832 572,835 581,520 610,437 627,241
Michigan 1,023,264 1,208,803 1,314,810 1,255,067 1,290,240 1,292,524
Minnesota 322,640 368,186 362,349 361,381 377,912 371,429
Mississippi 297,916 0 0 73,445 85,197 58,189
Missouri 378,771 413,361 425,161 432,339 427,615 826,394
Montana 46,995 52,209 55,372 58,030 57,475 55,382
Nebraska 150,840 163,772 142,377 149,405 147,245 169,982
Nevada 47,518 60,823 74,923 89,846 175,043 141,936
New Hampshire 6,200 9,206 13,407 0 2,000 83,529
New Jersey 459,087 523,904 525,864 541,820 553,461 595,626
New Mexico 212,456 243,069 261,015 273,018 248,990 261,318
New York 728,709 1,099,900 1,914,794 2,341,733 2,575,175 2,572,242
North Carolina 674,133 722,089 749,152 788,943 806,634 843,441
North Dakota 25,540 30,808 35,515 33,065 32,670 30,069
Ohio 277,617 378,476 436,146 507,337 534,265 698,049
Oklahoma 299,272 338,819 338,859 354,110 473,369 477,677
Oregon 360,926 378,739 330,874 345,410 372,789 369,447
Pennsylvania 1,037,374 1,140,211 1,192,031 1,265,891 1,534,331 1,568,237
Puerto Rico 898,171 865,285 857,310 842,827 865,299 907,236
Rhode Island 111,624 117,024 119,257 124,921 125,250 119,483
South Carolina 41,716 64,272 71,195 69,791 81,964 139,412
South Dakota 79,641 85,868 90,733 95,577 98,391 99,240
Tennessee 1,426,622 1,430,966 1,304,794 1,345,131 1,349,591 1,190,407
Texas 753,613 839,798 1,065,945 1,150,773 1,339,194 1,897,394
Utah 128,898 154,784 162,364 167,338 184,829 181,173
Vermont 78,181 82,261 85,751 86,263 87,061 86,347
Virgin Islands 0 0 0 0 0 0
Virginia 291,767 323,863 262,961 398,871 421,431 445,560
Washington 766,366 829,625 854,861 834,883 816,576 858,052
West Virginia 122,230 144,911 151,515 156,468 140,584 137,457
Wisconsin 266,577 317,106 349,246 374,003 377,621 403,306
Wyoming 0 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.

Sources: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2001; 2002; 2003; 2004; 2005; 2006. DHHS, CMS, Center
for Medicaid & State Operations.

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Medicaid Managed Care Plan Type, As of June 30, 2006


Commercial Medicaid-only
State HIO MCO MCO PCCM PIHP PAHP PACE Other
National Total 4 177 133 33 109 43 35 11
Alabama 0 0 0 1 2 0 0 0
Alaska 0 0 0 0 0 0 0 1
Arizona 0 0 25 0 1 0 0 0
Arkansas 0 0 0 1 0 1 0 0
California 4 24 2 0 1 13 4 1
Colorado 0 0 2 1 6 0 1 0
Connecticut 0 2 2 0 0 0 0 0
Delaware 0 0 1 0 0 0 0 1
District of Columbia 0 0 3 0 1 0 0 0
Florida 0 13 1 1 3 5 1 2
Georgia 0 0 1 1 1 1 0 0
Hawaii 0 2 1 0 2 0 0 1
Idaho 0 0 0 1 0 0 0 0
Illinois 0 1 2 0 0 0 0 0
Indiana 0 0 5 1 0 0 0 0
Iowa 0 1 0 1 1 0 0 0
Kansas 0 0 1 1 0 0 1 0
Kentucky 0 0 1 1 0 1 0 0
Louisiana 0 0 0 1 0 0 0 0
Maine 0 0 0 1 0 0 0 0
Maryland 0 0 7 0 0 0 1 0
Massachusetts 0 2 2 1 1 0 6 0
Michigan 0 4 11 0 18 0 1 0
Minnesota 0 6 3 0 0 0 0 0
Mississippi 0 0 0 0 0 1 0 0
Missouri 0 3 4 0 0 1 1 0
Montana 0 0 0 1 0 0 0 0
Nebraska 0 1 0 1 0 0 0 1
Nevada 0 2 0 0 0 1 0 0
New Hampshire 0 0 0 0 0 1 0 0
New Jersey 0 2 3 0 0 0 0 0
New Mexico 0 2 1 0 1 0 1 0
New York 0 20 19 4 12 1 4 1
North Carolina 0 1 0 2 2 0 0 0
North Dakota 0 0 1 1 0 0 0 0
Ohio 0 0 8 0 0 0 2 0
Oklahoma 0 0 0 1 0 2 0 0
Oregon 0 2 11 1 9 8 1 1
Pennsylvania 0 11 0 1 28 1 4 0
Puerto Rico 0 15 0 0 2 0 0 0
Rhode Island 0 2 1 0 0 0 1 0
South Carolina 0 0 2 1 0 2 1 0
South Dakota 0 0 0 1 0 1 0 0
Tennessee 0 4 4 0 2 0 1 2
Texas 0 8 2 2 1 0 2 0
Utah 0 0 0 1 12 1 0 0
Vermont 0 0 1 0 0 0 0 0
Virgin Islands 0 0 0 0 0 0 0 0
Virginia 0 5 2 1 0 1 0 0
Washington 0 7 1 1 1 1 1 0
West Virginia 0 3 0 1 0 0 0 0
Wisconsin 0 34 3 0 2 0 1 0
Wyoming 0 0 0 0 0 0 0 0

HIO=Health Insuring Organization; Commercial MCO=Commercial Managed Care Organization; Medicaid-only MCO=Medicaid-only
Managed Care Organization; PCCM=Primary Care Case Management; PIHP=Prepaid Inpatient Health Plan; PAHP=Prepaid Ambulatory Health
Plans; PACE=Program for All-Inclusive Care for the Elderly.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid & State
Operations.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Managed Care Enrollment by Plan Type,


As of June 30, 2006
Commercial Medicaid-
State HIO MCO only MCO PCCM PIHP PAHP PACE Other
National Total 517,537 9,936,268 9,362,928 6,467,252 8,244,584 5,752,996 12,500 2,509,586
Alabama 0 0 0 410,881 497,539 0 0 0
Alaska 0 0 0 0 0 0 0 97,353
Arizona 0 0 875,492 0 87,664 0 0 0
Arkansas 0 0 0 519,839 0 439,126 0 0
California 517,537 2,686,811 49,380 0 144 374,093 1,826 5,192
Colorado 0 0 80,927 39,749 346,064 0 980 0
Connecticut 0 209,554 89,498 0 0 0 0 0
Delaware 0 0 98,837 0 0 0 0 11,210
District of Columbia 0 0 89,912 0 3,270 0 0 0
Florida 0 546,410 203,769 676,185 192,302 349,100 121 67
Georgia 0 0 579,001 498,188 2,461 1,290,814 0 0
Hawaii 0 110,864 50,101 0 1,569 0 0 2,129
Idaho 0 0 0 139,875 0 0 0 0
Illinois 0 80,400 59,700 0 0 0 0 0
Indiana 0 0 537,496 67,395 0 0 0 0
Iowa 0 5,156 0 138,373 285,163 0 0 0
Kansas 0 0 79,234 82,181 0 0 185 0
Kentucky 0 0 141,691 304,444 0 652,935 0 0
Louisiana 0 0 0 689,609 0 0 0 0
Maine 0 0 0 162,397 0 0 0 0
Maryland 0 0 489,838 0 0 0 150 0
Massachusetts 0 120,949 238,188 268,104 289,406 0 1,388 0
Michigan 0 258,774 670,032 0 1,292,524 0 225 0
Minnesota 0 344,528 26,901 0 0 0 0 0
Mississippi 0 0 0 0 0 58,189 0 0
Missouri 0 99,950 253,265 0 0 473,017 162 0
Montana 0 0 0 55,382 0 0 0 0
Nebraska 0 31,221 0 38,308 0 0 0 169,982
Nevada 0 79,981 0 0 0 141,936 0 0
New Hampshire 0 0 0 0 0 83,529 0 0
New Jersey 0 213,835 381,791 0 0 0 0 0
New Mexico 0 186,144 58,025 0 261,318 0 271 0
New York 0 777,335 1,745,273 17,827 13,231 6,580 2,545 9,451
North Carolina 0 7,374 0 818,685 63,347 0 0 0
North Dakota 0 0 785 29,284 0 0 0 0
Ohio 0 0 697,475 0 0 0 574 0
Oklahoma 0 0 0 6,347 0 843,846 0 0
Oregon 0 27,136 247,479 10,102 335,216 362,937 623 357,734
Pennsylvania 0 1,109,313 0 296,066 1,190,693 33,127 958 0
Puerto Rico 0 907,236 0 0 776,121 0 0 0
Rhode Island 0 48,077 71,378 0 0 0 28 0
South Carolina 0 0 79,580 49,942 0 9,564 353 0
South Dakota 0 0 0 74,957 0 99,240 0 0
Tennessee 0 390,611 799,796 0 1,190,407 0 296 1,856,468
Texas 0 524,947 342,216 939,681 307,645 0 907 0
Utah 0 0 0 46,336 249,811 151,305 0 0
Vermont 0 0 86,347 0 0 0 0 0
Virgin Islands 0 0 0 0 0 0 0 0
Virginia 0 267,564 116,837 61,159 0 320,338 0 0
Washington 0 465,874 19,464 3,794 858,052 63,320 226 0
West Virginia 0 137,457 0 22,162 0 0 0 0
Wisconsin 0 298,767 103,220 0 637 0 682 0
Wyoming 0 0 0 0 0 0 0 0
* 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, 2006. DHHS, CMS, Center for Medicaid & State
Operations.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Managed Care Enrollment by Payment Arrangement,


As of June 30, 2006*
Fee-For- Physician FFS/Some
Service Risk –Based Non-Risk Services Administrative Risk-Based
State (FFS) Capitation Capitation Capitation Services Fee Capitation Other
National Total 7,088,452 32,018,214 1,426,172 9,413 1,856,468 307,645 97,287
Alabama 410,881 497,539 - - - - -
Alaska 97,353** - - - - - -
Arizona - 963,156 - - - - -
Arkansas 519,839 439,126 - - - - -
California - 3,634,983 - - - - -
Colorado 39,749 415,484 12,487 - - - -
Connecticut - 299,052 - - - - -
Delaware 11,210** 98,837 - - - - -
District of Columbia - 93,182 - - - - -
Florida 694,266 1,129,024 62,213** - - - 82,451
Georgia 498,188 1,872,276 - - - - -
Hawaii - 164,663** - - - - -
Idaho 139,875 - - - - - -
Illinois - 140,100 - - - - -
Indiana 67,395 537,496 - - - - -
Iowa 138,373 290,319 - - - - -
Kansas 82,181 79,419 - - - - -
Kentucky 304,444 794,626 - - - - -
Louisiana 689,609 - - - - - -
Maine 162,397 - - - - - -
Maryland - 489,988 - - - - -
Massachusetts 268,104 649,931 - - - - -
Michigan - 2,221,555 - - - - -
Minnesota - 371,429 - - - - -
Mississippi - 58,189 - - - - -
Missouri - 826,394 - - - - -
Montana 55,382 - - - - - -
Nebraska 208,290** 31,221 - - - - -
Nevada - 221,917 - - - - -
New Hampshire - - 83,529 - - - -
New Jersey - 595,626 - - - - -
New Mexico - 505,758 - - - - -
New York 5,850 2,566,392** - - - - -
North Carolina 818,685 70,721 - - - - -
North Dakota 29,284 785 - - - - -
Ohio - 698,049 - - - - -
Oklahoma - 843,846 6,347 - - - -
Oregon 367,836** 973,391 - - - - -
Pennsylvania 296,066 2,334,091 - - - - -
Puerto Rico - 1,683,357 - - - - -
Rhode Island - 119,483 - - - - -
South Carolina 49,942 80,084 - 9,413 - - -
South Dakota 74,957 99,240 - - - - -
Tennessee - 1,190,703 1,190,407 - 1,856,468** - -
Texas 924,845 868,070 - - - 307,645 14,836
Utah 46,336 329,927 71,189 - - - -
Vermont - 86,347 - - - - -
Virginia 61,159 704,739 - - - - -
Washington 3,794 1,406,936 - - - - -
West Virginia 22,162 137,457 - - - - -
Wisconsin - 403,306 - - - - -
Wyoming - - - - - - -

*Individual State totals may not sum to total managed care enrollment (pages 2-29 and 2-31) because State totals include individuals enrolled in
more than one plan type, including dental, mental, and long-term care.
**Includes managed care entities whose structure is “other” and not considered a PCCM, MCO, PIHP, PAHP, or PACE.

Source: Medicaid Managed Care Enrollment Report: Summary Statistics as of June 30, 2006. DHHS, CMS, Center for Medicaid & State
Operation.

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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.

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

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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.

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.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Section 1915(b) and 1115 Waivers

Date Originally
State Official Program Name Waiver Authority
Approved

Alabama Alabama Patient 1st 1915(b) 1915(b) 10/02/1996

Alabama Alabama Family Planning 1115 1115 07/01/2000

Alabama Alabama Hurricane Katrina Relief Program 1115 Katrina 09/22/2005

Alaska Alaska Denali KidCare 1115 1115 09/24/2004

Alaska Alaska Non Emergency Transportation 1915b 1915(b) 11/18/2005

Arizona Arizona Health Care Cost Containment System 1115 07/13/1982

Arizona Arizona HIFA 1115 1115 HIFA 12/12/2001

Arizona Arizona Hurricane Katrina Relief 1115 Katrina 03/06/2006

Arkansas Arkansas Independent Choices 1115 11/22/2000

Arkansas Arkansas RX Senior Care 1115 1115 Pending

Arkansas Arkansas ARKidsB 1115 1115 08/19/1997

Arkansas Primary Care Physician Program


Arkansas 1915(b) 06/11/1993
1915(b)

Arkansas Non Emergency Transportation Waiver


Arkansas 1915(b) 02/19/1998
1915(b)

Arkansas Arkansas TEFRA 1115 10/17/2002

Arkansas Independent Choices - Cash and


Arkansas 1115 10/9/1998
Counseling

Arkansas Arkansas Hurricane Katrina Relief Program 1115 Katrina 09/28/2005

Arkansas Arkansas Family Planning 1115 1115 Family Planning 06/18/1996

Arkansas Arkansas Safety Net Benefit Program HIFA 1115 1115 03/03/2006

California California Parental Coverage Expansion 1115 HIFA 01/25/2002

California California In Home Supportive Services (IHSS) 1115 7/31/2004

California California Geographic Managed Care Sacramento 1915(b) 11/22/1996

California California Two Plan Model 1915(b) 10/17/1998

California Medi-Cal Hospital Uninsured Care


California 1115 08/24/2005
1115 Waiver

California - ICF/DD-CN (Intermediate Care


California 1915(b) 08/17/2001
Facility/Developmentally Disabled..)

Specialty Mental Health Service Consolidation


California 1915(b) 11/16/2000
- Medi-Cal

Medicaid Demonstration Project for Los


California 1115 04/15/1996
Angeles County
California Family Planning, Access, Care and
California 1115 12/01/1999
Treatment (PACT) 1115

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Section 1915(b) and 1115 Waivers (Cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

California California Health Insuring Organizations (HIOs) 1915(b) 07/10/2003

California California Health Plan of San Mateo 1915(b) 12/30/1987

California California CalOPTIMA 1915(b) 10/01/1995

California Fee For Service Managed Care


California 1915(b) 02/28/1997
Network

California California Health San Diego 1915(b) 10/07/1998

California California Selective Provider Contracting1915(b) 1915(b) 07/21/1982

California Solano Partnership Health Plan


California 1915(b) 05/01/1994
1915(b)

California Children's Services and Sacramento


California 1915(b) 08/13/2003
Dental Geographic Managed Care

California Santa Barbara Health Initiative


California 1915(b) 01/01/1987
1915(b)

California Primary Care Case Management


California 1915(b) 12/20/1982
1915(b)

California California Central Coast Alliance for Health 1915(b) 01/01/1996

California California Hurricane Katrina Relief Program 1115 Katrina 12/07/2005

Colorado Colorado Family Planning 1115 1115 withdrawn

Colorado Community Mental Health Services Program 1915(b) 03/06/1998

Colorado Consumer Directed Attendant Support


Colorado 1115 08/10/2001
Project

Colorado Adult Prenatal Coverage in CHP+


Colorado HIFA 1115 09/27/2002
HIFA

Connecticut Connecticut Medicaid Transfer of Assets Reform 1115 pending

Connecticut Connecticut ConnPACE Program Rx 1115 pending

Connecticut Connecticut HUSKY Plan Part A 1915(b) 07/20/1995

Delaware Delaware Pharmacy Assistance Program 1115 1115 Disapproved

Delaware Delaware Healthy Adult Program HIFA 1115 Disapproved

Delaware Delaware Diamond State Health Plan 1115 1115 05/17/1995

District of Columbia District of Columbia 1115 for Childless Adults 1115 03/07/2002

D.C. Program to Enhance Mediciad Access for


District of Columbia 1115 01/19/2001
Low-Income HIV-Infected Individuals

District of Columbia DC Coverage Initiative HIFA 1115 Pending

District of Columbia Hurricane Katrina Relief


District of Columbia 1115 Katrina 09/28/2005
Program

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

Florida Coordinated Non Emergency


Florida 1915(b) 06/07/2001
Transportation 1915(b)

Florida Managed Care Waiver (Medipass)


Florida 1915(b) 01/1990
1915(b)

Florida Florida Family Planning 1115 1115 08/23/1998

Alzheimer's Medicaid Home and Community


Florida 1915(b)(c) 02/19/2004
Based Waiver Program

Florida Comprehensive Adult Day Health Care


Florida 1915(b)(c) 03/18/2003
Program

Florida Florida Consumer Directed Care Plus 1115 10/09/1998

Florida Statewide Inpatient Psychiatric Program


Florida 1915(b) 06/08/2001
(SIPP)

Florida Program for All Inclusive Care for


Florida 1115 N/A
Children 1115

Florida Florida Medicaid Reform 1115 1115 10/19/2005

Florida Florida MEDS-ADS 115 115 11/22/2005

Florida Florida Eligibility Privatization 1115 1115 Pending

Florida Florida Hurricane Katrina Relief Program 1115 Katrina 09/23/2005

Georgia Georgia Better Health Care Program 1915(b) 1915(b) 07/14/1993

Georgia HIV/AIDS 1115 N/A

MH/MR Preadmission Screening and Resident


Georgia 1915(b) 04/01/1994
Review (PASRR) Program

Georgia Georgia Non Emergency Transportation 1915(b) 1915(b) 09/08/1999

Georgia Georgia Hurricane Katrina Relief Program 1115 Katrina 09/28/2005

Hawaii Hawaii Prescription Plus 1115 1115 Disapproved

Hawaii Hawaii QUEST 1115 1115 07/16/1993

Idaho Idaho Access Card 1115 Waiver 1115 11/04/2004

Idaho Idaho Healthy Connections 1915(b) Waiver 1915(b) 09/17/1993

Idaho Idaho Hurricane Katrina Relief Program 1115 Katrina 09/27/2005

Illinois Illinois KidCare Parent Coverage HIFA 1115 HIFA 10/13/2002

Precription Drug Benefit for Illinois' Low


Illinois 1115 Pharmacy 01/28/2002
Income Seniors 1115

Illinois Illinois Family Planning 1115 1115 Family Planning 06/23/2003

Indiana Healthy Indiana Plan (HIP) 1115 Pending

Indiana Indiana Hoosier Healthwise 1915(b) 1915(b) 09/13/1993

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

2-41
National Pharmaceutical Council Pharmaceutical Benefits 2007

Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

Indiana Indiana Hurricane Katrina Relief Program 1115 Katrina 10/21/2005

Indiana Indiana Family Planning 1115 Demonstration 1115 Family Planning Pending

Iowa Iowa Family Planning 1115 01/10/2006

Iowa IowaCare 1115 1115 06/30/2005

Iowa Iowa Plan 1915(b) 12/09/1998

Kansas Kansas Managed Care Program 1915(b) 1915(b) 6/24/1998

Kansas Children & Family Services Behavioral


Kansas 1915(b) 5/27/2005
and Rehabilitative Treatment Services Waiver

Kentucky Non Emergency Medical


Kentucky 1915(b) 02/01/1996
Transportation Program

Kentucky Kentucky Health Care Partnership 1115 1115 12/09/1993

Louisiana Louisiana Community Care Statewide 1915(b) 1915(b) 06/29/1998

Louisiana Louisiana Models of Excellence Waiver 1915(b) 1915(b) 11/11/2002

Louisiana Louisiana HIFA 1115 withdrawn

Louisiana Louisiana Hurricane Katrina Relief Program 1115 Katrina 11/10/2005

Louisiana Louisiana Family Planning Waiver 1115 1115 Family Planning 06/06/2006

Maine MaineCare for Childless Adults HIFA 1115 1115 09/13/2002

Maine Maine - HIV/AIDS 1115 02/24/2000

Maryland Maryland Health Choice 1115 1115 10/30/1996

Maryland Maryland Funding for Pregnant Women 1115 1115 Pending

Maryland Maryland Community Choice 1115 N/A

Maryland Maryland Hurricane Katrina Relief Program 1115 Katrina 11/10/2005

Massachusetts Massachusetts MassHealth 1115 1115 04/24/1995

Massachusetts Massachusetts Family Planning 1115 Under Review

Massachusetts MA Community First 1115 N/A

Michigan Michigan EPIC Ex 1115 1115 Pharmacy 12/12/2005

Michigan Comprehensive Health Care Program


Michigan 1915(b) 10/10/1996
1915 (b)

Michigan Michigan Adult Benefits Waiver HIFA 1115 HIFA 01/16/2004

Michigan Specialty Services and Supports


Michigan 1915(b)(c) 06/26/1998
Waiver Program

Michigan Michigan Modernizing Medicaid 1115 Pending

Michigan Plan First! Family Planning Program


Michigan 1115 Family Planning 03/01/2006
1115

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

Minnesota Minnesota HIFA 1115 1115 HIFA Inactive

Minnesota Prepaid Medical Assistance Project


Minnesota 1115 04/27/1995
Plus

Consolidated Chemical Dependency Treatment


Minnesota 1915(b) 01/01/1988
Fund (CCDTF)

Minnesota Minnesota Senior Care Project 1915(b) 06/3020/05

Minnesota Minnesota Katrina Relief 1115 Katrina N/A

Minnesota Minnesota Care SCHIP 1115 1115 06/13/2001

Minnesota Minnesota Family Planning Project 1115 06/20/2004

Mississippi Non Emergency Transportation


Mississippi 1915(b) 04/11/2003
1915(b)

Mississippi Mississippi Family Planning 1115 1115 01/31/2003

Mississippi Healthier Mississippi 1115 09/10/2004

Mississippi Mississippi Hurricane Katrina Relief Program 1115 Katrina 09/28/2005

Missouri Missouri Managed Care Plus 1915(b) 1915(b) 10/01/1995

Missouri Missouri Family Planning 1115 Waiver 1115 Family Planning Under Review

Missouri Missouri Managed Care Plus (MC+) 1115 1115 04/29/1998

Montana Montana Passport to Health 1915(b) 1915(b) 08/31/1993

Montana Montana Basic Medicaid for Able Bodied Adults 1115 01/30/2004

Montana Montana Katrina Relief Program 1115 Katrina 03/20/2006

Nebraska Health Connection MH/SA Waiver 1915(b) 07/01/1995

Nevada Nevada Non Emergency Transportation 1915(b) 1915(b) 06/22/2004

Nevada Nevada Hurricane Katrina Relief Program 1115 Katrina 11/23/2005

Nevada Nevada HIFA 1115 1115 11/02/2006

New Hampshire New Hampshire Disease Management 1915(b) 1915(b) Pending

New Hampshire New Hampshire Granite Care Select 1915(b) 6/26/2007

New Jersey Family Coverage Under SCHIP for


New Jersey 1115 SCHIP 01/18/2001
Families and Program Coverage

New Jersey New Jersey Care 2000+ 1915(b) 11/2/1999

New Jersey Personal Preference Program


New Jersey 1115 10/9/1998
(Cash/Counseling)

New Mexico New Mexico 1115 HIFA 1115 HIFA 08/23/2002

New Mexico New Mexico Family Planning 1115 Family Planning 08/01/1997

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

New Mexico New Mexico SCHIP Waiver 1115 SCHIP 01/11/1999

New Mexico New Mexico Salud 1915(b) 1915(b) 07/01/1997

New Mexico NM Behavioral Health Waiver 1915(b) 06/24/2005

New York New York Partnership Plan 1115 07/15/1997

New York Non Emergency Transportation


New York 1915(b) 01/17/1996
Program 1915 b

New York Federal-State Health Reform


New York 1115 09/29/2006
Partnership (FSHRP)

North Carolina ACCESS HealthCare Connection


North Carolina 1915(b) 01/01/1991
1915(b)

North Carolina North Carolina Family Planning 1115 1115 Family Planning 11/05/2004

North Carolina - Piedmont Behavioral Health


North Carolina 1915(b)(c) 10/06/2004
Care

North Carolina North Carolina Katrina Waiver 1115 Katrina 02/17/2006

Ohio Ohio PremierCare 1915(b) 1915(b) 05/23/2001

Ohio Ohio Hurricane Katrina Relief Program 1115 Katrina 12/07/2005

Oklahoma Oklahoma Non Emergency Transportation 1915(b) 06/02/2004

Oklahoma Oklahoma SoonerCare 1115 1115 10/12/1995

Oklahoma Oklahoma SoonerCare Family Planning 1115 Family Planning 11/05/2004

Oregon Oregon Non Emergency Transportation 1915(b) 1915(b) 09/01/1994

Oregon Oregon Family Planning 1115 1115 Family Planning 10/01/1998

Oregon Oregon Health Plan 1115 HIFA 10/15/2002

Oregon OR Independent Choices 1115 11/22/00

Oregon Oregon Hurricane Katrina Relief Waiver 1115 Katrina 03/06/2006

Pennsylvania Pennsylvania Access Plus 1915(b) 1915(b) 12/03/2004

Pennsylvania Pennsylvania Health Choices 1915(b) 1915(b) 07/31/2002

Pennsylvania PA Family Planning Waiver 1115 1115 Family Planning 5/11/2007

Pennsylvania Lancaster County Health Plan


Pennsylvania 1915(b) N/A
1915(b)

Rhode Island Rhode Island RIteCare 1115 1115 11/01/1993

Rhode Island Rhode Island Rx + 1115 1115 Pending

Rhode Island Rhode Island Katrina Waiver 1115 Katrina 02/17/2006

Prescription Drug Benefit for South Carolina's


South Carolina 1115 Pharmacy 07/30/2002
Low Income Seniors

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

South Carolina South Carolina Health Connections 1115 1115 Pending

South Carolina South Carolina Hurricane Katrina Relief 1115 Katrina 10/20/2005

South Carolina South Carolina Family Planning Demonstration FP 1115 N/A

South Dakota South Dakota PRIME 1915(b) 1915(b) 03/26/1996

Tennessee Tennessee TennCare 1115 1115 05/30/2002

Tennessee TennCare for Medicaid Medicare


Tennessee 1915(b) 06/28/2002
Duals 1915(b)

Tennessee Tennessee Hurricane Katrina Relief Program 1115 Katrina 10/06/2005

Texas Texas PsychMed 1115 1115 Inactive

Texas Texas LoneStar Select I 1915(b) 1915(b) 07/01/1994

Texas Access Reform STAR MMC Consolidated


Texas 1915(b) 08/10/2001
1915(b)

Texas LoneStar Select II Contracting Program 1915(b) 1915(b) 03/10/1995

Texas Texas NorthStar Behavioral Health 1915(b) 09/07/1999

Texas Texas Star+Plus 1915(b) 01/30/1998

Texas Texas Disease Management 1915(b) 08/9/2005

Texas Texas 3 Share HIFA Demonstration 1115 HIFA Pending

Texas Texas Family Planning 1115 1115 Family Planning 12/21/2006

Texas Tex Kat Program 1115 Katrina 09/15/2005

Texas Texas SCHIP Cost Share 1115 1115 Pending

Utah Utah Primary Care Network PCN 1115 1115 02/08/2002

Utah Non-Emergency Transportation Waiver


Utah 1915(b) 09/19/2000
1915(b)

Home Health Services for San Juan & Grand


Utah 1915(b) N/A
Counties

Utah Utah - Prepaid Mental Health Plan 1915(b) 12/20/2001

Utah Choice of Health Care Delivery Program


Utah 1915(b) 03/23/1982
1915(b)

Utah Utah Katrina Relief Program 1115 Katrina 03/20/2006

Vermont Vermont Health Access Plan 1115 1115 07/28/1995

Vermont VT Long-Term Care Plan 1115 06/13/2005

Vermont Vermont Global Commitment to Healthcare 1115 09/27/2005

Virginia Viriginia Family Planning 1115 1115 Family Planning 07/22/2002

Virginia Virginia Medallion I 1915(b) 1915(b) 12/23/1991

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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Section 1915(b) and 1115 Waivers (cont.)

Date Originally
State Official Program Name Waiver Authority
Approved

Virginia Virginia Medallion II 1915(b) 1915(b) 09/28/1998

Virginia Non Emergency Transportation Waiver


Virginia 1915(b) 08/23/2005
1915(b)

Virginia Virginia FAMIS MOMS 1115 HIFA 06/30/2005

Virginia Virginia Katrina Relief Program 1115 Katrina 03/20/2006

Washington Washington Healthy Options 1915(b) 1915(b) 10/01/1993

Washington Washington Premium Proposal 1115 1115 02/13/2004

Washington Selective Hospital Contracting


Washington 1915(b) 04/01/1988
Program 1915(b)

Washington Washington Mental Health 1915(b) 03/01/2002

Washington Washington Disease Management 1915(b) 03/03/2003

Washington Washington Family Planning 1115 1115 Family Planning 03/06/2001

West Virginia West Virginia Mountain Health Trust 1915(b) 1915(b) 04/29/1996

West Virginia Physician Assured Access System


West Virginia 1915(b) 06/01/1992
PAAS 1915(b)

West Virginia West Virginia Dental and Vision Waiver 1115 Pending

Wisconsin Wisconsin Family Planning 1115 1115 Family Planning 06/14/2002

Wisconsin Wisconsin Badger Care 1115 1115 01/22/1999

Wisconsin Allied Services for Healthy Foster


Wisconsin 1915(b) 07/01/2004
Children 1915(b)

Wisconsin Wisconsin Family Care Concurrent b/c Waiver 1915(b)(c) 06/01/2001

Wisconsin Wisconsin Hurricane Katrina Relief Program 1115 Katrina 03/24/2006

Wyoming Wyoming Katrina Waiver 1115 Katrina 02/17/2006

Wyoming WY Family Planning 1115 Demonstration 1115 Family Planning Pending

Wyoming WY HIFA Demonstration 1115 HIFA Pending

Source: CMS, Medicaid Waivers and Demonstrations List, www.cms.hhs.gov/MedicaidStWaivProgDemoPGI/MWDL/list.asp

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Section 3:
State Characteristics

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STATE CHARACTERISTICS
Presented in Section 3 of the Compilation is State-by-State information on several topics. The
Section begins with a series of tables showing select State demographic characteristics including
age composition and racial/Hispanic status. Next, 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 2006 American
Community Survey conducted by the U.S. Bureau of the Census. Unfortunately, individuals
residing in “group quarters” are not included in this survey. Hence, the total population figure
(and the corresponding figures for each State) presented in this table is inconsistent with the
population total in the table showing insurance status.

The data on insurance status was compiled from the Current Population Survey, 2006 Annual
Social and Economic Supplement, 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 2006
Annual Social and Economic Supplement to the Current Population Survey, have been included in
this year’s Compilation.

HRSA’s Bureau of Health Professions, National Center for Health Workforce Analysis is
responsible for compiling the Area Resource File (ARF), an important annual data file for
researchers, planners, policymakers, and others seeking information on the health professions
workforce, health care facilities, health care utilization and expenditures, etc. at a variety of
geographic levels. Physician data come from the 2007 ARF. Nursing data come from HRSA’s
2004 National Sample Survey of Registered Nurses, the most comprehensive source of statistics
on individuals with active registered nurse licenses in the U.S., whether or not they are currently
employed in nursing.

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

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Age Demographics, 2006*


Total Percent Ages Percent Percent Percent
State Population 19 and under Ages 20-44 Ages 45-64 Ages 65+
National Total 299,398,484 27.4% 35.1% 25.0% 12.4%
Alabama 4,599,030 27.0% 33.9% 25.7% 13.4%
Alaska 670,053 29.9% 37.1% 26.2% 6.8%
Arizona 6,166,318 29.0% 35.4% 22.8% 12.8%
Arkansas 2,810,872 27.3% 33.8% 25.0% 13.9%
California 36,457,549 29.1% 37.0% 23.2% 10.8%
Colorado 4,753,377 27.2% 37.4% 25.4% 10.0%
Connecticut 3,504,809 26.1% 33.6% 26.9% 13.4%
Delaware 853,476 26.8% 34.3% 25.5% 13.4%
District of Columbia 581,530 23.2% 41.3% 23.2% 12.3%
Florida 18,089,888 24.6% 33.3% 25.3% 16.8%
Georgia 9,363,941 29.0% 37.2% 24.0% 9.7%
Hawaii 1,285,498 25.7% 35.0% 25.3% 14.0%
Idaho 1,466,465 29.8% 34.4% 24.2% 11.5%
Illinois 12,831,970 27.9% 35.6% 24.5% 12.0%
Indiana 6,313,520 27.7% 34.6% 25.2% 12.4%
Iowa 2,982,085 26.8% 33.0% 25.6% 14.6%
Kansas 2,764,075 28.1% 34.1% 24.9% 12.9%
Kentucky 4,206,074 26.3% 35.0% 26.0% 12.8%
Louisiana 4,287,768 28.5% 34.2% 25.1% 12.2%
Maine 1,321,574 23.8% 32.4% 29.2% 14.6%
Maryland 5,615,727 27.1% 35.2% 26.1% 11.6%
Massachusetts 6,437,193 25.4% 35.3% 26.1% 13.3%
Michigan 10,095,643 27.4% 34.0% 26.1% 12.5%
Minnesota 5,167,101 27.2% 35.0% 25.7% 12.1%
Mississippi 2,910,540 29.1% 34.0% 24.5% 12.4%
Missouri 5,842,713 26.9% 34.2% 25.5% 13.3%
Montana 944,632 25.8% 32.0% 28.4% 13.8%
Nebraska 1,768,331 28.1% 33.9% 24.7% 13.3%
Nevada 2,495,529 27.6% 36.7% 24.6% 11.1%
New Hampshire 1,314,895 25.4% 34.0% 28.3% 12.4%
New Jersey 8,724,560 26.5% 34.6% 26.0% 12.9%
New Mexico 1,954,599 29.0% 33.9% 24.7% 12.4%
New York 19,306,183 26.3% 35.2% 25.4% 13.1%
North Carolina 8,856,505 27.0% 35.5% 25.3% 12.2%
North Dakota 635,867 26.4% 33.5% 25.5% 14.6%
Ohio 11,478,006 26.9% 33.7% 26.1% 13.3%
Oklahoma 3,579,212 27.7% 34.2% 24.9% 13.2%
Oregon 3,700,758 25.6% 34.6% 26.8% 12.9%
Pennsylvania 12,440,621 25.5% 32.6% 26.7% 15.2%
Rhode Island 1,067,610 25.8% 34.6% 25.8% 13.9%
South Carolina 4,321,249 27.0% 34.2% 26.0% 12.8%
South Dakota 781,919 27.8% 32.7% 25.3% 14.2%
Tennessee 6,038,803 26.4% 35.0% 25.9% 12.7%
Texas 23,507,783 30.5% 36.9% 22.7% 9.9%
Utah 2,550,063 34.2% 37.5% 19.4% 8.8%
Vermont 623,908 24.4% 32.9% 29.4% 13.3%
Virginia 7,642,884 26.4% 36.1% 25.8% 11.6%
Washington 6,395,798 26.4% 35.7% 26.3% 11.5%
West Virginia 1,818,470 24.0% 32.7% 28.0% 15.3%
Wisconsin 5,556,506 26.4% 34.4% 26.1% 13.0%
Wyoming 515,004 26.5% 33.6% 27.7% 12.2%
This information was taken from the 2006 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 2006.
*Sum of percentages may not equal 100 percent due to rounding.
Source: U.S. Department of Commerce, Bureau of the Census, 2006 Population Estimates.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Race Demographics, 2006*


% Native
% American Hawaiian & % Indicated 2
Total Indian and Oth Pacif or More
State Population % White % Black % Asian Alaska Native Islndr Races
National Total 299,398,484 80.1% 12.8% 4.4% 1.0% 0.2% 1.6%
Alabama 4,599,030 71.2% 26.3% 0.9% 0.5% 0.0% 0.9%
Alaska 670,053 70.7% 3.7% 4.6% 15.4% 0.6% 4.9%
Arizona 6,166,318 87.3% 3.8% 2.4% 4.8% 0.2% 1.6%
Arkansas 2,810,872 81.1% 15.7% 1.0% 0.8% 0.1% 1.3%
California 36,457,549 76.9% 6.7% 12.4% 1.2% 0.4% 2.4%
Colorado 4,753,377 90.1% 4.1% 2.6% 1.1% 0.1% 1.8%
Connecticut 3,504,809 84.6% 10.2% 3.4% 0.4% 0.1% 1.4%
Delaware 853,476 74.5% 20.9% 2.8% 0.4% 0.1% 1.4%
District of Columbia 581,530 38.4% 56.5% 3.2% 0.4% 0.1% 1.4%
Florida 18,089,888 80.2% 15.8% 2.2% 0.4% 0.1% 1.3%
Georgia 9,363,941 65.8% 29.9% 2.8% 0.3% 0.1% 1.1%
Hawaii 1,285,498 28.6% 2.5% 40.0% 0.5% 9.1% 19.4%
Idaho 1,466,465 95.2% 0.7% 1.1% 1.4% 0.1% 1.5%
Illinois 12,831,970 79.3% 15.0% 4.2% 0.3% 0.1% 1.1%
Indiana 6,313,520 88.3% 8.9% 1.3% 0.3% 0.0% 1.1%
Iowa 2,982,085 94.6% 2.5% 1.6% 0.4% 0.0% 1.0%
Kansas 2,764,075 89.1% 6.0% 2.2% 1.0% 0.1% 1.7%
Kentucky 4,206,074 90.2% 7.5% 1.0% 0.2% 0.0% 1.0%
Louisiana 4,287,768 65.4% 31.7% 1.4% 0.6% 0.0% 0.9%
Maine 1,321,574 96.7% 0.8% 0.9% 0.6% 0.0% 1.0%
Maryland 5,615,727 63.6% 29.5% 4.9% 0.3% 0.1% 1.5%
Massachusetts 6,437,193 86.5% 6.9% 4.9% 0.3% 0.1% 1.3%
Michigan 10,095,643 81.2% 14.3% 2.4% 0.6% 0.0% 1.5%
Minnesota 5,167,101 89.3% 4.5% 3.5% 1.2% 0.1% 1.5%
Mississippi 2,910,540 60.9% 37.1% 0.8% 0.5% 0.0% 0.7%
Missouri 5,842,713 85.1% 11.5% 1.4% 0.5% 0.1% 1.3%
Montana 944,632 90.8% 0.4% 0.6% 6.4% 0.1% 1.6%
Nebraska 1,768,331 91.8% 4.4% 1.7% 1.0% 0.1% 1.2%
Nevada 2,495,529 81.7% 7.9% 6.0% 1.4% 0.5% 2.6%
New Hampshire 1,314,895 95.8% 1.1% 1.9% 0.3% 0.0% 1.0%
New Jersey 8,724,560 76.4% 14.5% 7.4% 0.3% 0.1% 1.3%
New Mexico 1,954,599 84.6% 2.5% 1.3% 9.8% 0.1% 1.6%
New York 19,306,183 73.7% 17.4% 6.9% 0.5% 0.1% 1.5%
North Carolina 8,856,505 74.0% 21.7% 1.9% 1.3% 0.1% 1.1%
North Dakota 635,867 91.9% 0.8% 0.7% 5.4% 0.0% 1.1%
Ohio 11,478,006 84.9% 12.0% 1.5% 0.2% 0.0% 1.3%
Oklahoma 3,579,212 78.3% 7.8% 1.7% 8.0% 0.1% 4.1%
Oregon 3,700,758 90.5% 1.9% 3.6% 1.4% 0.3% 2.4%
Pennsylvania 12,440,621 85.7% 10.7% 2.4% 0.2% 0.0% 1.0%
Rhode Island 1,067,610 88.7% 6.3% 2.7% 0.6% 0.1% 1.5%
South Carolina 4,321,249 68.5% 29.0% 1.1% 0.4% 0.1% 0.9%
South Dakota 781,919 88.4% 0.9% 0.7% 8.5% 0.0% 1.4%
Tennessee 6,038,803 80.4% 16.9% 1.3% 0.3% 0.1% 1.0%
Texas 23,507,783 82.7% 11.9% 3.4% 0.7% 0.1% 1.2%
Utah 2,550,063 93.5% 1.0% 2.0% 1.3% 0.8% 1.5%
Vermont 623,908 96.7% 0.7% 1.1% 0.4% 0.0% 1.1%
Virginia 7,642,884 73.3% 19.9% 4.8% 0.3% 0.1% 1.6%
Washington 6,395,798 84.8% 3.6% 6.6% 1.6% 0.5% 3.0%
West Virginia 1,818,470 94.9% 3.3% 0.6% 0.2% 0.0% 0.9%
Wisconsin 5,556,506 90.0% 6.0% 2.0% 0.9% 0.0% 1.1%
Wyoming 515,004 94.5% 0.9% 0.7% 2.5% 0.1% 1.4%
This information was taken from the 2006 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 2006.
*Sum of percentages may not equal 100 percent due to rounding. Source: U.S. Department of Commerce, Bureau of the Census, 2006 Population Estimates.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Hispanic Demographics, 2006

State Total Population Hispanic Population Percent Hispanic


National Total 299,398,484 44,321,038 14.8%
Alabama 4,599,030 113,890 2.5%
Alaska 670,053 37,548 5.6%
Arizona 6,166,318 1,803,378 29.2%
Arkansas 2,810,872 141,053 5.0%
California 36,457,549 13,074,156 35.9%
Colorado 4,753,377 934,413 19.7%
Connecticut 3,504,809 391,935 11.2%
Delaware 853,476 53,835 6.3%
District of Columbia 581,530 47,774 8.2%
Florida 18,089,888 3,646,499 20.2%
Georgia 9,363,941 703,246 7.5%
Hawaii 1,285,498 99,663 7.8%
Idaho 1,466,465 138,870 9.5%
Illinois 12,831,970 1,886,933 14.7%
Indiana 6,313,520 300,857 4.8%
Iowa 2,982,085 114,700 3.8%
Kansas 2,764,075 237,426 8.6%
Kentucky 4,206,074 85,938 2.0%
Louisiana 4,287,768 124,481 2.9%
Maine 1,321,574 13,529 1.0%
Maryland 5,615,727 337,341 6.0%
Massachusetts 6,437,193 511,014 7.9%
Michigan 10,095,643 393,281 3.9%
Minnesota 5,167,101 196,135 3.8%
Mississippi 2,910,540 53,381 1.8%
Missouri 5,842,713 164,194 2.8%
Montana 944,632 23,818 2.5%
Nebraska 1,768,331 130,304 7.4%
Nevada 2,495,529 610,052 24.4%
New Hampshire 1,314,895 29,872 2.3%
New Jersey 8,724,560 1,364,696 15.6%
New Mexico 1,954,599 860,688 44.0%
New York 19,306,183 3,139,456 16.3%
North Carolina 8,856,505 593,896 6.7%
North Dakota 635,867 10,637 1.7%
Ohio 11,478,006 267,750 2.3%
Oklahoma 3,579,212 247,450 6.9%
Oregon 3,700,758 379,038 10.2%
Pennsylvania 12,440,621 526,976 4.2%
Rhode Island 1,067,610 117,701 11.0%
South Carolina 4,321,249 151,289 3.5%
South Dakota 781,919 16,773 2.1%
Tennessee 6,038,803 194,706 3.2%
Texas 23,507,783 8,385,139 35.7%
Utah 2,550,063 286,113 11.2%
Vermont 623,908 7,135 1.1%
Virginia 7,642,884 479,530 6.3%
Washington 6,395,798 581,357 9.1%
West Virginia 1,818,470 16,767 0.9%
Wisconsin 5,556,506 258,696 4.7%
Wyoming 515,004 35,729 6.9%
This information was taken from the 2006 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 2006.

Source: U.S. Department of Commerce, Bureau of the Census, 2006 Population Estimates.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Insurance Status - Populations, 2006*

Total Medicaid Medicare Military Privately Not


State Population Population Population Insurance Insured Insured
National Total 296,824,000 38,281,000 40,343,000 10,547,000 201,690,000 46,995,000
Alabama 4,532,000 614,000 683,000 220,000 3,107,000 689,000
Alaska 659,000 80,000 58,000 91,000 428,000 109,000
Arizona 6,269,000 1,012,000 796,000 266,000 3,770,000 1,311,000
Arkansas 2,758,000 422,000 413,000 136,000 1,662,000 521,000
California 36,208,000 5,775,000 3,998,000 940,000 22,758,000 6,791,000
Colorado 4,803,000 421,000 496,000 190,000 3,392,000 826,000
Connecticut 3,462,000 406,000 499,000 92,000 2,639,000 325,000
Delaware 862,000 82,000 130,000 42,000 637,000 105,000
District of Columbia 569,000 117,000 65,000 12,000 381,000 66,000
Florida 18,062,000 1,791,000 3,083,000 984,000 11,318,000 3,828,000
Georgia 9,347,000 1,152,000 986,000 546,000 6,083,000 1,659,000
Hawaii 1,255,000 133,000 170,000 121,000 937,000 110,000
Idaho 1,475,000 172,000 200,000 56,000 1,019,000 227,000
Illinois 12,644,000 1,381,000 1,562,000 202,000 9,209,000 1,776,000
Indiana 6,337,000 643,000 826,000 184,000 4,773,000 748,000
Iowa 2,919,000 413,000 432,000 82,000 2,215,000 307,000
Kansas 2,723,000 320,000 405,000 90,000 2,033,000 335,000
Kentucky 4,106,000 602,000 602,000 159,000 2,738,000 639,000
Louisiana 4,212,000 659,000 659,000 98,000 2,468,000 921,000
Maine 1,315,000 236,000 236,000 68,000 929,000 122,000
Maryland 5,613,000 473,000 473,000 245,000 4,212,000 776,000
Massachusetts 6,335,000 827,000 827,000 84,000 4,685,000 657,000
Michigan 9,970,000 1,311,000 1,311,000 157,000 7,447,000 1,043,000
Minnesota 6,149,000 602,000 696,000 125,000 4,021,000 475,000
Mississippi 2,892,000 497,000 425,000 132,000 1,712,000 600,000
Missouri 5,800,000 677,000 949,000 173,000 4,114,000 772,000
Montana 931,000 108,000 138,000 48,000 630,000 160,000
Nebraska 1,767,000 152,000 235,000 117,000 1,326,000 217,000
Nevada 2,535,000 174,000 334,000 101,000 1,684,000 496,000
New Hampshire 1,309,000 88,000 183,000 42,000 918,000 150,000
New Jersey 8,660,000 676,000 1,126,000 85,000 6,364,000 1,341,000
New Mexico 1,943,000 308,000 273,000 114,000 1,081,000 445,000
New York 19,040,000 3,542,000 2,756,000 190,000 2,649,000 2,662,000
North Carolina 8,851,000 1,190,000 1,270,000 344,000 5,714,000 1,585,000
North Dakota 617,000 54,000 82,000 20,000 473,000 75,000
Ohio 11,319,000 1,596,000 1,591,000 348,000 8,339,000 1,138,000
Oklahoma 3,492,000 443,000 518,000 273,000 2,145,000 661,000
Oregon 3,715,000 401,000 506,000 106,000 2,534,000 665,000
Pennsylvania 12,345,000 1,473,000 1,986,000 164,000 9,275,000 1,203,000
Rhode Island 1,054,000 222,000 150,000 28,000 774,000 91,000
South Carolina 4,226,000 600,000 647,000 234,000 2,747,000 672,000
South Dakota 770,000 82,000 120,000 52,000 568,000 91,000
Tennessee 5,920,000 816,000 917,000 390,000 3,920,000 809,000
Texas 23,236,000 2,826,000 2,830,000 792,000 13,770,000 5,704,000
Utah 2,537,000 235,000 241,000 73,000 1,825,000 442,000
Vermont 620,000 115,000 89,000 18,000 442,000 63,000
Virginia 7,538,000 564,000 908,000 790,000 5,432,000 1,006,000
Washington 6,318,000 797,000 825,000 463,000 4,592,000 746,000
West Virginia 1,814,000 313,000 341,000 81,000 1,161,000 245,000
Wisconsin 5,476,000 643,000 722,000 144,000 4,224,000 481,000
Wyoming 516,000 46,000 79,000 32,000 378,000 75,000
*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, 2007 Annual Social and Economic
Supplement.

3-8
National Pharmaceutical Council Pharmaceutical Benefits 2007

Insurance Status - Percentages, 2006*

% Covered by % Covered by
Total % Covered by % Covered by Military Private
State Population Medicaid Medicare Insurance Insurance % Not Insured
National Total 296,824,000 12.9% 13.6% 3.6% 67.9% 15.8%
Alabama 4,532,000 13.5% 15.1% 4.9% 68.6% 15.2%
Alaska 659,000 12.1% 8.8% 13.8% 64.9% 16.5%
Arizona 6,269,000 16.1% 12.7% 4.2% 60.1% 20.9%
Arkansas 2,758,000 15.3% 15.0% 4.9% 60.3% 18.9%
California 36,208,000 15.9% 11.0% 2.6% 62.9% 18.8%
Colorado 4,803,000 8.8% 10.3% 4.0% 70.6% 17.2%
Connecticut 3,462,000 11.7% 14.4% 2.7% 76.2% 9.4%
Delaware 862,000 9.5% 15.1% 4.9% 73.9% 12.2%
District of Columbia 569,000 20.6% 11.4% 2.1% 67.0% 11.6%
Florida 18,062,000 9.9% 17.1% 5.4% 62.7% 21.2%
Georgia 9,347,000 12.3% 10.5% 5.8% 65.1% 17.7%
Hawaii 1,255,000 10.6% 13.5% 9.6% 74.7% 8.8%
Idaho 1,475,000 11.7% 13.6% 3.8% 69.1% 15.4%
Illinois 12,644,000 10.9% 12.4% 1.6% 72.8% 14.0%
Indiana 6,337,000 10.1% 13.0% 2.9% 75.3% 11.8%
Iowa 2,919,000 14.1% 14.8% 2.8% 75.9% 10.5%
Kansas 2,723,000 11.8% 14.9% 3.3% 74.7% 12.3%
Kentucky 4,106,000 14.7% 14.7% 3.9% 66.7% 15.6%
Louisiana 4,212,000 15.6% 15.6% 2.3% 58.6% 21.9%
Maine 1,315,000 17.9% 17.9% 5.2% 70.6% 9.3%
Maryland 5,613,000 8.4% 8.4% 4.4% 75.0% 13.8%
Massachusetts 6,335,000 13.1% 13.1% 1.3% 74.0% 10.4%
Michigan 9,970,000 13.1% 13.1% 1.6% 74.7% 10.5%
Minnesota 6,149,000 9.8% 11.3% 2.0% 65.4% 7.7%
Mississippi 2,892,000 17.2% 14.7% 4.6% 59.2% 20.7%
Missouri 5,800,000 11.7% 16.4% 3.0% 70.9% 13.3%
Montana 931,000 11.6% 14.8% 5.2% 67.7% 17.2%
Nebraska 1,767,000 8.6% 13.3% 6.6% 75.0% 12.3%
Nevada 2,535,000 6.9% 13.2% 4.0% 66.4% 19.6%
New Hampshire 1,309,000 6.7% 14.0% 3.2% 70.1% 11.5%
New Jersey 8,660,000 7.8% 13.0% 1.0% 73.5% 15.5%
New Mexico 1,943,000 15.9% 14.1% 5.9% 55.6% 22.9%
New York 19,040,000 18.6% 14.5% 1.0% 13.9% 14.0%
North Carolina 8,851,000 13.4% 14.3% 3.9% 64.6% 17.9%
North Dakota 617,000 8.8% 13.3% 3.2% 76.7% 12.2%
Ohio 11,319,000 14.1% 14.1% 3.1% 73.7% 10.1%
Oklahoma 3,492,000 12.7% 14.8% 7.8% 61.4% 18.9%
Oregon 3,715,000 10.8% 13.6% 2.9% 68.2% 17.9%
Pennsylvania 12,345,000 11.9% 16.1% 1.3% 75.1% 9.7%
Rhode Island 1,054,000 21.1% 14.2% 2.7% 73.4% 8.6%
South Carolina 4,226,000 14.2% 15.3% 5.5% 65.0% 15.9%
South Dakota 77,000 10.6% 15.6% 6.8% 73.7% 11.8%
Tennessee 5,920,000 13.8% 15.5% 6.6% 66.2% 13.7%
Texas 23,236,000 12.2% 12.2% 3.4% 59.3% 24.5%
Utah 2,537,000 9.3% 9.5% 2.9% 71.9% 17.4%
Vermont 620,000 18.5% 14.4% 2.9% 71.3% 10.2%
Virginia 7,538,000 7.5% 12.0% 10.5% 72.1% 13.3%
Washington 6,318,000 12.6% 13.1% 7.3% 72.7% 11.8%
West Virginia 1,814,000 17.3% 18.8% 4.5% 64.0% 13.5%
Wisconsin 5,476,000 11.7% 13.2% 2.6% 77.1% 8.8%
Wyoming 516,000 8.9% 15.3% 6.2% 73.3% 14.5%
*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, 2007 Annual Social and Economic
Supplement.

3-9
National Pharmaceutical Council Pharmaceutical Benefits 2007

Poverty Status - Populations, 2006

Population Population Population Population


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 296,450,000 36,460,000 54,190,000 63,117,000 90,469,000
Alabama 4,532,000 650,000 970,000 1,103,000 1,571,000
Alaska 658,000 58,000 91,000 114,000 167,000
Arizona 6,256,000 902,000 1,372,000 1,555,000 2,274,000
Arkansas 2,748,000 487,000 717,000 831,000 1,169,000
California 36,160,000 4,427,000 6,885,000 8,125,000 11,639,000
Colorado 4,797,000 466,000 714,000 844,000 1,234,000
Connecticut 3,457,000 275,000 422,000 485,000 735,000
Delaware 858,000 80,000 108,000 136,000 214,000
District of Columbia 569,000 104,000 129,000 146,000 193,000
Florida 18,029,000 2,068,000 3,271,000 3,842,000 5,601,000
Georgia 9,334,000 1,172,000 1,712,000 2,086,000 2,831,000
Hawaii 1,254,000 116,000 180,000 215,000 300,000
Idaho 1,472,000 141,000 262,000 313,000 479,000
Illinois 12,633,000 1,338,000 1,966,000 2,378,000 3,428,000
Indiana 6,334,000 674,000 979,000 1,151,000 1,747,000
Iowa 2,913,000 301,000 456,000 564,000 810,000
Kansas 2,719,000 349,000 478,000 568,000 793,000
Kentucky 4,106,000 690,000 972,000 1,111,000 1,499,000
Louisiana 4,206,000 713,000 1,026,000 1,200,000 1,595,000
Maine 1,313,000 134,000 213,000 252,000 381,000
Maryland 5,607,000 469,000 676,000 758,000 1,103,000
Massachusetts 6,324,000 758,000 1,021,000 1,144,000 1,641,000
Michigan 9,953,000 1,323,000 1,856,000 2,112,000 2,884,000
Minnesota 5,415,000 422,000 673,000 781,000 1,204,000
Mississippi 2,887,000 596,000 793,000 925,000 1,296,000
Missouri 5,797,000 659,000 1,018,000 1,189,000 1,800,000
Montana 930,000 125,000 195,000 209,000 310,000
Nebraska 1,765,000 180,000 276,000 320,000 484,000
Nevada 2,530,000 241,000 372,000 471,000 740,000
New Hampshire 1,308,000 71,000 129,000 155,000 250,000
New Jersey 8,650,000 762,000 1,092,000 1,249,000 1,791,000
New Mexico 1,939,000 328,000 450,000 514,000 726,000
New York 19,021,000 2,668,000 3,763,000 4,364,000 6,072,000
North Carolina 8,847,000 1,225,000 1,758,000 2,123,000 3,132,000
North Dakota 615,000 70,000 97,000 114,000 176,000
Ohio 11,297,000 1,371,000 2,037,000 2,257,000 3,257,000
Oklahoma 3,489,000 531,000 834,000 949,000 1,309,000
Oregon 3,705,000 439,000 671,000 776,000 1,133,000
Pennsylvania 12,326,000 1,397,000 1,950,000 2,261,000 3,302,000
Rhode Island 1,054,000 110,000 164,000 187,000 266,000
South Carolina 4,224,000 474,000 819,000 980,000 1,486,000
South Dakota 770,000 82,000 129,000 158,000 238,000
Tennessee 5,916,000 879,000 1,297,000 1,499,000 204,000
Texas 23,208,000 3,816,000 5,543,000 6,281,000 8,734,000
Utah 2,536,000 235,000 391,000 477,000 778,000
Vermont 618,000 48,000 82,000 96,000 142,000
Virginia 7,532,000 651,000 971,000 1,195,000 1,819,000
Washington 6,310,000 502,000 880,000 1,001,000 1,522,000
West Virginia 1,810,000 277,000 414,000 469,000 673,000
Wisconsin 5,471,000 555,000 842,000 992,000 1,425,000
Wyoming 516,000 51,000 75,000 86,000 141,000
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and
Economic Supplement.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Poverty Status - Percentages, 2006

Percent Percent Percent Percent


Total Below 100% Below 135% Below 150% Below 200%
State Population FPL* FPL* FPL* FPL*
National Total 296,450,000 12.3% 18.3% 21.3% 30.5%
Alabama 4,532,000 14.3% 21.4% 24.3% 34.7%
Alaska 658,000 8.8% 13.8% 17.3% 25.4%
Arizona 6,256,000 14.4% 21.9% 24.9% 36.3%
Arkansas 2,748,000 17.7% 26.1% 30.2% 42.5%
California 36,160,000 12.2% 19.0% 22.5% 32.2%
Colorado 4,797,000 9.7% 14.9% 17.6% 25.7%
Connecticut 3,457,000 8.0% 12.2% 14.0% 21.3%
Delaware 858,000 9.3% 12.6% 15.9% 24.9%
District of Columbia 569,000 18.3% 22.7% 25.7% 33.9%
Florida 18,029,000 11.5% 18.1% 21.3% 31.1%
Georgia 9,334,000 12.6% 18.3% 22.3% 30.3%
Hawaii 1,254,000 9.3% 14.4% 17.1% 23.9%
Idaho 1,472,000 9.6% 17.8% 21.3% 32.5%
Illinois 12,633,000 10.6% 15.6% 18.8% 27.1%
Indiana 6,334,000 10.6% 15.5% 18.2% 27.6%
Iowa 2,913,000 10.3% 15.7% 19.4% 27.8%
Kansas 2,719,000 12.8% 17.6% 20.9% 29.2%
Kentucky 4,106,000 16.8% 23.7% 27.1% 36.5%
Louisiana 4,206,000 17.0% 24.4% 28.5% 37.9%
Maine 1,313,000 10.2% 16.2% 19.2% 29.0%
Maryland 5,607,000 8.4% 12.1% 13.5% 19.7%
Massachusetts 6,324,000 12.0% 16.1% 18.1% 25.9%
Michigan 9,953,000 13.3% 18.6% 21.2% 29.0%
Minnesota 5,415,000 7.8% 12.4% 14.4% 22.2%
Mississippi 2,887,000 20.6% 27.5% 32.0% 44.9%
Missouri 5,797,000 11.4% 17.6% 20.5% 31.1%
Montana 930,000 13.4% 21.0% 22.5% 33.3%
Nebraska 1,765,000 10.2% 15.6% 18.1% 27.4%
Nevada 2,530,000 9.5% 14.7% 18.6% 29.2%
New Hampshire 1,308,000 5.4% 9.9% 11.9% 19.1%
New Jersey 8,650,000 8.8% 12.6% 14.4% 20.7%
New Mexico 1,939,000 16.9% 23.2% 26.5% 37.4%
New York 19,021,000 14.0% 19.8% 22.9% 31.9%
North Carolina 8,847,000 13.8% 19.9% 24.0% 35.4%
North Dakota 615,000 11.4% 15.8% 18.5% 28.6%
Ohio 11,297,000 12.1% 18.0% 20.0% 28.8%
Oklahoma 3,489,000 15.2% 23.9% 27.2% 37.5%
Oregon 3,705,000 11.8% 18.1% 20.9% 30.6%
Pennsylvania 12,326,000 11.3% 15.8% 18.3% 26.8%
Rhode Island 1,054,000 10.4% 15.6% 17.7% 25.2%
South Carolina 4,224,000 11.2% 19.4% 23.2% 35.2%
South Dakota 770,000 10.6% 16.8% 20.5% 30.9%
Tennessee 5,916,000 14.9% 21.9% 25.3% 3.4%
Texas 23,208,000 16.4% 23.9% 27.1% 37.6%
Utah 2,536,000 9.3% 15.4% 18.8% 30.7%
Vermont 618,000 7.8% 13.3% 15.5% 23.0%
Virginia 7,532,000 8.6% 12.9% 15.9% 24.2%
Washington 6,310,000 8.0% 13.9% 15.9% 24.1%
West Virginia 1,810,000 15.3% 22.9% 25.9% 37.2%
Wisconsin 5,471,000 10.1% 15.4% 18.1% 26.0%
Wyoming 516,000 9.9% 14.5% 16.7% 27.3%
*FPL- Federal Poverty Level

Source: U.S. Department of Commerce, Bureau of the Census, Current Population Survey, 2007 Annual Social and
Economic Supplement.

3-11
National Pharmaceutical Council Pharmaceutical Benefits 2007

Employment Status, 2006*

Total Civilian Population Unemployment


State Population Labor Force Unemployed Rate
National Total 228,815,000 151,428,000 7,001,000 4.6%
Alabama 3,542,000 2,200,000 79,000 3.6%
Alaska 485,000 347,000 23,000 6.7%
Arizona 4,625,000 2,977,000 123,000 4.1%
Arkansas 2,149,000 1,365,000 72,000 5.3%
California 27,438,000 17,902,000 873,000 4.9%
Colorado 3,630,000 2,652,000 115,000 4.3%
Connecticut 2,728,000 1,844,000 79,000 4.3%
Delaware 659,000 440,000 16,000 3.6%
District of Columbia 468,000 316,000 19,000 6.0%
Florida 14,221,000 8,989,000 296,000 3.3%
Georgia 6,978,000 4,742,000 220,000 4.6%
Hawaii 969,000 643,000 15,000 2.4%
Idaho 1,093,000 749,000 26,000 3.4%
Illinois 9,799,000 6,613,000 298,000 4.5%
Indiana 4,830,000 3,271,000 163,000 5.0%
Iowa 2,310,000 1,664,000 61,000 3.7%
Kansas 2,090,000 1,466,000 66,000 4.5%
Kentucky 3,242,000 2,039,000 117,000 5.7%
Louisiana 3,229,000 1,990,000 80,000 4.0%
Maine 1,061,000 711,000 33,000 4.6%
Maryland 4,319,000 3,009,000 117,000 3.9%
Massachusetts 5,078,000 3,404,000 170,000 5.0%
Michigan 7,796,000 5,081,000 351,000 6.9%
Minnesota 3,996,000 2,939,000 117,000 4.0%
Mississippi 2,176,000 1,307,000 89,000 6.8%
Missouri 4,490,000 3,032,000 147,000 4.8%
Montana 739,000 494,000 16,000 3.2%
Nebraska 1,343,000 974,000 29,000 3.0%
Nevada 1,897,000 1,295,000 54,000 4.2%
New Hampshire 1,041,000 737,000 25,000 3.4%
New Jersey 6,767,000 4,518,000 209,000 4.6%
New Mexico 1,472,000 935,000 40,000 4.2%
New York 15,070,000 9,499,000 426,000 4.5%
North Carolina 6,731,000 4,465,000 214,000 4.8%
North Dakota 493,000 358,000 12,000 3.2%
Ohio 8,870,000 5,934,000 325,000 5.5%
Oklahoma 2,699,000 1,720,000 69,000 4.0%
Oregon 2,906,000 1,899,000 103,000 5.4%
Pennsylvania 9,776,000 6,306,000 296,000 4.7%
Rhode Island 842,000 577,000 30,000 5.1%
South Carolina 3,309,000 2,126,000 138,000 6.5%
South Dakota 593,000 431,000 14,000 3.2%
Tennessee 4,663,000 2,990,000 155,000 5.2%
Texas 17,224,000 11,487,000 566,000 4.9%
Utah 1,815,000 1,311,000 38,000 2.9%
Vermont 503,000 361,000 13,000 3.6%
Virginia 5,804,000 3,999,000 120,000 3.0%
Washington 4,938,000 3,327,000 166,000 5.0%
West Virginia 1,453,000 807,000 40,000 4.9%
Wisconsin 4,325,000 3,063,000 145,000 4.7%
Wyoming 399,000 285,000 9,000 3.2%
*This information was compiled from the U.S. Department of Labor, Bureau of Labor Statistics News Release on State
and Regional Unemployment, 2006 Annual Averages, released on March 2, 2007. 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, March 2, 2007.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid/Medicare Certified Facilities, 2006

Skilled Nursing ICF-MR Home Health Rural Health


State Hospitals Facilities Facilities Agencies Clinics
National Total 6,016 15,047 6,444 8,955 3,689
Alabama 128 228 6 145 65
Alaska 24 15 0 16 0
Arizona 100 134 12 83 13
Arkansas 105 214 41 174 66
California 419 1,202 1,141 682 255
Colorado 92 193 3 137 47
Connecticut 45 244 120 86 0
Delaware 11 39 2 19 0
District of Columbia 14 19 112 24 0
Florida 237 678 105 791 149
Georgia 179 355 11 101 99
Hawaii 27 44 18 14 2
Idaho 49 75 65 50 0
Illinois 212 699 312 488 226
Indiana 158 493 530 206 54
Iowa 125 414 141 80 139
Kansas 159 267 31 135 186
Kentucky 120 292 9 104 131
Louisiana 233 290 520 222 94
Maine 45 113 20 29 41
Maryland 64 227 4 49 0
Massachusetts 114 440 6 125 1
Michigan 179 403 1 383 162
Minnesota 145 384 218 213 87
Mississippi 115 168 13 56 152
Missouri 142 486 18 169 320
Montana 64 92 1 36 43
Nebraska 96 195 4 71 120
Nevada 45 46 9 69 6
New Hampshire 30 73 1 36 15
New Jersey 108 365 9 49 0
New Mexico 52 67 42 68 12
New York 242 655 580 188 0
North Carolina 135 419 332 169 100
North Dakota 49 83 67 25 64
Ohio 220 946 433 472 12
Oklahoma 156 283 87 212 40
Oregon 59 121 1 57 0
Pennsylvania 238 711 210 320 56
Rhode Island 15 87 5 21 0
South Carolina 78 174 93 69 100
South Dakota 66 93 1 43 60
Tennessee 152 302 83 139 58
Texas 544 1,075 875 1,790 327
Utah 49 85 15 69 17
Vermont 15 40 2 12 18
Virginia 113 258 34 184 56
Washington 10 234 14 59 170
West Virginia 66 122 66 61 62
Wisconsin 144 372 19 128 47
Wyoming 29 33 2 27 17

Sources: OSCAR Report 10. Facility Counts: Active Providers. CMS, Center for Medicaid and State Operations, August 1,
2007 (hospitals and rural health clinics); http://www.cms.hhs.gov/HealthPlanRepFileData/05_Inst.asp (SNF and ICF-MR);
http://www.medicare.gov/Download/DownloadDB.asp (Home Health Compare).

3-13
National Pharmaceutical Council Pharmaceutical Benefits 2007

Licensed Pharmacies, As of June 30, 2006*

Hospital/ Independent Out-of-State or


Total Institutional Community Chain Pharmacies Non-Resident
State Pharmacies Pharmacies Pharmacies (Four or More) Pharmacies
National Total 85,300 7,655 17,250 16,591 15,059
Alabama 1,915 164 697 617 437
Alaska 118 20 (G) 218
Arizona 1,626 97 126 879 436
Arkansas 1,213 177 252
California 7,120 583 293
Colorado 908 398
Connecticut 651 (D) 51(D) 182 (D) 469 (D) 373 (D)
Delaware 550 13 25 147 365
District of Columbia 131 14 53 64 0
Florida 6,841 (F) 1,945 (O) (O) 419
Georgia 3,689 205 (M) (M)
Hawaii 220 212
Idaho 744 59 259 (A, E) 286
Illinois 3,077 234 2,668 (A) (A) 296
Indiana 1,396 437
Iowa 1,301 130 (F) 790 (A, F) (A) 358
Kansas 837 176 341 283 434
Kentucky 1,687 (P) 143 571 490 402
Louisiana 1,568 202 681 430 226
Maine 306 42 309
Maryland 1,581 (H) 86 (R) 352 726 368
Massachusetts 1,089 (I) 250 740 0
Michigan 2,547 150
Minnesota 1,601 249 584 987 373
Mississippi 962 130 220
Missouri 1,788 (J) 113 240 533 418
Montana 322 89 139 94 302
Nebraska 498 174 (K)
Nevada 836 268
New Hampshire 295 33 40 202 345
New Jersey 2,026
New Mexico 750 61 136 168 136
New York 4,812 470 (N) 2,211 2,124 331
North Carolina 2,215 (F) 174 590 1,048 341
North Dakota 629 47 150 39 369
Ohio 3,068 (L) 235 556 1,599 406
Oklahoma 1,550 168 (D) 930 (A) (A) 452
Oregon 1,196 124 448 624 469
Pennsylvania 3,244 0
Rhode Island 188 23 38 5 327
South Carolina 1,198 470
South Dakota 612 45 133 90 344
Tennessee 1,999 454 550 874 83
Texas 6,116 (B) 599 1,767 2,457 370
Utah 786 132 412 (A) (A) 342
Vermont 363 18 154 133 211
Virginia 1,600 509
Washington 1,378 120 (C) 1,177 769 383
West Virginia 572 (I) 393
Wisconsin 3,409 (Q) 0
Wyoming 140 (F) 30 354
*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: 2007 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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LEGEND

A — Chains included in independent community pharmacies figure.


B — Also licenses 923 nuclear, public health, clinic, ambulatory surgical center, and HMO pharmacies.
C — Includes 121 hospital, 35 nursing home, 19 home infusion, 7 nuclear, 42 HMO, and 18 other pharmacies.
D — Approximately.
E — Plus 28 limited service and 75 parenteral admixture pharmacies.
F — In-state.
G — Drug rooms.
H — Total includes other areas not listed: clinic, correctional, HMO, nursing home, IV, nuclear, research, and other.
105 pharmacies have waiver (specialty permits) Board issued 735 distributor permits.
I — Total also includes home IV and mail-order pharmacies.
J — Includes the following pharmacy categories: 9 long-term care, 3 home health, 10 radiopharmaceutical, 2 renal
dialysis, 2 sterile pharmaceuticals, 2 consultant pharmacy, 0 medical gas, 0 shared services, and 357 with multiple
classes.
K — Nebraska licenses out-of-state pharmacies.
L — Includes 272 nuclear, clinic, fluid therapy, mail-order, specialty, and pharmacies serving nursing homes only.
M — 2,202 (2,165 independent and chain pharmacies, 14 nuclear pharmacies, 18 prison pharmacies, 5 clinic
pharmacies, and 2 pharmacy schools).
N — 15 nuclear pharmacies.
O — For Florida, 4,477 are primarily community pharmacies but cannot be broken down by chain or independent.
P — Includes 9 charitable pharmacies.
Q — As of May 15, 2006.
R — Includes HMO clinics, Home Health, and Hospitals.

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Physicians, 2005

Primary Care
Office Based Physicians Percent
Physicians Physicians Physicians (Non-Federal, Office Based
(Non-Federal, Per 1,000 (Non-Federal, Percent Patient Care, Physicians
State Patient Care) Population Patient Care) Office Based Office Based)* Primary Care
National Total 690,592 2.3 554,482 80% 287,322 42%
Alabama 8,802 1.9 7,288 83% 3,953 45%
Alaska 1,286 1.9 1,181 92% 851 66%
Arizona 10,962 1.8 9,522 87% 4,756 43%
Arkansas 5,102 1.8 4,257 83% 2,668 52%
California 82,591 2.3 70,273 85% 36,665 44%
Colorado 10,653 2.3 9,155 86% 5,050 47%
Connecticut 10,989 3.1 8,424 77% 3,650 33%
Delaware 1,863 2.2 1,514 81% 749 40%
District of Columbia 3,395 5.8 2,240 66% 899 26%
Florida 38,575 2.2 33,796 88% 15,809 41%
Georgia 17,583 1.9 14,921 85% 7,976 45%
Hawaii 3,380 2.7 2,922 86% 1,539 46%
Idaho 2,237 1.6 2,086 93% 1,340 60%
Illinois 30,715 2.4 23,408 76% 12,575 41%
Indiana 12,249 1.8 10,218 83% 5,877 48%
Iowa 4,838 1.6 3,894 80% 2,463 51%
Kansas 5,431 2.0 4,486 83% 2,679 49%
Kentucky 8,645 2.1 7,248 84% 3,941 46%
Louisiana 10,332 2.3 8,257 80% 4,120 40%
Maine 3,145 2.4 2,656 84% 1,561 50%
Maryland 18,222 3.3 14,215 78% 6,403 35%
Massachusetts 24,236 3.8 17,485 72% 7,544 31%
Michigan 21,522 2.1 16,210 75% 8,726 41%
Minnesota 12,938 2.5 10,386 80% 6,938 54%
Mississippi 4,618 1.6 3,855 83% 2,162 47%
Missouri 12,242 2.1 9,400 77% 4,562 37%
Montana 1,904 2.0 1,763 93% 1,071 56%
Nebraska 3,772 2.1 2,996 79% 1,929 51%
Nevada 4,089 1.7 3,721 91% 1,923 47%
New Hampshire 3,084 2.4 2,594 84% 1,449 47%
New Jersey 23,821 2.7 18,868 79% 8,342 35%
New Mexico 3,941 2.0 3,259 83% 1,992 51%
New York 64,498 3.3 44,677 69% 19,534 30%
North Carolina 19,195 2.2 15,760 82% 8,494 44%
North Dakota 1,377 2.2 1,160 84% 768 56%
Ohio 26,420 2.3 20,203 76% 10,637 40%
Oklahoma 5,405 1.5 4,514 84% 2,508 46%
Oregon 8,575 2.4 7,449 87% 4,245 50%
Pennsylvania 31,516 2.5 23,548 75% 11,102 35%
Rhode Island 3,363 3.1 2,478 74% 1,142 34%
South Carolina 8,804 2.1 7,255 82% 4,087 46%
South Dakota 1,501 1.9 1,327 88% 835 56%
Tennessee 14,031 2.4 11,710 83% 6,182 44%
Texas 42,896 1.9 35,459 83% 18,666 44%
Utah 4,609 1.9 3,805 83% 2,075 45%
Vermont 1,961 3.2 1,479 75% 932 48%
Virginia 17,556 2.3 14,363 82% 7,948 45%
Washington 14,458 2.3 12,462 86% 7,526 52%
West Virginia 3,666 2.0 2,860 78% 1,588 43%
Wisconsin 12,730 2.3 10,688 84% 6,376 50%
Wyoming 869 1.7 787 91% 515 59%
*Primary care physicians include General Practice, General Family Practice, General Internal Medicine, Ob-Gyn, and General Pediatrics.
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, Area Resource File,
June 2007.

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Other Providers, 2004/2006

# FTE # FTE
Registered Registered Nurses* Pharmacists** Pharmacists**
State Nurses* per 1,000 population (Licensed by State) per 1,000 population
National Total 2,056,960 7.0 372,032 1.2
Alabama 31,736 7.0 7,596 1.7
Alaska 5,839 8.9 660 1.0
Arizona 35,036 5.7 7,672 1.2
Arkansas 18,318 6.7 3,920 1.4
California 175,183 4.9 33,922 0.9
Colorado 29,268 6.4 5,807 1.2
Connecticut 26,698 7.6 4,637 1.3
Delaware 7,194 8.7 1,479 1.7
District of Columbia 10,194 17.6 1,341 2.3
Florida 117,447 6.8 21,540 1.2
Georgia 58,910 6.6 11,284 1.2
Hawaii 7,978 6.3 1,660 1.3
Idaho 7,401 5.3 1,722 1.2
Illinois 95,490 7.5 14,458 1.1
Indiana 46,677 7.5 8,481 1.3
Iowa 27,451 9.3 5,156 1.7
Kansas 21,328 7.8 3,709 1.3
Kentucky 33,435 8.1 5,713 1.4
Louisiana 32,183 7.2 6,375 1.5
Maine 12,799 9.7 1,546 1.2
Maryland 39,725 7.2 7,820 1.4
Massachusetts 59,337 9.2 9,902 1.5
Michigan 70,630 7.0 11,322 1.1
Minnesota 40,454 7.9 6,484 1.3
Mississippi 21,768 7.5 3,483 1.2
Missouri 49,174 8.5 7,486 1.3
Montana 6,520 7.0 1,639 1.7
Nebraska 15,990 9.2 3,004 1.7
Nevada 12,733 5.5 8,475 3.4
New Hampshire 13,669 10.5 2,073 1.6
New Jersey 59,691 6.9 13,927 1.6
New Mexico 11,811 6.2 2,379 1.2
New York 148,653 7.7 19,798 1.0
North Carolina 68,030 8.0 10,494 1.2
North Dakota 6,391 10.1 2,122 3.3
Ohio 93,830 8.2 15,185 1.3
Oklahoma 21,651 6.1 4,953 1.4
Oregon 24,459 6.8 4,125 1.1
Pennsylvania 106,912 8.6 18,707 1.5
Rhode Island 9,133 8.5 1,906 1.8
South Carolina 26,921 6.4 5,824 1.3
South Dakota 7,857 10.2 1,504 1.9
Tennessee 48,252 8.2 7,588 1.3
Texas 129,442 5.7 22,723 1.0
Utah 13,056 5.4 2,358 0.9
Vermont 5,006 8.1 885 1.4
Virginia 47,904 6.4 9,142 1.2
Washington 38,740 6.2 7,541 1.2
West Virginia 14,125 7.8 3,024 1.7
Wisconsin 40,954 7.4 6,433 1.2
Wyoming 3,577 7.1 1,048 2.0
*FTE- Full-time equivalent employees as of 2004. Excludes 4,261 RNs for whom full-time/part-time status is unknown.
**As of June 30, 2006
Source: USDHHS, HRSA, Bureau of Health Professions, National Center for Health Workforce Information & Analysis, 2004 National
Sample Survey of Registered Nurses. 2007 National Association of Boards of Pharmacy, Survey of Pharmacy Law.

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Section 4:
Pharmacy Program
Characteristics

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THE MEDICAID DRUG PROGRAM

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

MEDICAID PRESCRIPTION DRUG REIMBURSEMENT

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

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

Multiple-Source Drugs

A multiple-source drug is one that is marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different proprietary
names or under a proprietary name and without such a name.

A specific upper limit for a multiple-source drug may be established if the following requirements are
met:

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

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.

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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.

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Drug Expenditures Trends, 2004-2005*

State 2004 2005 % Change 2004-2005


National Total $40,065,314,592 $43,077,457,835 7.5%
Alabama $594,477,767 $606,578,572 2.0%
Alaska $115,273,427 $127,315,710 10.5%
Arizona $5,367,723 $5,486,350 2.2%
Arkansas $380,446,105 $419,350,865 10.2%
California $4,817,590,501 $5,187,275,034 7.7%
Colorado $264,117,222 $285,371,981 8.1%
Connecticut $448,164,399 $496,715,211 10.9%
Delaware $122,552,631 $122,026,857 -0.4%
District of Columbia $106,453,411 $105,948,589 -0.5%
Florida $2,472,756,351 $2,503,151,114 1.2%
Georgia $1,213,833,584 $1,184,915,057 -2.9%
Hawaii $117,149,907 $119,852,050 2.3%
Idaho $153,351,334 $168,780,832 10.1%
Illinois $1,751,647,987 $1,716,361,486 -2.0%
Indiana $703,941,201 $751,525,376 6.8%
Iowa $371,927,390 $412,274,229 10.9%
Kansas $274,203,278 $296,283,292 8.1%
Kentucky $802,700,636 $794,519,116 -1.0%
Louisiana $944,175,123 $1,082,597,269 14.7%
Maine $281,693,429 $282,039,741 0.1%
Maryland $490,288,888 $578,238,275 17.9%
Massachusetts $987,294,716 $1,067,378,270 8.1%
Michigan $874,729,802 $965,368,582 10.4%
Minnesota $394,600,158 $441,908,835 12.0%
Mississippi $668,097,090 $665,504,688 -0.4%
Missouri $1,119,655,471 $1,246,144,317 11.3%
Montana $99,334,048 $105,154,540 5.9%
Nebraska $231,317,773 $228,576,569 -1.2%
Nevada $127,920,160 $134,564,289 5.2%
New Hampshire $128,552,504 $133,253,555 3.7%
New Jersey $1,016,646,964 $1,158,553,486 14.0%
New Mexico $117,451,186 $116,252,520 -1.0%
New York $4,782,579,851 $5,253,655,620 9.9%
North Carolina $1,575,005,070 $1,790,399,967 13.7%
North Dakota $59,722,091 $64,157,312 7.4%
Ohio $1,819,580,108 $1,981,230,721 8.9%
Oklahoma $416,314,217 $500,420,840 20.2%
Oregon $245,180,310 $261,373,083 6.6%
Pennsylvania $952,341,486 $1,009,804,038 6.0%
Rhode Island $166,067,772 $173,884,102 4.7%
South Carolina $673,035,838 $716,694,085 6.5%
South Dakota $81,936,507 $88,963,445 8.6%
Tennessee $2,196,066,176 $2,344,351,015 6.8%
Texas $2,202,097,688 $2,416,879,360 9.8%
Utah $192,093,154 $221,854,365 15.5%
Vermont $160,039,523 $184,730,219 15.4%
Virginia $582,093,270 $634,701,038 9.0%
Washington $649,265,744 $682,553,233 5.1%
West Virginia $376,426,405 $431,614,161 14.7%
Wisconsin $684,912,153 $759,682,514 10.9%
Wyoming $52,845,063 $51,242,060 -3.0%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2004 and FY 2005.

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Ranking Based on Drug Expenditures, 2004-2005*

% of 2005 National
2005 2005 Medicaid Drug 2004 2004
State Payments Ranking Expenditures Payments Ranking
National Total $43,077,457,835 $40,065,314,592
New York $5,253,655,620 1 12.2% $4,782,579,851 2
California $5,187,275,034 2 12.0% $4,817,590,501 1
Florida $2,503,151,114 3 5.8% $2,472,756,351 3
Texas $2,416,879,360 4 5.6% $2,202,097,688 4
Tennessee $2,344,351,015 5 5.4% $2,196,066,176 5
Ohio $1,981,230,721 6 4.6% $1,819,580,108 6
North Carolina $1,790,399,967 7 4.2% $1,575,005,070 8
Illinois $1,716,361,486 8 4.0% $1,751,647,987 7
Missouri $1,246,144,317 9 2.9% $1,119,655,471 10
Georgia $1,184,915,057 10 2.8% $1,213,833,584 9
New Jersey $1,158,553,486 11 2.7% $1,016,646,964 11
Louisiana $1,082,597,269 12 2.5% $944,175,123 13
Massachusetts $1,067,378,270 13 2.5% $987,294,716 14
Pennsylvania $1,009,804,038 14 2.3% $952,341,486 12
Michigan $965,368,582 15 2.2% $874,729,802 15
Kentucky $794,519,116 16 1.8% $802,700,636 16
Wisconsin $759,682,514 17 1.8% $684,912,153 18
Indiana $751,525,376 18 1.7% $703,941,201 17
South Carolina $716,694,085 19 1.7% $673,035,838 19
Washington $682,553,233 20 1.6% $649,265,744 21
Mississippi $665,504,688 21 1.5% $668,097,090 20
Virginia $634,701,038 22 1.5% $582,093,270 23
Alabama $606,578,572 23 1.4% $594,477,767 22
Maryland $578,238,275 24 1.3% $490,288,888 24
Oklahoma $500,420,840 25 1.2% $416,314,217 26
Connecticut $496,715,211 26 1.2% $448,164,399 25
Minnesota $441,908,835 27 1.0% $394,600,158 27
West Virginia $431,614,161 28 1.0% $376,426,405 29
Arkansas $419,350,865 29 1.0% $380,446,105 28
Iowa $412,274,229 30 1.0% $371,927,390 30
Kansas $296,283,292 31 0.7% $274,203,278 33
Colorado $285,371,981 32 0.7% $264,117,222 31
Maine $282,039,741 33 0.7% $281,693,429 32
Oregon $261,373,083 34 0.6% $245,180,310 34
Nebraska $228,576,569 35 0.5% $231,317,773 35
Utah $221,854,365 36 0.5% $192,093,154 36
Vermont $184,730,219 37 0.4% $160,039,523 38
Rhode Island $173,884,102 38 0.4% $166,067,772 37
Idaho $168,780,832 39 0.4% $153,351,334 39
Nevada $134,564,289 40 0.3% $127,920,160 41
New Hampshire $133,253,555 41 0.3% $128,552,504 40
Alaska $127,315,710 42 0.3% $115,273,427 43
Delaware $122,026,857 43 0.3% $122,552,631 45
Hawaii $119,852,050 44 0.3% $117,149,907 44
New Mexico $116,252,520 45 0.3% $117,451,186 42
District of Columbia $105,948,589 46 0.2% $106,453,411 46
Montana $105,154,540 47 0.2% $99,334,048 47
South Dakota $88,963,445 48 0.2% $81,936,507 48
North Dakota $64,157,312 49 0.1% $59,722,091 49
Wyoming $51,242,060 50 0.1% $52,845,063 50
Arizona $5,486,350 51 0.0% $5,367,723 51
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2004 and FY 2005.

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Drugs as a Percentage of Total Net Expenditures, 2005

Total Medicaid
Net Medical Assistance Total Drug % of Total
State Expenditures Expenditures* Net Expenditures
National Total $299,659,808,819 $43,077,457,835 14.4%
Alabama $3,837,473,614 $606,578,572 15.8%
Alaska $983,488,511 $127,315,710 12.9%
Arizona $5,725,919,558 $5,486,350 0.1%
Arkansas $2,809,920,508 $419,350,865 14.9%
California $33,662,911,379 $5,187,275,034 15.4%
Colorado $2,796,729,720 $285,371,981 10.2%
Connecticut $4,027,599,803 $496,715,211 12.3%
Delaware $868,667,588 $122,026,857 14.0%
District of Columbia $1,254,159,659 $105,948,589 8.4%
Florida $13,218,246,322 $2,503,151,114 18.9%
Georgia $7,333,266,041 $1,184,915,057 16.2%
Hawaii $1,033,126,200 $119,852,050 11.6%
Idaho $1,008,634,738 $168,780,832 16.7%
Illinois $10,785,542,795 $1,716,361,486 15.9%
Indiana $5,234,229,575 $751,525,376 14.4%
Iowa $2,376,772,384 $412,274,229 17.3%
Kansas $1,967,790,699 $296,283,292 15.1%
Kentucky $4,253,083,096 $794,519,116 18.7%
Louisiana $5,313,395,456 $1,082,597,269 20.4%
Maine $2,242,388,876 $282,039,741 12.6%
Maryland $5,136,302,340 $578,238,275 11.3%
Massachusetts $9,556,863,877 $1,067,378,270 11.2%
Michigan $8,656,266,850 $965,368,582 11.2%
Minnesota $5,528,371,422 $441,908,835 8.0%
Mississippi $3,342,615,012 $665,504,688 19.9%
Missouri $6,528,988,350 $1,246,144,317 19.1%
Montana $696,069,297 $105,154,540 15.1%
Nebraska $1,377,175,781 $228,576,569 16.6%
Nevada $1,184,065,213 $134,564,289 11.4%
New Hampshire $1,244,582,951 $133,253,555 10.7%
New Jersey $7,508,874,058 $1,158,553,486 15.4%
New Mexico $2,363,669,655 $116,252,520 4.9%
New York $42,752,347,265 $5,253,655,620 12.3%
North Carolina $8,844,879,833 $1,790,399,967 20.2%
North Dakota $508,464,760 $64,157,312 12.6%
Ohio $11,572,449,325 $1,981,230,721 17.1%
Oklahoma $2,712,779,961 $500,420,840 18.4%
Oregon $2,810,667,717 $261,373,083 9.3%
Pennsylvania $15,786,514,016 $1,009,804,038 6.4%
Rhode Island $1,671,398,242 $173,884,102 10.4%
South Carolina $4,068,509,449 $716,694,085 17.6%
South Dakota $608,250,647 $88,963,445 14.6%
Tennessee $7,557,403,733 $2,344,351,015 31.0%
Texas $17,264,066,130 $2,416,879,360 14.0%
Utah $1,341,242,046 $221,854,365 16.5%
Vermont $859,483,644 $184,730,219 21.5%
Virginia $4,425,080,633 $634,701,038 14.3%
Washington $5,700,850,706 $682,553,233 12.0%
West Virginia $2,161,356,254 $431,614,161 20.0%
Wisconsin $4,751,656,671 $759,682,514 16.0%
Wyoming $405,216,459 $51,242,060 12.6%
*Rebates have not been subtracted from these figures.

Source: CMS, CMS-64 Report, FY 2005.

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Drugs as a Percentage of Total Net Expenditures, 2003-2005*

State 2003 2004 2005


National Total 13.0% 14.3% 14.4%
Alabama 15.4% 16.3% 15.8%
Alaska 11.4% 13.0% 12.9%
Arizona 0.1% 0.1% 0.1%
Arkansas 13.3% 14.7% 14.9%
California 14.0% 15.7% 15.4%
Colorado 8.8% 10.0% 10.2%
Connecticut 11.5% 11.6% 12.3%
Delaware 15.3% 15.5% 14.0%
District of Columbia 7.6% 9.5% 8.4%
Florida 18.4% 19.3% 18.9%
Georgia 17.0% 17.2% 16.2%
Hawaii 12.7% 12.9% 11.6%
Idaho 16.3% 16.3% 16.7%
Illinois 15.9% 17.5% 15.9%
Indiana 14.7% 14.4% 14.4%
Iowa 15.5% 16.6% 17.3%
Kansas 13.0% 15.4% 15.1%
Kentucky 18.5% 19.6% 18.7%
Louisiana 18.7% 19.1% 20.4%
Maine 15.1% 13.9% 12.6%
Maryland 9.9% 10.7% 11.3%
Massachusetts 12.3% 11.3% 11.2%
Michigan 9.5% 10.6% 11.2%
Minnesota 7.5% 7.1% 8.0%
Mississippi 19.9% 20.3% 19.9%
Missouri 17.0% 18.4% 19.1%
Montana 15.6% 14.9% 15.1%
Nebraska 15.9% 16.2% 16.6%
Nevada 10.5% 12.3% 11.4%
New Hampshire 12.3% 11.2% 10.7%
New Jersey 9.8% 12.8% 15.4%
New Mexico 4.3% 5.3% 4.9%
New York 10.6% 11.7% 12.3%
North Carolina 18.3% 19.8% 20.2%
North Dakota 12.2% 12.5% 12.6%
Ohio 14.9% 15.8% 17.1%
Oklahoma 13.0% 16.6% 18.4%
Oregon 9.8% 9.4% 9.3%
Pennsylvania 6.2% 6.8% 6.4%
Rhode Island 9.8% 10.1% 10.4%
South Carolina 16.0% 17.5% 17.6%
South Dakota 13.3% 14.6% 14.6%
Tennessee 20.1% 31.2% 31.0%
Texas 12.5% 13.7% 14.0%
Utah 14.9% 15.5% 16.5%
Vermont 18.1% 20.0% 21.5%
Virginia 14.4% 15.2% 14.3%
Washington 11.9% 12.4% 12.0%
West Virginia 18.6% 19.4% 20.0%
Wisconsin 12.4% 15.5% 16.0%
Wyoming 14.6% 14.4% 12.6%
*Percentages are based on figures that have not had rebates subtracted from them.

Source: CMS, CMS-64 Report, FY 2003 - FY 2005.

4-8
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2004

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $13,300,359,808 $3,969,414,844 $3,648,306,434 $2,469,562,269 $3,274,866,917
Alabama $208,760,996 $69,043,166 $60,931,002 $35,879,041 $62,771,380
Alaska $47,912,513 $9,505,258 $10,076,774 $10,087,697 $9,000,355
Arizona*
Arkansas $155,702,637 $38,171,834 $41,975,653 $19,069,811 $43,560,568
California $1,610,536,923 $630,157,032 $421,979,467 $378,449,383 $493,683,362
Colorado $122,978,421 $26,900,240 $22,474,930 $14,187,562 $25,233,231
Connecticut $198,383,506 $50,937,823 $36,772,205 $36,272,702 $32,042,343
Delaware $41,021,683 $11,732,238 $17,612,565 $3,126,934 $11,315,099
District of Columbia $26,670,897 $12,520,390 $23,179,899 $2,643,629 $6,592,102
Florida $747,292,514 $270,773,916 $363,341,806 $198,477,510 $191,344,602
Georgia $407,156,598 $120,487,467 $147,835,763 $55,381,643 $116,295,273
Hawaii $43,073,550 $17,937,928 $8,511,363 $4,330,362 $11,541,866
Idaho $71,352,803 $11,207,631 $10,474,850 $8,530,670 $14,690,005
Illinois**
Indiana $329,400,563 $63,864,597 $51,774,597 $37,105,204 $65,429,310
Iowa $180,751,055 $32,264,220 $30,515,629 $22,760,834 $34,717,131
Kansas $130,448,685 $23,299,032 $19,290,087 $22,768,014 $23,256,463
Kentucky $299,579,345 $89,039,723 $73,109,907 $41,944,307 $83,980,921
Louisiana $289,784,312 $93,920,065 $115,974,399 $64,822,495 $80,944,494
Maine $119,962,268 $28,225,919 $19,041,538 $28,918,551 $27,272,891
Maryland $223,828,886 $59,018,665 $40,017,606 $33,385,048 $32,668,403
Massachusetts $437,346,870 $94,472,294 $93,663,246 $72,171,009 $80,120,349
Michigan $447,139,945 $81,118,326 $45,939,633 $46,444,308 $69,242,799
Minnesota $203,255,537 $24,499,964 $22,934,171 $29,259,476 $28,421,319
Mississippi $210,940,132 $101,240,783 $68,988,274 $36,686,079 $66,591,404
Missouri $471,964,290 $115,900,356 $95,050,827 $40,690,835 $105,701,660
Montana $45,102,777 $7,459,968 $6,150,907 $5,131,898 $8,361,839
Nebraska $105,213,526 $21,345,302 $17,889,099 $9,481,172 $22,289,480
Nevada $54,004,427 $11,892,140 $11,024,517 $4,638,057 $9,828,218
New Hampshire $64,375,785 $10,219,677 $6,549,308 $8,369,457 $11,012,547
New Jersey $341,505,598 $126,475,891 $110,144,283 $79,960,008 $75,482,040
New Mexico**
New York $1,477,360,243 $547,267,499 $733,035,427 $346,610,504 $425,428,586
North Carolina $543,405,555 $175,726,290 $140,877,989 $157,859,974 $139,958,047
North Dakota $29,044,762 $5,398,111 $3,944,563 $2,884,297 $5,367,993
Ohio $755,434,684 $184,869,267 $156,813,358 $122,914,780 $166,743,130
Oklahoma $172,393,633 $36,570,700 $41,689,442 $20,604,328 $41,918,694
Oregon $147,403,531 $15,273,079 $10,964,664 $8,939,913 $16,522,989
Pennsylvania $404,913,210 $110,273,064 $64,274,505 $96,565,142 $85,279,878
Rhode Island $71,998,124 $21,461,519 $11,163,274 $14,165,053 $13,220,350
South Carolina $241,712,165 $102,316,506 $71,166,206 $29,469,037 $78,905,290
South Dakota $35,494,580 $5,758,477 $7,020,500 $7,328,902 $7,696,219
Tennessee**
Texas $750,907,166 $229,611,591 $239,350,204 $128,549,116 $221,602,731
Utah $90,793,203 $13,103,636 $13,704,039 $14,269,056 $16,005,029
Vermont $20,380,595 $4,923,113 $3,924,394 $2,831,497 $4,837,757
Virginia $216,282,993 $74,189,057 $44,188,648 $52,170,367 $49,166,042
Washington $215,060,401 $51,783,776 $36,951,943 $44,456,162 $47,672,718
West Virginia $148,004,350 $45,398,113 $30,465,631 $22,502,144 $39,328,691
Wisconsin $321,759,763 $88,777,279 $41,226,534 $43,727,866 $66,809,859
Wyoming $22,563,808 $3,081,922 $4,320,808 $2,740,435 $5,011,460
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2004.

4-9
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2004 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average $1,268,709,776 $1,504,382,071 $1,780,432,781 $4,539,258,679 $35,755,293,579
Alabama $19,815,936 $28,276,590 $30,130,751 $93,636,378 $609,245,240
Alaska $4,236,261 $4,702,727 $7,297,448 $12,322,584 $115,141,617
Arizona*
Arkansas $15,089,745 $20,212,100 $22,302,405 $53,697,466 $409,782,219
California $154,643,546 $119,405,722 $273,003,668 $461,107,379 $4,542,966,482
Colorado $11,231,161 $14,098,886 $8,493,735 $34,949,118 $280,547,284
Connecticut $13,954,956 $17,727,053 $19,448,788 $48,084,018 $453,623,394
Delaware $4,397,712 $4,948,366 $5,145,925 $15,613,980 $114,914,502
District of Columbia $1,844,427 $2,118,470 $4,119,643 $11,970,077 $91,659,534
Florida $84,995,587 $102,867,469 $132,999,437 $303,067,303 $2,395,160,144
Georgia $44,108,288 $63,249,138 $60,174,610 $197,123,630 $1,211,812,410
Hawaii $5,706,853 $4,405,121 $7,303,532 $12,792,380 $115,602,955
Idaho $5,947,343 $6,458,100 $3,853,852 $16,587,939 $149,103,193
Illinois**
Indiana $29,725,442 $34,463,246 $61,441,511 $102,961,022 $776,165,492
Iowa $12,417,134 $18,409,947 $10,842,034 $43,851,314 $386,529,298
Kansas $8,849,086 $12,576,734 $9,873,381 $30,332,674 $280,694,156
Kentucky $31,804,260 $53,791,138 $37,300,733 $113,248,663 $823,798,997
Louisiana $30,168,868 $45,859,178 $48,365,184 $157,515,097 $927,354,092
Maine $9,405,074 $11,919,851 $11,623,735 $25,627,824 $281,997,651
Maryland $13,097,536 $13,898,001 $29,865,381 $42,225,645 $488,005,171
Massachusetts $28,219,888 $33,704,489 $38,426,993 $100,869,810 $978,994,948
Michigan $32,181,251 $32,307,939 $55,846,178 $91,605,196 $901,825,575
Minnesota $12,809,076 $14,795,693 $16,753,741 $40,961,946 $393,690,923
Mississippi $22,684,360 $33,882,763 $32,051,245 $89,074,230 $662,139,270
Missouri $38,296,575 $59,234,130 $55,920,224 $149,412,057 $1,132,170,954
Montana $4,261,207 $4,887,086 $3,064,524 $11,854,757 $96,274,963
Nebraska $8,939,346 $11,010,780 $8,419,450 $29,000,045 $233,588,200
Nevada $4,516,008 $5,936,937 $10,643,715 $15,284,714 $127,768,733
New Hampshire $4,110,542 $6,720,017 $2,965,942 $14,653,555 $128,976,830
New Jersey $35,679,895 $43,449,706 $65,546,285 $131,578,491 $1,009,822,197
New Mexico**
New York $182,586,702 $165,350,243 $229,409,543 $639,902,270 $4,746,951,017
North Carolina $54,413,248 $70,605,784 $70,282,003 $218,643,112 $1,571,772,002
North Dakota $2,464,988 $2,861,449 $1,682,198 $7,114,750 $60,763,111
Ohio $56,744,399 $101,205,281 $71,165,315 $240,076,427 $1,855,966,641
Oklahoma $17,396,906 $20,036,410 $23,059,956 $46,342,187 $420,012,256
Oregon $5,860,382 $8,296,626 $9,343,855 $16,214,738 $238,819,777
Pennsylvania $34,783,700 $60,401,478 $70,317,964 $131,016,175 $1,057,825,116
Rhode Island $5,242,264 $7,200,855 $5,771,722 $16,991,501 $167,214,662
South Carolina $26,550,002 $31,574,570 $32,393,334 $100,541,806 $714,628,916
South Dakota $3,172,046 $4,121,980 $3,312,522 $11,246,610 $85,151,836
Tennessee**
Texas $94,573,950 $96,244,690 $100,239,771 $370,863,735 $2,231,942,954
Utah $5,658,786 $7,456,053 $2,766,670 $19,584,825 $183,341,297
Vermont $2,045,354 $2,095,719 $1,828,575 $6,144,343 $49,011,347
Virginia $20,969,064 $28,697,738 $32,941,936 $77,399,118 $596,004,963
Washington $16,555,811 $17,206,755 $10,090,619 $50,041,660 $489,819,845
West Virginia $14,321,406 $17,966,680 $10,815,009 $45,634,292 $374,436,316
Wisconsin $29,817,176 $35,312,820 $30,347,538 $83,348,189 $741,127,024
Wyoming $2,416,229 $2,429,563 $1,440,201 $7,143,649 $51,148,075
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2004.

4-10
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2004

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 167,888,750 79,371,749 44,019,700 33,525,189 53,642,322
Alabama 3,278,516 1,590,111 1,084,735 611,990 1,133,807
Alaska 584,955 237,819 120,430 111,598 160,090
Arizona*
Arkansas 1,940,172 872,682 789,138 289,294 735,854
California 16,140,871 8,762,370 4,163,569 3,826,736 6,211,702
Colorado 1,869,444 696,456 466,021 264,850 607,516
Connecticut 2,132,602 994,667 265,547 384,063 568,378
Delaware 538,520 208,070 168,827 69,670 179,106
District of Columbia 281,615 238,963 89,086 34,972 107,267
Florida 9,805,117 5,812,626 2,781,099 2,112,140 3,136,531
Georgia 5,909,547 2,729,143 2,417,822 989,503 2,179,471
Hawaii 490,293 336,920 89,324 142,354 176,389
Idaho 842,808 233,923 199,437 115,892 250,988
Illinois**
Indiana 4,392,459 1,552,226 910,144 928,081 1,141,298
Iowa 2,405,468 813,817 573,808 325,830 670,385
Kansas 1,551,388 591,586 353,575 268,149 475,833
Kentucky 4,645,620 2,073,878 1,366,167 1,089,815 1,444,433
Louisiana 3,938,337 1,856,000 1,607,037 642,164 1,335,519
Maine 2,015,551 770,556 347,931 351,711 586,256
Maryland 2,633,151 1,258,463 312,811 371,774 659,700
Massachusetts 5,812,606 2,421,077 974,401 937,398 1,610,341
Michigan 6,282,409 2,321,047 761,712 843,742 1,394,537
Minnesota 2,168,242 621,246 306,388 464,346 510,208
Mississippi 2,825,237 1,954,769 1,072,504 500,967 1,075,376
Missouri 5,780,979 2,584,837 1,255,130 918,442 1,789,360
Montana 579,675 180,716 120,309 95,081 171,680
Nebraska 1,382,247 484,928 375,678 322,118 406,308
Nevada 624,279 272,312 124,908 88,113 179,704
New Hampshire 887,305 249,895 141,013 175,189 203,533
New Jersey 3,964,285 2,369,974 706,224 846,406 1,209,970
New Mexico**
New York 16,651,586 9,648,142 4,963,852 4,298,342 5,976,807
North Carolina 6,812,234 3,684,497 1,937,463 1,455,037 2,452,646
North Dakota 375,058 153,187 83,016 51,875 119,577
Ohio 10,712,189 4,250,302 2,447,799 2,555,093 3,098,614
Oklahoma 2,106,058 749,897 758,715 319,697 648,626
Oregon 2,007,873 459,454 200,114 232,258 376,993
Pennsylvania 5,047,146 2,436,122 967,173 1,126,691 1,584,252
Rhode Island 870,717 346,964 117,378 175,104 206,611
South Carolina 3,143,775 2,208,842 964,823 489,627 1,436,448
South Dakota 422,113 155,469 142,829 75,437 142,546
Tennessee**
Texas 9,555,330 3,325,626 4,684,673 1,690,336 2,849,109
Utah 1,226,270 279,704 293,800 183,928 314,835
Vermont 249,031 100,613 50,198 39,517 78,797
Virginia 3,017,582 1,546,359 583,196 809,102 918,666
Washington 3,266,958 1,315,922 523,389 765,203 934,552
West Virginia 2,294,623 944,174 607,461 373,840 675,911
Wisconsin 4,160,520 2,605,992 663,934 718,305 1,439,276
Wyoming 265,989 69,406 85,112 43,409 76,516

* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2004.

4-11
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2004 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average 12,858,711 30,249,413 13,374,644 110,167,864 545,098,342
Alabama 227,396 673,411 262,701 2,682,619 11,545,286
Alaska 36,707 93,014 33,986 256,715 1,635,314
Arizona*
Arkansas 146,838 357,751 139,053 1,361,082 6,631,864
California 1,257,486 2,430,679 1,591,923 9,951,195 54,336,531
Colorado 121,849 351,496 118,012 971,534 5,467,178
Connecticut 147,746 303,980 175,517 992,217 5,964,717
Delaware 39,080 108,626 33,781 350,778 1,696,458
District of Columbia 23,958 48,848 25,167 224,251 1,074,127
Florida 976,550 1,938,542 961,015 6,322,293 33,845,913
Georgia 477,858 1,397,467 489,393 4,840,641 21,430,845
Hawaii 69,406 82,720 47,561 326,396 1,761,363
Idaho 55,809 135,658 42,852 371,928 2,249,295
Illinois**
Indiana 252,246 707,340 331,131 2,723,249 12,938,174
Iowa 136,072 371,056 149,482 1,150,391 6,596,309
Kansas 95,197 248,781 98,869 820,171 4,503,549
Kentucky 350,381 977,033 384,185 3,401,282 15,732,794
Louisiana 329,371 930,317 359,032 3,603,150 14,600,927
Maine 106,289 308,112 90,583 689,442 5,266,431
Maryland 156,801 328,935 219,477 1,081,585 7,022,697
Massachusetts 280,117 804,194 319,206 2,389,395 15,548,735
Michigan 327,833 725,159 456,014 2,494,063 15,606,516
Minnesota 98,537 278,693 99,914 941,974 5,489,548
Mississippi 252,852 540,406 292,655 2,225,936 10,740,702
Missouri 353,492 1,072,302 437,990 3,263,920 17,456,452
Montana 38,232 99,061 26,936 267,472 1,579,162
Nebraska 94,634 238,851 91,552 1,003,496 4,399,812
Nevada 45,535 127,665 45,552 325,019 1,833,087
New Hampshire 40,184 143,511 40,200 449,864 2,330,694
New Jersey 385,643 695,640 382,934 2,702,315 13,263,391
New Mexico**
New York 1,904,657 3,429,346 1,293,585 13,896,087 62,062,404
North Carolina 608,135 1,307,947 511,445 4,906,941 23,676,345
North Dakota 24,720 54,569 26,244 198,945 1,087,191
Ohio 656,535 2,154,127 824,394 7,110,698 33,809,751
Oklahoma 154,964 435,049 97,085 1,096,146 6,366,237
Oregon 54,836 187,056 75,117 566,209 4,159,910
Pennsylvania 347,281 934,426 705,002 3,005,516 16,153,609
Rhode Island 60,429 133,178 58,933 404,984 2,374,298
South Carolina 268,346 597,461 324,087 2,350,308 11,783,717
South Dakota 32,478 74,591 29,661 270,458 1,345,582
Tennessee**
Texas 777,489 2,223,580 657,848 10,093,801 35,857,792
Utah 55,947 175,023 47,561 537,159 3,114,227
Vermont 16,037 42,821 14,114 124,262 715,390
Virginia 242,302 519,649 274,114 2,158,209 10,069,179
Washington 196,331 371,824 152,037 1,540,253 9,066,469
West Virginia 163,120 387,534 134,768 1,212,992 6,794,423
Wisconsin 350,271 654,116 386,065 2,344,346 13,322,825
Wyoming 20,734 47,868 15,911 166,177 791,122

*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2004.

4-12
National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Average Cost Per Prescription, 2004*

Drug Prescriptions Average


State Payments Processed Prescription Cost
National Average $35,755,293,579 545,098,342 $65.59
Alabama $609,245,240 11,545,286 $52.77
Alaska $115,141,617 1,635,314 $70.41
Arizona**
Arkansas $409,782,219 6,631,864 $61.79
California $4,542,966,482 54,336,531 $83.61
Colorado $280,547,284 5,467,178 $51.31
Connecticut $453,623,394 5,964,717 $76.05
Delaware $114,914,502 1,696,458 $67.74
District of Columbia $91,659,534 1,074,127 $85.33
Florida $2,395,160,144 33,845,913 $70.77
Georgia $1,211,812,410 21,430,845 $56.55
Hawaii $115,602,955 1,761,363 $65.63
Idaho $149,103,193 2,249,295 $66.29
Illinois***
Indiana $776,165,492 12,938,174 $59.99
Iowa $386,529,298 6,596,309 $58.60
Kansas $280,694,156 4,503,549 $62.33
Kentucky $823,798,997 15,732,794 $52.36
Louisiana $927,354,092 14,600,927 $63.51
Maine $281,997,651 5,266,431 $53.55
Maryland $488,005,171 7,022,697 $69.49
Massachusetts $978,994,948 15,548,735 $62.96
Michigan $901,825,575 15,606,516 $57.79
Minnesota $393,690,923 5,489,548 $71.72
Mississippi $662,139,270 10,740,702 $61.65
Missouri $1,132,170,954 17,456,452 $64.86
Montana $96,274,963 1,579,162 $60.97
Nebraska $233,588,200 4,399,812 $53.09
Nevada $127,768,733 1,833,087 $69.70
New Hampshire $128,976,830 2,330,694 $55.34
New Jersey $1,009,822,197 13,263,391 $76.14
New Mexico***
New York $4,746,951,017 62,062,404 $76.49
North Carolina $1,571,772,002 23,676,345 $66.39
North Dakota $60,763,111 1,087,191 $55.89
Ohio $1,855,966,641 33,809,751 $54.89
Oklahoma $420,012,256 6,366,237 $65.97
Oregon $238,819,777 4,159,910 $57.41
Pennsylvania $1,057,825,116 16,153,609 $65.49
Rhode Island $167,214,662 2,374,298 $70.43
South Carolina $714,628,916 11,783,717 $60.65
South Dakota $85,151,836 1,345,582 $63.28
Tennessee***
Texas $2,231,942,954 35,857,792 $62.24
Utah $183,341,297 3,114,227 $58.87
Vermont $49,011,347 715,390 $68.51
Virginia $596,004,963 10,069,179 $59.19
Washington $489,819,845 9,066,469 $54.03
West Virginia $374,436,316 6,794,423 $55.11
Wisconsin $741,127,024 13,322,825 $55.63
Wyoming $51,148,075 791,122 $64.65

*Rebates have not been subtracted from these figures.


**Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
*** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.
Source: CMS, State Drug Utilization Data, FY 2004.

4-13
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2005

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $13,733,672,000 $4,409,779,315 $3,795,913,778 $2,700,933,651 $3,549,133,873
Alabama $214,552,130 $73,802,209 $56,724,127 $42,880,640 $62,577,950
Alaska $51,014,894 $11,684,647 $11,472,017 $12,305,340 $10,512,077
Arizona*
Arkansas $170,203,870 $44,199,827 $40,494,234 $25,043,648 $46,474,770
California $1,577,940,461 $682,118,842 $428,390,448 $403,356,229 $462,655,404
Colorado $134,522,019 $31,069,329 $24,334,273 $15,250,451 $29,352,001
Connecticut $207,432,304 $57,960,246 $38,900,924 $40,001,158 $36,536,080
Delaware $37,017,954 $11,410,832 $18,490,842 $3,949,655 $11,869,250
District of Columbia $31,752,935 $14,786,072 $7,891,417 $3,211,132 $7,918,431
Florida $692,119,817 $297,390,891 $373,470,079 $215,858,221 $219,223,786
Georgia $398,614,954 $126,712,089 $159,154,053 $70,040,037 $128,895,843
Hawaii $44,911,145 $19,251,022 $8,794,470 $3,724,301 $12,795,327
Idaho $71,222,640 $11,532,719 $11,186,208 $8,725,592 $15,618,743
Illinois**
Indiana $323,309,355 $71,032,439 $45,461,298 $43,184,105 $63,929,980
Iowa $198,345,246 $36,978,920 $32,909,189 $21,727,070 $38,930,947
Kansas $139,644,790 $27,725,243 $20,320,128 $26,999,791 $25,896,170
Kentucky $273,903,838 $86,644,725 $68,996,989 $37,610,724 $83,549,039
Louisiana $304,695,909 $104,488,213 $125,903,628 $71,097,667 $88,786,676
Maine $122,675,758 $32,682,598 $19,919,917 $33,336,199 $32,003,288
Maryland $235,878,248 $65,233,868 $44,863,927 $34,062,328 $36,101,160
Massachusetts $438,462,703 $102,324,635 $98,710,494 $79,285,503 $87,437,122
Michigan $465,642,417 $92,298,628 $56,806,194 $62,302,650 $78,582,106
Minnesota $220,614,609 $30,636,546 $24,491,736 $32,874,924 $32,255,840
Mississippi $197,640,832 $95,740,331 $67,825,156 $24,652,569 $65,517,465
Missouri $508,352,069 $140,298,572 $100,989,144 $46,536,754 $122,625,807
Montana $49,313,924 $8,372,267 $6,528,375 $5,224,250 $9,202,773
Nebraska $113,869,878 $24,858,618 $18,368,009 $9,244,009 $24,930,071
Nevada $55,822,280 $13,007,296 $11,236,673 $4,507,500 $10,342,649
New Hampshire $67,832,710 $11,590,852 $6,914,941 $8,439,575 $12,275,482
New Jersey $373,529,060 $150,004,977 $118,893,816 $91,234,292 $89,192,201
New Mexico**
New York $1,552,391,330 $625,561,684 $788,859,153 $361,966,786 $478,979,355
North Carolina $599,486,231 $204,569,508 $152,027,401 $174,448,054 $160,898,618
North Dakota $30,502,365 $5,935,677 $4,170,398 $2,572,846 $5,928,454
Ohio $794,592,304 $206,292,755 $150,805,411 $175,539,234 $188,600,216
Oklahoma $184,266,645 $43,651,603 $45,209,726 $29,227,955 $49,617,242
Oregon $159,525,446 $15,790,550 $9,734,364 $8,507,078 $15,961,846
Pennsylvania $373,905,197 $106,055,869 $57,962,409 $58,189,032 $81,182,254
Rhode Island $74,733,675 $23,064,893 $11,509,528 $15,060,588 $14,161,908
South Carolina $249,532,462 $109,550,871 $76,671,996 $32,671,736 $84,043,918
South Dakota $36,887,007 $6,464,738 $7,362,362 $7,712,871 $8,549,059
Tennessee**
Texas $800,062,681 $262,986,093 $253,264,190 $150,787,827 $248,184,183
Utah $105,497,120 $16,041,107 $15,929,708 $16,032,323 $19,073,269
Vermont $20,138,225 $5,732,917 $4,024,154 $3,872,914 $4,718,765
Virginia $226,513,235 $80,628,883 $43,975,229 $56,436,937 $53,220,641
Washington $293,834,554 $66,578,485 $47,705,204 $48,282,935 $66,030,231
West Virginia $168,731,118 $52,797,324 $33,163,561 $37,055,041 $46,158,335
Wisconsin $319,637,524 $99,102,590 $40,550,320 $42,744,865 $72,772,136
Wyoming $22,596,132 $3,136,315 $4,545,958 $3,158,315 $5,065,005
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2005.

4-14
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2005 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average $1,531,040,695 $1,596,864,325 $1,998,438,628 $4,775,919,111 $38,091,695,376
Alabama $24,902,512 $26,906,221 $36,933,895 $90,883,496 $630,163,180
Alaska $5,255,423 $5,105,214 $10,059,442 $13,778,167 $131,187,221
Arizona*
Arkansas $18,069,153 $21,417,826 $24,380,875 $54,212,690 $444,496,893
California $192,095,334 $127,816,349 $286,819,093 $429,053,695 $4,590,245,855
Colorado $13,767,441 $15,695,757 $9,426,888 $38,883,092 $312,301,251
Connecticut $17,629,346 $19,935,083 $22,897,258 $53,228,609 $494,521,008
Delaware $5,257,686 $4,200,231 $4,684,696 $15,507,441 $112,388,587
District of Columbia $2,924,181 $2,471,190 $4,860,522 $13,764,239 $89,580,119
Florida $100,347,671 $108,548,324 $147,058,338 $316,945,389 $2,470,962,516
Georgia $44,594,047 $67,576,711 $63,100,564 $190,863,020 $1,249,551,318
Hawaii $7,371,604 $4,498,000 $8,502,032 $14,156,230 $124,004,131
Idaho $6,945,664 $6,164,709 $4,197,023 $16,715,213 $152,308,511
Illinois**
Indiana $32,440,671 $33,643,946 $76,146,048 $98,359,441 $787,507,283
Iowa $15,643,316 $18,894,992 $12,624,738 $46,233,132 $422,287,550
Kansas $11,255,310 $13,421,479 $11,580,473 $31,179,253 $308,022,637
Kentucky $33,464,592 $50,973,672 $39,967,530 $118,371,796 $793,482,905
Louisiana $34,330,832 $50,106,962 $49,998,356 $161,817,388 $991,225,631
Maine $10,869,487 $13,004,310 $11,795,168 $28,510,727 $304,797,452
Maryland $16,551,728 $15,976,236 $30,127,136 $44,818,569 $523,613,200
Massachusetts $34,273,891 $35,801,824 $47,032,500 $105,604,352 $1,028,933,024
Michigan $39,756,274 $36,295,568 $56,333,032 $96,767,421 $984,784,290
Minnesota $15,548,784 $15,764,632 $21,201,894 $45,413,234 $438,802,199
Mississippi $24,256,906 $27,533,003 $36,366,456 $80,103,307 $619,636,025
Missouri $50,091,418 $62,451,303 $64,889,970 $167,455,537 $1,263,690,574
Montana $5,364,423 $5,053,922 $3,495,037 $12,332,512 $104,887,483
Nebraska $11,022,585 $11,866,646 $8,637,603 $30,919,635 $253,717,054
Nevada $5,367,911 $6,383,591 $9,908,700 $15,563,837 $132,140,437
New Hampshire $4,695,907 $6,840,460 $3,739,775 $15,061,722 $137,391,424
New Jersey $46,846,440 $50,599,505 $74,917,112 $155,552,870 $1,150,770,273
New Mexico**
New York $211,252,457 $172,267,631 $254,109,864 $716,433,091 $5,161,821,351
North Carolina $64,885,022 $81,250,090 $82,523,055 $243,656,396 $1,763,744,375
North Dakota $2,794,304 $3,298,133 $2,034,759 $7,731,194 $64,968,130
Ohio $70,270,337 $105,004,513 $72,270,082 $241,525,465 $2,004,900,317
Oklahoma $22,920,597 $23,558,595 $27,967,206 $53,652,385 $480,071,954
Oregon $6,401,798 $8,281,421 $10,262,503 $16,025,750 $250,490,756
Pennsylvania $36,212,113 $57,971,113 $70,200,216 $120,431,391 $962,109,594
Rhode Island $6,370,996 $7,774,511 $6,421,812 $17,693,234 $176,791,145
South Carolina $31,534,376 $33,911,644 $37,270,088 $102,302,056 $757,489,147
South Dakota $3,662,431 $4,733,561 $2,634,571 $11,629,219 $89,635,819
Tennessee**
Texas $119,441,273 $102,902,689 $128,618,140 $413,010,166 $2,479,257,242
Utah $7,407,843 $8,488,557 $3,037,342 $22,148,801 $213,656,070
Vermont $2,362,088 $2,046,736 $1,752,162 $5,865,446 $50,513,407
Virginia $27,376,114 $30,480,949 $36,095,697 $81,306,462 $636,034,147
Washington $29,815,033 $28,202,835 $32,757,379 $73,385,010 $686,591,666
West Virginia $18,706,956 $21,003,967 $12,706,954 $49,301,388 $439,624,644
Wisconsin $36,029,761 $38,366,790 $34,832,125 $90,896,400 $774,932,511
Wyoming $2,656,659 $2,372,924 $1,262,519 $6,869,243 $51,663,070
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2005.

4-15
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2005

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 170,427,000 83,641,573 45,217,584 34,767,721 55,118,108
Alabama 3,232,377 1,599,474 1,085,636 644,601 1,122,760
Alaska 610,394 274,332 132,139 126,111 176,203
Arizona*
Arkansas 2,010,056 906,451 797,064 309,713 739,529
California 15,109,303 9,201,039 3,849,081 3,749,245 5,820,996
Colorado 1,951,438 745,356 510,657 273,249 648,137
Connecticut 2,185,526 1,072,706 275,250 415,595 602,431
Delaware 535,501 203,661 174,139 67,245 175,637
District of Columbia 317,407 265,006 59,784 39,592 112,959
Florida 9,722,766 6,174,856 2,848,958 2,205,231 3,383,461
Georgia 5,861,309 2,725,527 2,570,140 1,063,572 2,205,235
Hawaii 497,817 354,399 90,949 148,055 182,372
Idaho 835,517 242,690 217,691 114,922 246,632
Illinois**
Indiana 4,137,565 1,609,777 775,277 928,445 1,085,729
Iowa 2,521,064 894,375 622,769 361,015 699,054
Kansas 1,649,419 629,139 372,469 279,853 496,858
Kentucky 4,528,809 2,032,296 1,355,734 1,065,834 1,394,072
Louisiana 3,983,412 1,923,705 1,710,966 660,789 1,376,986
Maine 2,052,292 816,224 366,491 370,755 612,210
Maryland 2,754,822 1,343,091 338,537 390,093 700,452
Massachusetts 5,765,456 2,489,395 959,958 963,925 1,602,847
Michigan 6,457,330 2,448,637 834,280 930,390 1,452,311
Minnesota 2,257,637 666,445 326,779 484,725 536,286
Mississippi 2,635,134 1,807,777 1,053,455 439,131 1,025,501
Missouri 6,139,842 2,883,016 1,306,399 1,065,719 1,931,857
Montana 591,123 187,570 125,063 99,015 175,685
Nebraska 1,434,507 518,840 397,467 345,237 421,290
Nevada 639,293 287,520 124,591 92,333 182,254
New Hampshire 908,891 263,570 150,385 175,071 214,359
New Jersey 4,090,116 2,590,500 754,730 906,408 1,326,516
New Mexico**
New York 17,070,337 10,354,197 5,146,710 4,479,018 6,335,159
North Carolina 7,141,343 3,954,735 2,052,837 1,533,553 2,577,796
North Dakota 380,673 158,590 92,834 53,868 121,278
Ohio 11,170,571 4,583,729 2,384,308 2,641,502 3,226,628
Oklahoma 2,309,383 819,705 845,779 388,735 715,057
Oregon 1,933,176 415,564 183,974 225,094 325,629
Pennsylvania 4,714,134 2,338,546 894,317 991,202 1,494,551
Rhode Island 891,322 368,066 117,465 179,032 208,483
South Carolina 3,187,298 2,220,303 1,005,899 514,780 1,410,470
South Dakota 428,323 162,233 156,281 79,726 149,127
Tennessee**
Texas 9,880,766 3,466,170 4,998,083 1,758,482 2,951,423
Utah 1,343,038 320,991 335,403 201,063 346,332
Vermont 255,142 110,272 54,629 47,901 73,472
Virginia 3,085,474 1,598,875 604,891 826,757 946,086
Washington 4,180,750 1,740,708 700,145 923,497 1,269,554
West Virginia 2,539,372 1,051,990 657,038 432,186 754,162
Wisconsin 4,231,728 2,748,853 701,823 729,301 1,483,433
Wyoming 268,047 70,672 98,330 46,155 78,849

* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2005.

4-16
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2005 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average 13,872,440 31,707,457 13,668,638 110,492,191 558,912,712
Alabama 249,974 694,644 247,378 2,589,866 11,466,710
Alaska 44,674 102,589 37,678 277,212 1,781,332
Arizona*
Arkansas 163,863 367,964 131,600 1,290,170 6,716,410
California 1,481,054 2,462,289 1,580,317 8,783,238 52,036,562
Colorado 133,969 369,963 120,668 983,483 5,736,920
Connecticut 169,312 323,166 182,273 1,025,352 6,251,611
Delaware 44,977 110,129 30,635 334,680 1,676,604
District of Columbia 28,904 53,811 29,464 248,686 1,155,613
Florida 977,582 2,013,218 1,031,348 6,455,672 34,813,092
Georgia 422,757 1,451,034 489,590 4,881,777 21,670,941
Hawaii 78,672 84,267 49,640 335,040 1,821,211
Idaho 59,982 134,853 43,874 380,176 2,276,337
Illinois**
Indiana 246,947 681,706 333,228 2,490,801 12,289,475
Iowa 148,981 392,669 155,720 1,222,532 7,018,179
Kansas 108,372 261,488 100,219 827,685 4,725,502
Kentucky 353,525 983,113 380,345 3,448,554 15,542,282
Louisiana 339,626 996,979 355,880 3,604,383 14,952,726
Maine 109,353 326,020 98,520 723,994 5,475,859
Maryland 181,817 361,515 231,784 1,131,438 7,433,549
Massachusetts 305,702 805,523 322,087 2,384,308 15,599,201
Michigan 362,779 785,156 467,378 2,580,723 16,318,984
Minnesota 107,496 293,020 103,820 987,480 5,763,688
Mississippi 236,774 502,867 272,941 2,015,122 9,988,702
Missouri 415,649 1,165,688 485,404 3,530,175 18,923,749
Montana 41,823 100,203 27,046 272,478 1,620,006
Nebraska 105,789 249,910 96,657 1,056,357 4,626,054
Nevada 49,906 131,855 51,137 330,829 1,889,718
New Hampshire 43,174 133,998 44,477 436,470 2,370,395
New Jersey 442,378 755,398 387,161 2,886,268 14,139,475
New Mexico**
New York 1,947,303 3,592,303 1,119,760 13,203,806 63,248,593
North Carolina 634,829 1,418,575 525,697 5,156,017 24,995,382
North Dakota 26,449 58,191 26,508 201,365 1,119,756
Ohio 728,016 2,253,944 864,499 7,110,606 34,963,803
Oklahoma 201,845 488,102 107,014 1,211,519 7,087,139
Oregon 55,744 168,024 71,831 536,571 3,915,607
Pennsylvania 346,344 874,882 665,002 2,770,224 15,089,202
Rhode Island 68,114 136,714 69,663 414,330 2,453,189
South Carolina 264,171 627,410 325,835 2,358,438 11,914,604
South Dakota 36,195 78,939 30,019 278,381 1,399,224
Tennessee**
Texas 893,880 2,327,948 813,612 10,860,530 37,950,894
Utah 65,825 195,210 49,106 587,937 3,444,905
Vermont 17,037 42,698 15,392 122,725 739,268
Virginia 276,240 538,056 267,360 2,173,778 10,317,517
Washington 248,490 632,589 258,590 2,120,753 12,075,076
West Virginia 193,375 437,372 149,244 1,306,689 7,521,428
Wisconsin 391,320 691,822 405,454 2,396,776 13,780,510
Wyoming 21,452 49,643 15,783 166,797 815,728

*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2005.

4-17
National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Average Cost Per Prescription, 2005*

Drug Prescriptions Average


State Payments Processed Prescription Cost
National Average $38,091,695,376 558,912,712 $68.15
Alabama $630,163,180 11,466,710 $54.96
Alaska $131,187,221 1,781,332 $73.65
Arizona**
Arkansas $444,496,893 6,716,410 $66.18
California $4,590,245,855 52,036,562 $88.21
Colorado $312,301,251 5,736,920 $54.44
Connecticut $494,521,008 6,251,611 $79.10
Delaware $112,388,587 1,676,604 $67.03
District of Columbia $89,580,119 1,155,613 $77.52
Florida $2,470,962,516 34,813,092 $70.98
Georgia $1,249,551,318 21,670,941 $57.66
Hawaii $124,004,131 1,821,211 $68.09
Idaho $152,308,511 2,276,337 $66.91
Illinois***
Indiana $787,507,283 12,289,475 $64.08
Iowa $422,287,550 7,018,179 $60.17
Kansas $308,022,637 4,725,502 $65.18
Kentucky $793,482,905 15,542,282 $51.05
Louisiana $991,225,631 14,952,726 $66.29
Maine $304,797,452 5,475,859 $55.66
Maryland $523,613,200 7,433,549 $70.44
Massachusetts $1,028,933,024 15,599,201 $65.96
Michigan $984,784,290 16,318,984 $60.35
Minnesota $438,802,199 5,763,688 $76.13
Mississippi $619,636,025 9,988,702 $62.03
Missouri $1,263,690,574 18,923,749 $66.78
Montana $104,887,483 1,620,006 $64.75
Nebraska $253,717,054 4,626,054 $54.85
Nevada $132,140,437 1,889,718 $69.93
New Hampshire $137,391,424 2,370,395 $57.96
New Jersey $1,150,770,273 14,139,475 $81.39
New Mexico***
New York $5,161,821,351 63,248,593 $81.61
North Carolina $1,763,744,375 24,995,382 $70.56
North Dakota $64,968,130 1,119,756 $58.02
Ohio $2,004,900,317 34,963,803 $57.34
Oklahoma $480,071,954 7,087,139 $67.74
Oregon $250,490,756 3,915,607 $63.97
Pennsylvania $962,109,594 15,089,202 $63.76
Rhode Island $176,791,145 2,453,189 $72.07
South Carolina $757,489,147 11,914,604 $63.58
South Dakota $89,635,819 1,399,224 $64.06
Tennessee***
Texas $2,479,257,242 37,950,894 $65.33
Utah $213,656,070 3,444,905 $62.02
Vermont $50,513,407 739,268 $68.33
Virginia $636,034,147 10,317,517 $61.65
Washington $686,591,666 12,075,076 $56.86
West Virginia $439,624,644 7,521,428 $58.45
Wisconsin $774,932,511 13,780,510 $56.23
Wyoming $51,663,070 815,728 $63.33

*Rebates have not been subtracted from these figures.


**Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
*** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.
Source: CMS, State Drug Utilization Data, FY 2005.

4-18
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2006

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Total $7,700,546,892 $1,542,565,701 $2,595,119,847 $1,213,134,157 $2,010,561,660
Alabama $143,746,263 $29,984,767 $46,662,490 $21,266,913 $43,033,435
Alaska $33,241,269 $4,611,581 $9,106,509 $6,283,982 $5,911,697
Arizona*
Arkansas $120,775,180 $14,558,092 $36,126,566 $17,801,495 $32,430,203
California $916,478,860 $224,184,513 $241,260,807 $164,265,390 $268,043,142
Colorado $80,174,650 $10,640,557 $17,869,192 $8,254,254 $17,480,342
Connecticut $74,852,777 $14,141,558 $20,075,685 $12,409,803 $12,872,634
Delaware $32,178,552 $7,543,843 $14,746,762 $5,365,936 $10,516,995
District of Columbia $25,548,587 $7,427,462 $4,988,651 $2,203,638 $4,989,320
Florida $314,145,818 $75,521,349 $201,686,102 $80,376,193 $99,887,497
Georgia $234,302,560 $51,013,715 $103,749,889 $36,274,747 $72,037,944
Hawaii $23,127,594 $4,865,756 $4,683,872 $2,268,440 $4,455,398
Idaho $47,744,673 $4,337,593 $8,337,967 $5,220,520 $9,941,860
Illinois**
Indiana $119,928,901 $20,040,525 $16,200,880 $16,697,798 $21,212,940
Iowa $114,434,163 $12,557,860 $24,632,339 $11,402,849 $22,151,730
Kansas $75,217,177 $8,386,720 $12,156,381 $11,160,841 $12,551,899
Kentucky $164,544,818 $42,190,381 $52,291,447 $22,139,298 $52,842,763
Louisiana $191,578,852 $42,378,843 $108,767,280 $38,712,365 $58,147,923
Maine $70,513,562 $12,885,929 $13,490,132 $16,817,459 $19,500,312
Maryland $142,829,425 $11,374,011 $24,409,946 $7,410,054 $10,715,505
Massachusetts $206,084,564 $33,334,340 $59,973,952 $21,136,913 $42,721,614
Michigan $247,854,895 $10,371,673 $35,087,371 $15,017,919 $26,345,293
Minnesota $105,365,936 $12,443,620 $15,635,016 $16,383,207 $18,531,175
Mississippi $86,969,491 $19,889,378 $44,854,273 $9,341,908 $27,944,889
Missouri $249,014,975 $47,194,066 $55,666,945 $20,952,104 $58,798,320
Montana $29,830,562 $2,837,818 $4,323,700 $2,683,522 $4,634,992
Nebraska $66,174,725 $7,159,551 $13,216,063 $6,365,731 $13,534,467
Nevada $37,531,155 $4,881,067 $8,565,274 $2,881,887 $6,011,462
New Hampshire $33,169,018 $3,899,765 $4,646,416 $3,966,267 $7,339,516
New Jersey $176,610,382 $42,896,940 $71,187,349 $32,240,506 $38,578,589
New Mexico**
New York $998,122,069 $291,182,550 $648,616,265 $142,047,799 $339,493,318
North Carolina $335,821,426 $63,780,863 $109,302,988 $79,259,159 $90,679,910
North Dakota $14,465,289 $1,408,343 $2,766,567 $1,099,853 $2,681,601
Ohio $448,392,643 $90,909,082 $87,780,976 $114,665,119 $105,983,118
Oklahoma $109,447,270 $13,693,120 $34,117,111 $17,149,198 $32,566,766
Oregon $88,803,635 $4,616,121 $4,863,296 $3,940,110 $7,388,078
Pennsylvania $169,093,547 $33,747,110 $33,888,739 $17,938,067 $39,236,433
Rhode Island $32,360,407 $6,887,360 $6,006,430 $5,967,807 $5,478,297
South Carolina $136,947,640 $28,725,321 $50,035,501 $16,902,273 $44,715,335
South Dakota $20,067,869 $1,665,243 $5,674,689 $3,052,793 $5,086,563
Tennessee**
Texas $561,737,141 $88,326,294 $221,818,603 $78,950,703 $166,489,536
Utah $64,828,269 $6,459,755 $11,025,175 $8,676,963 $11,575,737
Vermont $12,464,283 $1,869,488 $2,991,551 $1,376,888 $2,726,718
Virginia $100,982,471 $16,673,791 $22,178,943 $20,699,036 $20,603,187
Washington $166,564,339 $28,117,648 $26,671,731 $26,572,238 $39,009,489
West Virginia $126,890,388 $29,233,450 $26,190,868 $28,581,250 $31,999,775
Wisconsin $134,454,261 $50,496,502 $22,702,578 $26,968,386 $38,273,699
Wyoming $15,134,561 $1,220,387 $4,088,580 $1,984,576 $3,410,244
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2006.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Expenditures by Category, 2006 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average $818,108,654 $744,328,825 $1,198,511,289 $2,853,858,420 $20,676,735,445
Alabama $19,499,211 $14,020,830 $24,879,590 $64,838,385 $407,931,884
Alaska $2,833,646 $2,724,173 $4,641,142 $8,403,128 $77,757,127
Arizona*
Arkansas $14,630,219 $9,786,634 $14,823,473 $39,726,486 $300,658,348
California $82,902,027 $57,519,946 $214,364,933 $233,135,375 $2,402,154,993
Colorado $7,017,156 $6,930,067 $6,937,339 $21,303,692 $176,607,249
Connecticut $5,152,854 $5,172,366 $10,360,664 $22,154,497 $177,192,838
Delaware $4,562,247 $3,003,717 $2,745,930 $11,854,076 $92,518,058
District of Columbia $1,594,547 $1,748,463 $3,065,731 $9,053,604 $60,620,003
Florida $45,069,196 $42,953,771 $108,702,993 $144,256,944 $1,112,599,863
Georgia $25,326,476 $32,207,168 $36,526,355 $114,072,252 $705,511,106
Hawaii $1,825,446 $1,580,528 $5,982,712 $7,961,557 $56,751,303
Idaho $4,431,676 $3,146,359 $3,448,561 $10,819,832 $97,429,041
Illinois**
Indiana $13,362,647 $9,532,772 $41,859,401 $52,670,361 $311,506,225
Iowa $9,032,101 $9,858,695 $8,347,641 $25,178,243 $237,595,621
Kansas $5,760,622 $5,070,803 $7,947,380 $15,829,567 $154,081,390
Kentucky $20,607,958 $25,954,477 $20,936,142 $76,672,179 $478,179,463
Louisiana $24,255,850 $31,645,989 $30,710,516 $108,336,504 $634,534,122
Maine $5,363,342 $7,564,323 $7,050,279 $16,829,459 $170,014,797
Maryland $4,130,464 $3,515,563 $14,958,326 $12,868,548 $232,211,842
Massachusetts $15,608,493 $12,192,897 $32,019,478 $54,615,766 $477,688,017
Michigan $12,746,756 $7,425,208 $26,752,683 $37,871,620 $419,473,418
Minnesota $8,128,640 $6,806,297 $11,543,947 $27,905,968 $222,743,806
Mississippi $11,501,217 $8,942,660 $18,410,348 $38,724,260 $266,578,424
Missouri $25,134,460 $24,523,450 $34,762,130 $90,597,900 $606,644,350
Montana $2,713,509 $2,296,988 $2,949,472 $6,367,975 $58,638,538
Nebraska $6,162,850 $6,143,913 $6,744,105 $18,490,678 $143,992,083
Nevada $2,985,989 $3,311,541 $5,099,908 $8,817,362 $80,085,645
New Hampshire $2,654,103 $2,696,695 $1,492,142 $7,644,890 $67,508,812
New Jersey $17,350,933 $17,579,775 $29,720,047 $63,453,188 $489,617,709
New Mexico**
New York $124,570,887 $113,576,351 $140,008,671 $486,869,777 $3,284,487,687
North Carolina $38,849,460 $40,131,764 $47,427,452 $153,085,320 $958,338,342
North Dakota $1,262,635 $1,282,869 $1,165,327 $3,848,021 $29,980,505
Ohio $40,677,917 $45,783,580 $38,807,475 $149,124,532 $1,122,124,442
Oklahoma $17,499,026 $13,897,068 $28,462,775 $48,204,260 $315,036,594
Oregon $2,562,224 $3,050,596 $7,180,358 $7,300,034 $129,704,452
Pennsylvania $17,648,555 $17,721,188 $33,582,881 $55,474,673 $418,331,193
Rhode Island $2,190,159 $2,207,954 $3,161,071 $7,312,534 $71,572,019
South Carolina $16,739,759 $16,672,622 $18,679,468 $69,615,830 $399,033,749
South Dakota $2,208,896 $2,133,782 $779,128 $6,082,650 $46,751,613
Tennessee**
Texas $86,087,871 $62,285,205 $73,151,821 $336,580,952 $1,675,428,126
Utah $4,260,105 $4,615,122 $1,259,995 $13,798,586 $126,499,707
Vermont $1,088,566 $875,545 $813,502 $3,574,351 $27,780,892
Virginia $11,094,798 $10,906,018 $13,042,209 $34,907,023 $251,087,476
Washington $14,420,598 $14,078,152 $27,522,310 $39,254,040 $382,210,545
West Virginia $13,923,110 $12,162,474 $6,543,816 $35,977,765 $311,502,896
Wisconsin $18,905,113 $15,882,983 $18,325,654 $47,972,830 $373,982,006
Wyoming $1,774,340 $1,209,484 $814,008 $4,420,946 $34,057,126
* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2006.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2006

Hormones and
Central Nervous Cardiovascular Anti-Infective Gastrointestinal Synthetic
State System Drugs Drugs Agents Drugs Substitutes
National Average 101,452,174 28,203,842 30,878,339 17,766,354 26,670,619
Alabama 2,140,899 626,089 875,200 306,598 639,857
Alaska 400,715 101,198 100,459 60,469 86,118
Arizona*
Arkansas 1,407,588 296,563 715,074 169,241 455,748
California 9,045,439 2,802,484 2,272,797 1,780,218 2,987,599
Colorado 1,069,789 226,303 348,885 113,335 296,045
Connecticut 842,376 248,753 99,701 150,737 172,392
Delaware 474,668 130,858 156,811 59,810 146,347
District of Columbia 249,844 126,349 41,333 23,539 62,707
Florida 4,682,035 1,496,059 1,687,208 736,934 1,247,809
Georgia 3,325,834 1,005,160 1,505,795 477,122 1,072,908
Hawaii 291,116 89,187 40,895 104,963 59,613
Idaho 584,587 91,635 185,790 60,558 139,064
Illinois**
Indiana 1,738,698 418,362 243,969 474,287 310,445
Iowa 1,565,908 286,447 465,216 174,881 337,777
Kansas 875,285 180,285 226,501 103,177 194,544
Kentucky 3,114,057 925,591 1,045,996 717,153 778,443
Louisiana 2,572,304 746,509 1,427,240 324,959 811,707
Maine 1,195,715 287,935 265,162 168,878 328,132
Maryland 1,504,685 238,501 124,899 81,527 177,577
Massachusetts 3,216,404 867,308 583,917 439,162 731,786
Michigan 3,681,581 263,324 419,125 289,437 335,703
Minnesota 1,214,947 247,991 197,012 306,870 240,828
Mississippi 1,227,077 398,210 756,906 138,912 401,681
Missouri 3,293,133 922,232 763,857 523,803 819,297
Montana 356,695 61,087 85,760 55,737 76,651
Nebraska 868,548 143,502 297,662 250,327 189,594
Nevada 414,998 105,097 83,276 46,699 86,000
New Hampshire 504,913 84,574 106,934 93,683 99,823
New Jersey 1,809,268 722,488 350,018 286,848 468,141
New Mexico**
New York 11,966,230 4,698,451 4,045,185 3,073,156 3,954,280
North Carolina 4,261,361 1,174,949 1,581,818 658,914 1,238,184
North Dakota 204,089 35,843 62,089 17,811 46,265
Ohio 6,478,642 1,857,167 1,398,871 1,495,818 1,536,416
Oklahoma 1,468,699 256,625 661,126 180,832 400,746
Oregon 1,114,049 100,201 93,804 152,376 118,415
Pennsylvania 3,120,422 989,450 604,944 515,994 742,156
Rhode Island 444,880 98,040 51,035 79,066 70,050
South Carolina 1,819,565 555,888 726,125 229,727 656,080
South Dakota 242,537 39,570 120,351 33,928 67,594
Tennessee**
Texas 7,148,798 1,140,878 4,049,974 969,390 1,671,886
Utah 873,697 126,180 247,456 115,845 187,596
Vermont 179,815 34,077 41,798 21,819 38,697
Virginia 1,603,379 316,100 310,353 433,665 307,837
Washington 2,600,102 683,471 408,939 621,500 645,765
West Virginia 1,971,453 567,686 537,186 282,285 485,447
Wisconsin 2,106,763 1,363,795 384,407 339,608 704,710
Wyoming 178,587 25,390 79,480 24,756 44,159

* Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2006.

4-21
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescriptions Processed by Category, 2006 (Con't.)

Unclassified Blood
Therapeutic Autonomic Formulation and
State Agents Drugs Coagulation Other Totals
National Average 6,268,434 17,537,906 4,891,738 63,907,736 297,577,142
Alabama 168,748 454,060 88,786 1,660,430 6,960,667
Alaska 20,134 62,007 10,788 156,362 998,250
Arizona*
Arkansas 115,553 239,732 31,557 852,224 4,283,280
California 490,423 1,331,965 940,240 5,341,431 26,992,596
Colorado 53,060 198,805 28,935 476,276 2,811,433
Connecticut 35,658 111,426 41,682 367,873 2,070,598
Delaware 34,489 90,999 14,446 258,039 1,366,467
District of Columbia 11,727 37,341 15,756 148,948 717,544
Florida 353,914 942,475 276,286 2,666,541 14,089,261
Georgia 201,071 762,350 180,934 2,630,570 11,161,744
Hawaii 17,075 39,586 18,354 187,607 848,396
Idaho 32,321 86,270 15,178 241,371 1,436,774
Illinois**
Indiana 60,883 224,143 109,361 1,051,010 4,631,158
Iowa 74,570 222,141 47,273 687,138 3,861,351
Kansas 44,893 117,478 23,634 375,721 2,141,518
Kentucky 193,352 607,576 148,184 2,304,238 9,834,590
Louisiana 206,173 675,836 128,269 2,360,905 9,253,902
Maine 46,200 182,939 26,170 360,048 2,861,179
Maryland 29,873 111,830 57,114 292,043 2,618,049
Massachusetts 125,210 383,543 87,330 1,213,739 7,648,399
Michigan 78,102 230,965 109,658 877,786 6,285,681
Minnesota 44,793 147,473 37,259 591,387 3,028,560
Mississippi 100,173 252,461 58,145 1,051,456 4,385,021
Missouri 180,439 558,733 186,344 1,793,995 9,041,833
Montana 18,383 54,971 6,505 130,934 846,723
Nebraska 52,845 145,155 28,543 705,180 2,681,356
Nevada 21,349 76,150 17,695 169,091 1,020,355
New Hampshire 19,261 67,274 12,445 217,324 1,206,231
New Jersey 131,048 299,878 102,911 1,190,262 5,360,862
New Mexico**
New York 991,934 2,542,133 405,051 8,927,090 40,603,510
North Carolina 314,040 827,444 157,782 3,036,909 13,251,401
North Dakota 8,953 28,863 5,480 77,492 486,885
Ohio 345,995 1,153,570 340,786 3,837,740 18,445,005
Oklahoma 138,427 323,674 34,860 708,101 4,173,090
Oregon 17,057 76,252 17,161 285,319 1,974,634
Pennsylvania 159,531 409,135 242,006 1,438,404 8,222,042
Rhode Island 20,348 51,280 21,006 188,706 1,024,411
South Carolina 113,591 357,987 104,118 1,409,132 5,972,213
South Dakota 18,183 43,981 5,486 135,529 707,159
Tennessee**
Texas 611,094 1,640,532 271,786 8,561,048 26,065,386
Utah 30,652 116,790 18,019 365,710 2,081,945
Vermont 7,224 22,715 4,337 73,197 423,679
Virginia 90,846 223,178 82,272 1,109,731 4,477,361
Washington 97,358 359,914 87,068 1,249,585 6,753,702
West Virginia 132,063 314,339 70,166 897,331 5,257,956
Wisconsin 196,115 297,400 170,233 1,146,725 6,709,756
Wyoming 13,303 33,157 4,339 100,058 503,229

*Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
** Data not reported for Illinois, New Mexico and Tennessee due to inconsistencies.

Source: CMS, State Drug Utilization Data, FY 2006.

4-22
National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Average Cost Per Prescription, 2006*

Drug Prescriptions Average


State Payments Processed Prescription Cost
National Average $20,676,735,445 297,577,142 $69.48
Alabama $407,931,884 6,960,667 $58.61
Alaska $77,757,127 998,250 $77.89
Arizona**
Arkansas $300,658,348 4,283,280 $70.19
California $2,402,154,993 26,992,596 $88.99
Colorado $176,607,249 2,811,433 $62.82
Connecticut $177,192,838 2,070,598 $85.58
Delaware $92,518,058 1,366,467 $67.71
District of Columbia $60,620,003 717,544 $84.48
Florida $1,112,599,863 14,089,261 $78.97
Georgia $705,511,106 11,161,744 $63.21
Hawaii $56,751,303 848,396 $66.89
Idaho $97,429,041 1,436,774 $67.81
Illinois
Indiana $311,506,225 4,631,158 $67.26
Iowa $237,595,621 3,861,351 $61.53
Kansas $154,081,390 2,141,518 $71.95
Kentucky $478,179,463 9,834,590 $48.62
Louisiana $634,534,122 9,253,902 $68.57
Maine $170,014,797 2,861,179 $59.42
Maryland $232,211,842 2,618,049 $88.70
Massachusetts $477,688,017 7,648,399 $62.46
Michigan $419,473,418 6,285,681 $66.73
Minnesota $222,743,806 3,028,560 $73.55
Mississippi $266,578,424 4,385,021 $60.79
Missouri $606,644,350 9,041,833 $67.09
Montana $58,638,538 846,723 $69.25
Nebraska $143,992,083 2,681,356 $53.70
Nevada $80,085,645 1,020,355 $78.49
New Hampshire $67,508,812 1,206,231 $55.97
New Jersey $489,617,709 5,360,862 $91.33
New Mexico
New York $3,284,487,687 40,603,510 $80.89
North Carolina $958,338,342 13,251,401 $72.32
North Dakota $29,980,505 486,885 $61.58
Ohio $1,122,124,442 18,445,005 $60.84
Oklahoma $315,036,594 4,173,090 $75.49
Oregon $129,704,452 1,974,634 $65.69
Pennsylvania $418,331,193 8,222,042 $50.88
Rhode Island $71,572,019 1,024,411 $69.87
South Carolina $399,033,749 5,972,213 $66.82
South Dakota $46,751,613 707,159 $66.11
Tennessee
Texas $1,675,428,126 26,065,386 $64.28
Utah $126,499,707 2,081,945 $60.76
Vermont $27,780,892 423,679 $65.57
Virginia $251,087,476 4,477,361 $56.08
Washington $382,210,545 6,753,702 $56.59
West Virginia $311,502,896 5,257,956 $59.24
Wisconsin $373,982,006 6,709,756 $55.74
Wyoming $34,057,126 503,229 $67.68

*Rebates have not been subtracted from these figures.


**Data not reported for Arizona. Arizona has a 1115 waiver for which special rules apply.
Source: CMS, State Drug Utilization Data, FY 2006.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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 DHHS 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 DHHS and the agreement provides for a minimum
aggregate rebate of 10% of the State’s expenditures for the manufacturer’s products.

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

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

! For all innovator products, reimbursement requires: (1) a rebate that is the greater of 15.1
percent of the average manufacturer’s price (AMP) or the difference between the AMP and
the manufacturer’s “best price,” and (2) an additional rebate for any price increase for a
product that exceeds the increase in the Consumer Price Index (CPI-U) for all items since the
fall of 1990. AMP is the average price paid by wholesalers for products distributed to the
retail class of trade. The best price is the lowest price offered to any other customer,
excluding Federal Supply Schedule prices, prices to State pharmaceutical assistance
programs, and prices that are nominal in amount, and includes all discounts and rebates.
! For generic drugs (non-innovator drugs), reimbursement requires: a rebate of 11 percent of
each product’s AMP.

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

4-24
National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Drug Rebates, 2005

Allocation of
State Drug Rebate Monies1 Total Rebates2 Federal Share2
National Total $12,409,442,413 $7,171,923,418
Alabama Medicaid General $145,238,083 $103,232,896
Alaska Medicaid General $27,511,193 $15,840,945
Arizona* - - -
Arkansas Medicaid Drug Budget $93,635,941 $70,052,049
California Medicaid Drug Budget $2,056,515,858 $1,055,322,930
Colorado Medicaid General $74,633,154 $37,746,924
Connecticut General Fund $109,418,487 $54,760,945
Delaware Medicaid General $35,424,633 $18,108,454
District of Columbia General Fund $24,703,979 $17,293,632
Florida Medicaid Drug Budget $728,568,990 $429,549,051
Georgia Medicaid General $336,290,253 $204,764,236
Hawaii General Fund $25,103,501 $14,678,017
Idaho Medicaid General $48,525,397 $34,268,635
Illinois Medicaid Drug Budget $575,457,731 $289,935,647
Indiana General Fund $204,350,287 $128,403,306
Iowa Medicaid Drug Budget $90,050,305 $57,237,973
Kansas Medicaid Drug Budget $93,125,615 $56,998,633
Kentucky General Fund $217,275,788 $151,461,068
Louisiana Medicaid Drug Budget $278,830,912 $198,561,571
Maine General Fund $99,804,572 $64,958,802
Maryland Medicaid Drug Budget $154,069,573 $77,297,337
Massachusetts General Fund $281,523,695 $140,761,848
Michigan Medicaid Drug Budget $325,135,732 $184,773,823
Minnesota General Fund $118,040,245 $59,142,717
Mississippi General Fund $180,055,329 $138,986,927
Missouri Medicaid Drug Budget $300,271,256 $184,397,584
Montana Medicaid General $25,166,744 $18,138,955
Nebraska Medicaid General $68,431,450 $41,009,525
Nevada General Fund $34,103,702 $19,100,049
New Hampshire General Fund $37,566,506 $18,924,184
New Jersey Medicaid Drug Budget $261,578,682 $131,087,744
New Mexico Medicaid General $25,417,996 $18,885,572
New York General Fund $1,300,131,531 $650,065,766
North Carolina Medicaid General $452,693,066 $288,839,970
North Dakota Medicaid Drug Budget $15,334,927 $10,380,570
Ohio Medicaid General $591,916,354 $353,797,769
Oklahoma Medicaid General $103,412,619 $72,740,150
Oregon General Fund $60,464,711 $37,234,839
Pennsylvania Medicaid General $253,722,496 $137,457,156
Rhode Island General Fund $44,671,288 $24,738,960
South Carolina Medicaid Drug Budget $217,001,438 $152,540,481
South Dakota Medicaid Drug Budget $22,083,160 $14,646,662
Tennessee Medicaid General $768,857,139 $498,296,312
Texas Medicaid Drug Budget $736,763,024 $449,541,903
Utah General Fund $39,887,001 $28,627,828
Vermont Health Access Trust Fund $45,054,392 $27,124,381
Virginia Virginia Health Care Fund $174,023,976 $87,234,401
Washington General Fund $176,803,507 $89,333,600
West Virginia Medicaid General $114,327,436 $85,345,432
Wisconsin Medicaid General $202,803,404 $120,383,018
Wyoming Medicaid Drug Budget $13,665,355 $7,912,241

*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
Sources: 1As reported by State drug program administrators in the 2007 NPC Survey; 2 CMS, CMS-64 Report, FY 2005.
Includes reported state supplemental rebates for AL, CA, FL, GA, HI, IA, ID, IL, KS, KY, LA, ME, MI, MN, NH, NV, OH,
TN, VA, VT, WA, and WV.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Medicaid Drug Rebate Trends, 2001-2005

State 2001 2002** 2003** 2004** 2005**


National Total $4,948,222,331 $5,917,504,760 $7,008,382,303 $9,652,191,744 $12,409,442,413
Alabama $76,624,463 $84,994,286 $102,784,110 $127,283,554 $145,238,083
Alaska $11,337,883 $14,347,654 $15,060,446 $29,188,871 $27,511,193
Arizona* - - - - -
Arkansas $45,744,406 $56,688,398 $58,097,761 $82,286,907 $93,635,941
California $786,113,991 $946,651,118 $1,207,800,866 $1,611,941,832 $2,056,515,858
Colorado $34,264,574 $39,054,140 $32,446,928 $60,264,706 $74,633,154
Connecticut $61,916,192 $62,627,160 $81,550,711 $96,617,771 $109,418,487
Delaware $17,042,045 $16,990,455 $28,352,506 $25,068,377 $35,424,633
District of Columbia $10,446,499 $11,445,790 $15,120,780 $20,512,606 $24,703,979
Florida $297,362,792 $353,649,807 $464,880,949 $670,836,774 $728,568,990
Georgia $110,087,285 $205,469,531 $219,238,104 $256,980,634 $336,290,253
Hawaii $14,363,603 $15,267,796 $19,212,047 $27,794,342 $25,103,501
Idaho $18,841,154 $22,939,130 $31,430,642 $30,041,654 $48,525,397
Illinois $170,733,612 $190,316,986 $292,630,625 $469,399,409 $575,457,731
Indiana $103,148,144 $126,512,101 $131,850,261 $177,387,116 $204,350,287
Iowa $42,602,101 $50,092,788 $62,173,583 $84,729,745 $90,050,305
Kansas $39,731,568 $29,755,595 $59,849,370 $65,409,297 $93,125,615
Kentucky $104,759,238 $133,330,557 $124,919,867 $169,285,080 $217,275,788
Louisiana $115,254,842 $113,729,749 $165,904,174 $220,068,423 $278,830,912
Maine $41,847,632 $47,395,300 $68,331,107 $80,173,931 $99,804,572
Maryland $34,263,429 $54,261,949 $77,934,401 $90,642,415 $154,069,573
Massachusetts $180,517,139 $191,118,385 $208,146,240 $277,112,233 $281,523,695
Michigan $111,716,756 $172,522,597 $179,774,542 $246,698,471 $325,135,732
Minnesota $54,548,714 $62,655,474 $54,081,115 $92,188,275 $118,040,245
Mississippi $88,481,567 $115,221,421 $114,233,479 $125,406,134 $180,055,329
Missouri $133,927,028 $147,281,505 $178,620,625 $220,602,904 $300,271,256
Montana $13,359,968 $15,955,235 $17,172,113 $20,783,447 $25,166,744
Nebraska $30,219,685 $47,855,128 $42,766,762 $46,634,148 $68,431,450
Nevada $16,330,579 $13,547,604 $21,078,909 $28,947,187 $34,103,702
New Hampshire $13,934,765 $20,888,707 $27,628,562 $33,253,239 $37,566,506
New Jersey $124,127,231 $127,373,014 $149,040,244 $197,451,860 $261,578,682
New Mexico $12,110,896 $13,274,387 $19,585,223 $24,519,599 $25,417,996
New York $543,984,948 $663,973,100 $598,407,083 $962,452,836 $1,300,131,531
North Carolina $207,551,841 $207,064,443 $260,487,290 $324,686,591 $452,693,066
North Dakota $8,780,182 $11,651,682 $11,369,358 $14,069,176 $15,334,927
Ohio $217,702,350 $263,267,258 $325,329,459 $447,436,396 $591,916,354
Oklahoma $40,177,945 $51,471,649 $59,205,487 $74,198,766 $103,412,619
Oregon $34,991,037 $54,474,938 $65,706,778 $53,842,614 $60,464,711
Pennsylvania $129,265,110 $154,338,235 $149,563,463 $196,449,883 $253,722,496
Rhode Island $21,467,002 $26,213,636 $30,477,726 $38,067,294 $44,671,288
South Carolina $95,438,155 $98,272,773 $119,101,600 $163,587,518 $217,001,438
South Dakota $9,405,933 $12,056,925 $14,808,661 $17,559,898 $22,083,160
Tennessee $102,644,077 $180,613,885 $224,072,761 $492,767,285 $768,857,139
Texas $268,557,241 $305,110,523 $392,292,711 $507,363,520 $736,763,024
Utah $21,949,963 $36,756,960 $25,931,043 $45,818,326 $39,887,001
Vermont $22,045,277 $24,488,863 $28,595,852 $35,983,462 $45,054,392
Virginia $79,484,868 $76,776,155 $112,854,618 $137,924,722 $174,023,976
Washington $91,250,830 $100,874,789 $123,683,508 $148,998,346 $176,803,507
West Virginia $52,402,218 $48,976,536 $69,568,029 $107,509,922 $114,327,436
Wisconsin $79,554,207 $89,226,751 $118,267,026 $162,034,977 $202,803,404
Wyoming $5,809,366 $8,681,912 $6,962,798 $11,929,271 $13,665,355

*Does not apply for Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported state supplemental rebates.
Source: CMS, CMS-64 Report, FY 2001 - FY 2005.

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Medicaid Drug Rebate Trends


Annual Percent Change, 2000-2005

% Change % Change % Change % Change % Change


State 00-01 01-02 02-03 03-04 04-05
National Total 24.3% 19.6% 18.4% 37.7% 22.22%
Alabama 25.6% 10.9% 20.9% 23.8% 12.36%
Alaska 31.9% 26.5% 5.0% 93.8% -6.10%
Arizona* - - - - -
Arkansas 12.1% 23.9% 2.5% 41.6% 12.12%
California 30.8% 20.4% 27.6% 33.5% 21.62%
Colorado 18.8% 14.0% -16.9% 85.7% 19.25%
Connecticut 25.9% 1.1% 30.2% 18.5% 11.70%
Delaware 23.7% -0.3% 66.9% -11.6% 29.23%
District of Columbia 13.4% 9.6% 32.1% 35.7% 16.97%
Florida 19.6% 18.9% 31.5% 44.3% 7.92%
Georgia 19.8% 86.6% 6.7% 17.2% 23.58%
Hawaii 31.2% 6.3% 25.8% 44.7% -10.72%
Idaho 34.7% 21.8% 37.0% -4.4% 38.09%
Illinois 18.9% 11.5% 53.8% 60.4% 18.43%
Indiana 22.1% 22.7% 4.2% 34.5% 13.19%
Iowa 18.2% 17.6% 24.1% 36.3% 5.91%
Kansas 28.1% -25.1% 101.1% 9.3% 29.76%
Kentucky 11.8% 27.3% -6.3% 35.5% 22.09%
Louisiana 35.9% -1.3% 45.9% 32.6% 21.07%
Maine 32.4% 13.3% 44.2% 17.3% 19.67%
Maryland -18.6% 58.4% 43.6% 16.3% 41.17%
Massachusetts 23.5% 5.9% 8.9% 33.1% 1.57%
Michigan 47.6% 54.4% 4.2% 37.2% 24.12%
Minnesota 26.2% 14.9% -13.7% 70.5% 21.90%
Mississippi 44.4% 30.2% -0.9% 9.8% 30.35%
Missouri 21.7% 10.0% 21.3% 23.5% 26.53%
Montana 21.6% 19.4% 7.6% 21.0% 17.42%
Nebraska -2.5% 58.4% -10.6% 9.0% 31.85%
Nevada 235.8% -17.0% 55.6% 37.3% 15.12%
New Hampshire -7.6% 49.9% 32.3% 20.4% 11.48%
New Jersey 17.6% 2.6% 17.0% 32.5% 24.52%
New Mexico 36.1% 9.6% 47.5% 25.2% 3.53%
New York 15.7% 22.1% -9.9% 60.8% 25.97%
North Carolina 48.2% -0.2% 25.8% 24.6% 28.28%
North Dakota 35.0% 32.7% -2.4% 23.7% 8.25%
Ohio 26.8% 20.9% 23.6% 37.5% 24.41%
Oklahoma 8.2% 28.1% 15.0% 25.3% 28.25%
Oregon 9.2% 55.7% 20.6% -18.1% 10.95%
Pennsylvania 8.6% 19.4% -3.1% 31.3% 22.57%
Rhode Island 11.7% 22.1% 16.3% 24.9% 14.78%
South Carolina 30.6% 3.0% 21.2% 37.4% 24.61%
South Dakota 30.7% 28.2% 22.8% 18.6% 20.48%
Tennessee 148.5% 76.0% 24.1% 119.9% 35.91%
Texas 20.8% 13.6% 28.6% 29.3% 31.14%
Utah 0.3% 67.5% -29.5% 76.7% -14.87%
Vermont 23.4% 11.1% 16.8% 25.8% 20.13%
Virginia 5.1% -3.4% 47.0% 22.2% 20.74%
Washington 30.8% 10.5% 22.6% 20.5% 15.73%
West Virginia 12.1% -6.5% 42.0% 54.5% 5.96%
Wisconsin 19.9% 12.2% 32.5% 37.0% 20.10%
Wyoming 23.1% 49.4% -19.8% 71.3% 12.70%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
Source: CMS, CMS-64 Report, FY 2000 - FY 2005.

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Rebates as a Percent of Drug Expenditures, 2005

Rebates as % Drug
State Drug Expenditures Rebates** Expenditure
National Total $43,077,457,835 $12,409,442,413 28.8%
Alabama $606,578,572 $145,238,083 23.9%
Alaska $127,315,710 $27,511,193 21.6%
Arizona* $5,486,350 - -
Arkansas $419,350,865 $93,635,941 22.3%
California $5,187,275,034 $2,056,515,858 39.6%
Colorado $285,371,981 $74,633,154 26.2%
Connecticut $496,715,211 $109,418,487 22.0%
Delaware $122,026,857 $35,424,633 29.0%
District of Columbia $105,948,589 $24,703,979 23.3%
Florida $2,503,151,114 $728,568,990 29.1%
Georgia $1,184,915,057 $336,290,253 28.4%
Hawaii $119,852,050 $25,103,501 20.9%
Idaho $168,780,832 $48,525,397 28.8%
Illinois $1,716,361,486 $575,457,731 33.5%
Indiana $751,525,376 $204,350,287 27.2%
Iowa $412,274,229 $90,050,305 21.8%
Kansas $296,283,292 $93,125,615 31.4%
Kentucky $794,519,116 $217,275,788 27.3%
Louisiana $1,082,597,269 $278,830,912 25.8%
Maine $282,039,741 $99,804,572 35.4%
Maryland $578,238,275 $154,069,573 26.6%
Massachusetts $1,067,378,270 $281,523,695 26.4%
Michigan $965,368,582 $325,135,732 33.7%
Minnesota $441,908,835 $118,040,245 26.7%
Mississippi $665,504,688 $180,055,329 27.1%
Missouri $1,246,144,317 $300,271,256 24.1%
Montana $105,154,540 $25,166,744 23.9%
Nebraska $228,576,569 $68,431,450 29.9%
Nevada $134,564,289 $34,103,702 25.3%
New Hampshire $133,253,555 $37,566,506 28.2%
New Jersey $1,158,553,486 $261,578,682 22.6%
New Mexico $116,252,520 $25,417,996 21.9%
New York $5,253,655,620 $1,300,131,531 24.7%
North Carolina $1,790,399,967 $452,693,066 25.3%
North Dakota $64,157,312 $15,334,927 23.9%
Ohio $1,981,230,721 $591,916,354 29.9%
Oklahoma $500,420,840 $103,412,619 20.7%
Oregon $261,373,083 $60,464,711 23.1%
Pennsylvania $1,009,804,038 $253,722,496 25.1%
Rhode Island $173,884,102 $44,671,288 25.7%
South Carolina $716,694,085 $217,001,438 30.3%
South Dakota $88,963,445 $22,083,160 24.8%
Tennessee $2,344,351,015 $768,857,139 32.8%
Texas $2,416,879,360 $736,763,024 30.5%
Utah $221,854,365 $39,887,001 18.0%
Vermont $184,730,219 $45,054,392 24.4%
Virginia $634,701,038 $174,023,976 27.4%
Washington $682,553,233 $176,803,507 25.9%
West Virginia $431,614,161 $114,327,436 26.5%
Wisconsin $759,682,514 $202,803,404 26.7%
Wyoming $51,242,060 $13,665,355 26.7%
*Does not apply to Arizona. Arizona has a 1115 waiver for which special rules apply.
**Includes reported State supplemental rebates.
Source: CMS, CMS-64 Report, FY 2005.

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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.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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

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

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

! Name and description of the medication;


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

! Name, address, telephone number, date of birth (or age) and gender;
! Individual history where significant, including a disease state or states, known allergies and
drug reactions, and a comprehensive list of medications and relevant devices; and
! Pharmacist comments relevant to the individual’s pharmaceutical therapy.
Retrospective DUR. This activity continuously assesses data on drug use against established
standards, preferably using automated claims processing and information retrieval techniques to
monitor for therapeutic appropriateness, overutilization and underutilization, appropriate use of
generic products, therapeutic duplication, drug-disease contraindications, drug-drug interactions,
incorrect drug dosage or duration of drug treatment, clinical abuse/misuse and, as necessary,
introduce remedial strategies in order to improve the quality of care and to conserve program funds or
personal expenditures. This activity is also intended to identify patterns of fraud, abuse, gross
overuse, or inappropriate of medically unnecessary care among physicians, pharmacists, and
recipients, or with respect to specific drugs or groups of drugs.

State Drug Use Review Board. Each State must provide for the establishment of a DUR board of
health practitioners (one-third to one-half physicians and at least one-third pharmacists) to help
implement the DUR program. Each State must require its DUR board to make annual reports to
DHHS on its activities and on cost savings resulting from the DUR program.
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National Pharmaceutical Council Pharmaceutical Benefits 2007

Pharmacy Advisory Committees


Preferred Product Introduction
State Pharmacy Advisory Committee Meetings
Process
Alabama Pharmacy Advisory Committee Quarterly Introductory letter, Electronic submission
Alaska None - Introductory letter
Arizona* - - Inform health plans directly
Arkansas None - Introductory letter, E-mail Pamela Ford
California Medi-Cal Contract Drug Advisory Comm. Ad Hoc Petition with specific content requirements
Colorado None - Introductory letter
Connecticut DUR Board and P & T Committee advise Quarterly Introductory letter
Delaware DUR Board Bi-Monthly Introductory letter
District of Columbia Pharmacy Services Committee Monthly Introductory letter
Florida None - Introductory letter
Georgia None Quarterly PBM’s quarterly forum
Hawaii DUR Board Quarterly Formulary kit
Idaho None - Mail dossier
Pharm. Subcommittee of Medicaid Introductory letter and manuf. report to First
Illinois Bi-Monthly
Advisory Committee DataBank
Indiana DUR Board Monthly Electronic form
Iowa DUR Board 8 per year Dossier to info@iowamedicaidpdl.com
Kansas None - Introductory letter
Kentucky Pharmacy & Therapeutics Committee Bi-Monthly Introductory letter, Package insert
Louisiana Pharmacy Advisory Committee Semiannually Intro. ltr., Package insert, & FDA approval ltr.
Maine DUR Committee Monthly Introductory letter
Maryland Medicaid Advisory Committee Quarterly Introductory letter
Massachusetts DUR Board Quarterly Introductory letter
Michigan Pharmacy & Therapeutics Committee Quarterly FDB files
Minnesota None - Introductory letter, Contact M.C. Woheltz
Mississippi None - Introductory letter
Missouri Pharmacy Advisory Group Quarterly AMPC format dossier
Montana DUR Board Monthly Introductory letter, Electronic submission
Nebraska DUR Board Bi-Monthly Introductory letter
Nevada DUR Board Quarterly Introductory letter
New Hampshire None - Introductory letter
New Jersey None - Introductory letter
New Mexico None - Introductory letter
New York Pharmacy Advisory Committee Quarterly Introductory letter
North Carolina Pharmacy & Therapeutics Committee Monthly Introductory letter
North Dakota None - Contact First DataBank
Ohio Pharmacy & Therapeutics Committee Quarterly Introductory letter
Oklahoma DUR Board Monthly E-mail to pharmacy@okhca.org
Oregon DUR Board Quarterly Introductory letter
Pennsylvania Pharmacy & Therapeutics Committee Quarterly Introductory letter/e-mail to State agency
Rhode Island None - Introductory letter
South Carolina Medical Care Advisory Committee Quarterly Introductory letter
South Dakota Pharmacy & Therapeutics Committee Ad Hoc Introductory letter
Tennessee* TennCare Pharmacy Advisory Comm. Quarterly Introductory letter
Texas None - State form
Utah DUR Board Monthly Introductory letter
Vermont DUR Board 10 per year Introductory letter
Virginia None - Introductory letter
Washington Drug Evaluation Matrix Team Weekly AMCP format dossier
West Virginia Medical Services Fund Advisory Council Quarterly Introductory letter
Wisconsin None - Introductory letter
Wyoming None - 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 2007 NPC Survey.

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Pharmacy Benefit Design - Coverage


State Cosmetics Fertility Drugs Experimental Drugs
Alabama Not Covered Not Covered Not Covered
Alaska Covered with Restrictions Not Covered Not Covered
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Not Covered Not Covered Not Covered
Colorado Not Covered Not Covered Not Covered
Connecticut Not Covered Not Covered Not Covered
Delaware Not Covered Not Covered Not Covered
District of Columbia Not Covered 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 Covered with Restrictions 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.
**Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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Pharmacy Benefit Design - Coverage (Con’t)


Disposable Needles for Syringe Combinations Blood Glucose Test
State Prescribed Insulin Insulin Use for Insulin Use Strips
Alabama Covered with Restrictions Covered Covered Covered
Alaska Covered Covered as DME Covered as DME Covered as DME
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 Covered with Restrictions
Florida Covered Not Covered Not Covered Not Covered
Georgia Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Hawaii Covered Covered as DME Covered as DME Covered as DME
Idaho Covered Covered as DME Covered as DME Covered as DME
Illinois Covered with Restrictions Covered Covered Covered with Restrictions
Indiana Covered Covered Covered Covered
Iowa Covered Not Covered Not Covered Not Covered
Kansas Covered Covered with PA as DME Covered with PA as DME Covered as DME
Kentucky Covered Not Covered Covered Not Covered
Louisiana Covered Covered Covered Covered
Maine Covered Covered Covered Covered
Maryland Covered Covered Covered Covered as DME
Massachusetts Covered Covered with Restrictions Covered with Restrictions Covered with Restrictions
Michigan Covered Covered Covered as DME Covered as DME
Minnesota Covered Covered as DME Covered as DME Covered as DME
Mississippi Covered Not Covered Not Covered Not Covered
Missouri Covered Covered Covered Covered
Montana Covered, PA Required Covered as DME Covered as DME Covered as DME
Nebraska Covered, PA Required Covered as DME Covered as DME 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 Not Covered Not Covered Not Covered
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 Not Covered Not Covered
Utah Covered Covered Covered Covered
Vermont Covered Covered Covered Covered
Virginia Covered Covered as DME Covered Covered as DME
Washington Covered Covered Covered Covered
West Virginia Covered with Restrictions Covered with Limitations Covered with Limitations Covered
Wisconsin Covered Covered as DMS Covered as DMS Covered as DMS
Wyoming Covered Covered Covered Covered
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
**Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Pharmacy Benefit Design - Coverage (Con’t)


Urine Ketone Total Interdialytic Parenteral
State Test Strips Parenteral Nutrition Nutrition
Alabama Not Covered Covered Covered with Restrictions
Alaska Covered as DME Covered under Home Infusion Covered under Home Infusion
Arizona* - - -
Arkansas Not Covered Not Covered Not Covered
California Covered Covered, PA Required Not Covered
Colorado DME Covered Covered
Connecticut Covered Not Covered Not Covered
Delaware Covered Covered Covered
District of Columbia Not Covered Covered with Restrictions Covered with Restrictions
Florida Not Covered Covered Covered
Georgia Covered with Restrictions Covered, PA Required Covered, PA Required
Hawaii Covered as DME Covered, PA Required Covered, PA Required
Idaho Covered as DME Covered as DME Covered as DME
Illinois Covered Covered Covered
Indiana Covered Covered Covered
Iowa Not Covered Not Covered Not Covered
Kansas Covered as DME Covered with PA as DME Covered with PA as DME
Kentucky Not Covered Covered, PA Required Covered, PA Required
Louisiana Covered Covered as DME Covered as DME
Maine Covered Covered Covered
Maryland Covered as DME Covered Covered with Restrictions
Massachusetts Covered with Restrictions Covered with Restrictions Not Covered
Michigan Covered as DME Covered, PA required Covered
Minnesota Covered as DME Covered Covered
Mississippi Not Covered Covered Not Covered
Missouri Covered Covered Covered
Montana Not Covered Covered, PA Required Covered, PA Required
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 Not Covered Not Covered Not Covered
North Dakota Not Covered Covered Not Covered
Ohio Covered as DME Covered as DME, PA Required Covered as DME, PA Required
Oklahoma Covered as DME Covered with Restrictions N/A
Oregon** Covered as DME Covered, PA Required Covered, PA Required
Pennsylvania Covered Not Covered Not 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 Covered, PA Required Covered, PA Required
Tennessee Covered Covered Covered
Texas Not Covered Not Covered Not Covered
Utah Covered Not Covered Not Covered
Vermont Not Covered Covered as DME Not Covered
Virginia Covered as DME Covered Covered
Washington Covered Covered Covered
West Virginia Covered Covered under DME Covered under DME
Wisconsin Covered as DMS 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.
**Subject to the restrictions of the Oregon Health Plan.
PA= Prior Authorization, DME = Durable Medical Equipment, DMS = Durable Medical Supplies
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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

*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Coverage of Vaccines and Unit Dose


State Method for Vaccine Reimbursement ^ Reimbursement for Unit Dose
Alabama VCP Yes
Alaska EPSDT, VCP Yes
Arizona* - -
Arkansas EPSDT, CHIP, VCP No
California VCP No
Colorado EPSDT No
Connecticut CHIP No
Delaware CHIP, VCP No
District of Columbia EPSDT, VCP Yes
Florida VCP Yes
Georgia EPSDT, CHIP, VCP Yes
Hawaii EPSDT, CHIP Yes
Idaho VCP Yes
Illinois VCP No
Indiana VCP Yes
Iowa VCP Yes
Kansas VCP No
Kentucky EPSDT, CHIP, VCP, Pharmacy Program Yes
Louisiana EPSDT, VCP No
Maine EPSDT, VCP, Prescription Drug "Safety Net Program" No
Maryland VCP No
Massachusetts Department of Public Health No
Michigan EPSDT, CHIP, VCP Yes
Minnesota CHIP, VCP Yes
Mississippi VCP Yes
Missouri VCP (Pharmacy Program for adults) Yes
Montana EPSDT, CHIP, VCP Yes
Nebraska VCP No
Nevada EPSDT Yes
New Hampshire EPSDT, CHIP, VCP Yes
New Jersey VCP Yes
Yes – for commercially unit dose
New Mexico EPSDT, CHIP, VCP, Dept. of Health
packaged drugs
New York EPSDT, CHIP, VCP No
North Carolina VCP No
North Dakota EPSDT No
Ohio VCP No
Oklahoma EPSDT, VCP No
Oregon VCP No
Pennsylvania EPSDT, CHIP, VCP No
Rhode Island VCP No
South Carolina VCP Yes
South Dakota EPSDT, CHIP, VCP Yes
Tennessee EPSDT, VCP No
Texas EPSDT, CHIP No
Utah VCP Yes
Vermont VCP Yes
Virginia EPSDT, VCP Yes
Washington EPSDT Yes
West Virginia EPSDT, CHIP, VCP, Physician Payment Program Yes
Wisconsin EPSDT, CHIP, VCP No
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 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Coverage of Over-the-Counter Medications


Allergy, Asthma,
State and Sinus Analgesics Cough and Cold Smoking Deterrents
Alabama Covered Covered Covered with Restrictions Not Covered
Alaska Not Covered Not Covered Not Covered Covered
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Covered with Restrictions
California Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req.
Colorado Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Connecticut Covered Not Covered Covered with Restrictions Not Covered
Delaware Covered Covered Covered Covered with Restrictions
District of Columbia Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Florida Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Georgia Limited Coverage Covered with Restrictions Covered with Restrictions Not Covered
Hawaii Covered Covered Limited Coverage Covered with Restrictions
Idaho Limited Coverage Not Covered Not Covered Not Covered
Illinois Covered with Restrictions Covered with Restrictions Limited Coverage Covered
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered Covered Covered Covered
Kansas Covered Covered Covered with Restrictions Covered with Restrictions
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Louisiana Covered with Restrictions Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Maryland Covered with Restrictions Limited Coverage Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Not Covered Covered
Minnesota Limited Coverage Limited Coverage Limited Coverage Limited Coverage
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 PA Required
Nebraska Covered with Restrictions Covered with Restrictions Covered with Restrictions Not Covered
Nevada Covered Covered Covered Covered
New Hampshire Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
New Jersey Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered
New Mexico Covered Covered Covered Covered
New York Covered Covered Covered Limited Coverage
North Carolina Covered Not Covered Not Covered Covered
North Dakota Covered with Restrictions Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Covered with Restrictions Not Covered Not Covered Covered with Restrictions
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered Covered with Restrictions Covered with Restrictions Covered
Rhode Island Not Covered Covered Covered Not Covered
South Carolina Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
South Dakota Limited Coverage 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 Separate program
Vermont Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
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 Covered Covered Not Covered
Wyoming Covered Covered Covered Covered with Restrictions
*Within Federal and State guidelines, individual managed care and pharmacy benefit management organizations make
formulary/drug decisions.
PA= Prior Authorization
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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


Digestive Products
State (non- H2 antagonists) H2 Antagonists Feminine Products Topical Products
Alabama Covered Covered Not Covered Covered
Alaska Not Covered Not Covered Limited Coverage Limited Coverage
Arizona* - - - -
Arkansas Limited Coverage Limited Coverage Limited Coverage Limited Coverage
California Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req. Partial Coverage, PA Req.
Colorado Covered with Restrictions Covered with Restrictions Not Covered Not Covered
Connecticut Covered with Restrictions Covered Not Covered Covered
Delaware Covered Covered Covered with Restrictions Covered
District of Columbia Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Florida Covered with Restrictions Not Covered Covered with Restrictions Not Covered
Georgia Not Covered Covered with Restrictions Not Covered Covered with Restrictions
Hawaii Covered Limited Coverage N/A Limited Coverage
Idaho Covered with Restrictions Not Covered Not Covered Limited Coverage
Illinois Covered Covered with Restrictions Not Covered Covered with Restrictions
Indiana Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Iowa Covered with Restrictions Not Covered Covered Covered
Kansas Covered Covered Covered with Restrictions Covered
Kentucky Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Louisiana Not Covered Not Covered Not Covered Not Covered
Maine Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Maryland Not Covered Covered with Restrictions Not Covered Not Covered
Massachusetts Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Michigan Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Minnesota Limited Coverage Not Covered Covered Limited Coverage
Mississippi Limited Coverage Limited Coverage Limited Coverage Limited Coverage
Missouri Limited Coverage Limited Coverage Not Covered Limited Coverage
Montana Covered Covered Not Covered Not Covered
Nebraska Covered with Restrictions Covered with Restrictions Not Covered Covered with Restrictions
Nevada Covered Covered Not Covered Covered with Restrictions
New Hampshire Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
New Jersey Not Covered Not Covered Not Covered Covered with Restrictions
New Mexico Covered Covered Not Covered Covered
New York Covered Covered Covered Covered
North Carolina Covered Not Covered Not Covered Not Covered
North Dakota Covered Covered Not Covered Covered with Restrictions
Ohio Selective Coverage Selective Coverage Selective Coverage Selective Coverage
Oklahoma Covered with Restrictions Not Covered Not Covered Not Covered
Oregon Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
Pennsylvania Covered with Restrictions Covered Not Covered Covered with Restrictions
Rhode Island Not Covered Not Covered Covered Covered
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 Covered with Restrictions Covered Covered Covered
Vermont Covered with Restrictions Covered with Restrictions Covered with Restrictions Covered with Restrictions
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 Not Covered Covered Covered
Wyoming Covered with Restrictions Covered Not 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 2007 NPC Survey.

4-38
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prior Authorization Process and Procedures


State PA Procedure Prior Authorization Committee Members Meetings
Alabama Yes Pharmacy and Therapeutics Committee 9 Quarterly
Alaska Yes No - -
Arizona* - - - -
Arkansas Yes DUR Board 9 Quarterly
California Yes No - -
Colorado Yes No - -
Connecticut Yes Pharmaceutical and Therapeutics Committee 14 Quarterly
Delaware Yes No - -
District of Columbia Yes No - -
Florida Yes No - -
Georgia Yes No - -
Hawaii Yes Yes 8 N/A
Idaho Yes PA Review Committee 5 Semi-annually
Illinois Yes Committee on Drugs and Therapeutics 12 Min. quarterly
Indiana Yes No - -
Iowa Yes No - -
Kansas Yes DUR Board 9 Bi-monthly
Kentucky Yes Pharmacy and Therapeutics Advisory Committee 14 Bi-monthly
Louisiana Yes Pharmaceutical and Therapeutics Committee 21 Semi-annually
Maine Yes DUR Board 13 9 meetings/yr.
Maryland Yes DUR Board 10 Quarterly
Massachusetts Yes No - -
Michigan Yes No - -
Minnesota Yes Drug Formulary Committee 9 Quarterly
Mississippi Yes Pharmacy and Therapeutics Committee 12 Quarterly
Missouri Yes Prior Authorization Committee 9 Quarterly
Montana Yes DUR Board 10 Monthly
Nebraska Yes No - -
Nevada Yes No - -
New Hampshire Yes Pharmacy and Therapeutics Advisory Committee 13 Quarterly
New Jersey Yes No - -
New Mexico Yes No - -
New York Yes Pharmacy and Therapeutics Committee 18 Quarterly
North Carolina Yes No - -
North Dakota Yes DUR Board 14 Quarterly
Ohio Yes No - -
Oklahoma Yes No - -
Oregon Yes Health Resources Commission 11 Monthly
Pennsylvania Yes Pharmacy and Therapeutics Committee 25 Quarterly
Rhode Island Yes No - -
South Carolina Yes Pharmacy and Therapeutics Committee 14 Quarterly
South Dakota Yes Pharmacy and Therapeutics Committtee 8 5 - 8/yr.
Tennessee Yes No - -
Texas Yes No - -
Utah Yes No - -
Vermont Yes No - -
Virginia Yes Pharmacy and Therapeutics Committee 12 Quarterly
Washington Yes DUR Team and Drug Eval. Matrix Team 8 Daily, weekly
West Virginia Yes Pharmaceutical and Therapeutics Committee 15 3 meetings/yr.
Wisconsin Yes Prior Authorization Advisory Comm. 11 Semi-annually
Wyoming Yes DUR Board 10 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 2007 NPC Survey.

4-39
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prior Authorization Process and Procedures (Con’t)


State Initiated By: Annual Requests % Approved
Alabama M.D., R.Ph., Pharm. Tech. 420,000 60%
Alaska M.D., R.Ph. (some drugs) 3,700 95%
Arizona* - - -
Arkansas M.D. 415,000 72%
California M.D., R.Ph. 1,800,000 76%
Colorado M.D., M.D.’s Agent 18,000 90%
Connecticut M.D., R.Ph. 37,000 94%
Delaware M.D., R.Ph. 34,000 92%
District of Columbia M.D., R.Ph. 4,800 65%
Florida M.D. 440,000 78%
Georgia M.D., R.Ph. 125,000 72%
Hawaii M.D., R.Ph., Pharm. Tech. 8,000 98%
Idaho M.D., R.Ph., N.P., P.A. 60,000 90%
Illinois M.D., R.Ph. 370,000 70%
Indiana M.D., Other Providers N/A N/A
Iowa M.D. 60,000 60%
Kansas M.D., R.Ph. 4,700 81%
Kentucky M.D., R.Ph. 285,000 58%
Louisiana M.D. 217,000 83%
Maine M.D. 78,000 80%
Maryland M.D., R.Ph. 36,000 99%
Massachusetts M.D., Other Licensed Prescriber N/A N/A
Michigan M.D. 100,000 98%
Minnesota M.D., R.Ph. 17,000 87%
Mississippi M.D. 282,000 20%
Missouri M.D., R.Ph., Other Authorized Prescriber 99,000 60%
Montana M.D., R.Ph., Pharm. Tech. 18,000 74%
Nebraska M.D., R.Ph. 15,000 65%
Nevada M.D. N/A N/A
New Hampshire M.D. 11,700 79%
New Jersey M.D., R.Ph. 715,000 95%
New Mexico M.D. N/A N/A
New York M.D./Ordering Provider 285,000 100%
North Carolina M.D., R.Ph. 23,000 19%
North Dakota M.D., R.Ph., Pharm. Tech. 2,000 60%
Ohio M.D., R.Ph. (sometimes) 133,000 99%
Oklahoma M.D., R.Ph. 168,000 70%
Oregon M.D. 21,400 90%
Pennsylvania M.D. 42,000 75%
Rhode Island M.D. N/A N/A
South Carolina M.D., R.Ph. 60,000 70%
South Dakota M.D., R.Ph. 20,000 20%
Tennessee M.D. 180,000 74%
Texas M.D. 2,500 95%
Utah M.D., R.Ph. 8,000 85%
Vermont M.D., Prescribing Agent 20,566 81%
Virginia M.D., R.Ph. 21,000 84%
Washington R.Ph., Pharm. Tech. N/A N/A
West Virginia M.D., R.Ph., Other Prescribers 131,000 79%
Wisconsin M.D., R.Ph., Pharm. Tech. 182,000 97%
Wyoming M.D., Nurse Pract., R.N. 375 43%

*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 2007 NPC Survey.

4-40
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prior Authorization Process and Procedures (Con’t)


State Reviewer Review Time Response Vehicle
Alabama M.D., R.N., R.Ph., Pharm. Tech. <8 hours Fax, mail
Alaska R.Ph., Pharm. Tech. 24 hours or less Phone, fax
Arizona* - - -
Arkansas M.D., R.Ph. 1-3 minutes Phone, fax, mail
California R.Ph. One business day Phone, fax
Colorado M.D., R.Ph. 24 hours Phone, fax, mail, e-mail
Connecticut R.Ph., Pharm. Tech. 2 hours Phone, fax, mail
Delaware M.D., R.Ph., R.N, Pharm. Tech. < 1 working day Phone, mail, e-mail
District of Columbia R.Ph. 72 hours Phone, fax
Florida R.Ph., Pharm. Tech. 24 hours Phone, fax, mail, e-mail
Georgia Pharm. Tech. (R.Ph. must review denials) 10 minutes Phone, fax, mail
Hawaii R.Ph., Pharm. Tech. 24 hours Phone, fax, mail
Idaho R.Ph., Pharm. Tech. Immediately to 24 hours Fax
Illinois M.D., R.Ph. 24 hours or less Phone, fax, mail
Indiana Medicaid Director or designee 10 days Phone, letter
Iowa R.Ph. 30 minutes Fax
Kansas R.N. 15-30 minutes Mail
Kentucky R.N., R.Ph. 4-24 hours Phone, fax
Louisiana R.Ph. 3-5 minutes Phone, fax
Maine M.D., R.Ph. 3 hours Fax
Maryland R.Ph., Pharm. Tech. 24 hours Phone, fax
Massachusetts R.Ph. <24 hours Phone, fax, mail
Michigan M.D., R.Ph., Pharm. Tech. <24 hours Phone, fax
Minnesota R.N. Within minutes Phone, mail
Mississippi M.D., R.N., R.Ph., Pharm. Tech. 3 hours Phone, mail
Missouri M.D., R.Ph., R.N., Info. Specialist < 5 minutes Phone, fax
Montana R.Ph., Pharm. Tech. 1-2 minutes Phone, fax, mail
Nebraska R.Ph., Pharm, Tech. 1 business day Phone, fax
Nevada R.Ph., Pharm. Tech. 24 hours Phone
New Hampshire R.Ph., Pharm. Tech. 24 hours or less Phone, fax with written follow-up of denials
New Jersey R.N., R.Ph. 3 minutes Phone, fax, mail
New Mexico R.Ph. <24 hours Phone, fax, mail
New York Call ctr. & voice interactive system Processed during call PA issued to prescriber by phone
North Carolina R.Ph., Pharm. Tech. 24 hours Phone, fax, mail
North Dakota R.Ph. 4 hours Fax, mail
Ohio R.Ph., Pharm. Tech. Immediately to 24 hours Phone, fax
Oklahoma R.Ph., Pharm. Tech, Pharm. Intern 24 hours or less Fax, secure provider website notice
Oregon R.Ph., Pharm. Tech. 24 hours or less Fax
Pennsylvania M.D., R.Ph., Pharm. Tech. 24 hours Phone, mail
Rhode Island R.Ph., Pharm. Tech. <24 hours Phone, fax
South Carolina R.Ph. Minutes to 24 hours Phone, fax, mail
South Dakota M.D., R.N., R.Ph., Pharm. Tech. <8 hours Fax, mail
Tennessee R.Ph. Same day Fax
Texas R.Ph. 24 hours Phone, fax, e-mail
Utah R.N. 24 hours Phone
Vermont M.D., R.Ph., Pharm. Tech, Med. Dir. 24 hours or less Phone, fax
Virginia R.Ph., Pharm. Tech. 24 hours Phone, fax
Washington M.D., R.Ph. 24 hours Phone, fax
West Virginia R.Ph. 3.5 min-2 hours Phone, fax
Wisconsin R.Ph. 24 hours Mail
Wyoming M.D., R.Ph. 14 days Fax

*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 2007 NPC Survey.

4-41
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prior Authorization
Analgesics,
State Anabolic Steroids Antipyretics, NSAIDs Anorectics
Alabama Covered Covered, PA Required Covered, PA Required
Alaska Covered Covered 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 Partial Coverage, PA Required Not Covered
Connecticut Covered Covered Not Covered
Delaware Covered Partial Coverage, PA Required Partial Coverage, PA Required
District of Columbia Not Covered Covered Partial Coverage, PA Required
Florida Covered Covered Not Covered
Georgia Covered, PA Required Covered, PA Required Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Not Covered Covered, PA Required Not Covered
Illinois Covered Covered Not Covered
Indiana** N/A N/A Not Covered
Iowa Covered Covered, PA Required Not Covered
Kansas Covered Partial Coverage Partial Coverage
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 Not Covered Covered Not Covered
Minnesota Not Covered Covered Not Covered
Mississippi Covered Covered Not Covered
Missouri Partial Coverage, PA Required Covered Not Covered
Montana Covered Covered, PA Required Not Covered
Nebraska Not Covered Covered, PA Required Not Covered
Nevada Partial Coverage Covered Not Covered
New Hampshire Covered Covered, PA Required Covered, PA Required
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered, PA Required
New York Covered Covered Not Covered
North Carolina Covered Covered, PA Required Not Covered
North Dakota Covered Covered Partial Coverage, PA Required
Ohio Partial Coverage Partial Coverage Not Covered
Oklahoma Not Covered Covered, PA Required Partial Coverage, PA Required
Oregon**** Covered, PA Required Covered Covered, PA Required
Pennsylvania Covered Covered Not Covered
Rhode Island Covered Covered Covered, PA Required
South Carolina Covered Covered Not Covered
South Dakota Covered Covered, PA Required Covered, PA Required
Tennessee Covered Covered, PA Required Not Covered
Texas Covered Covered Covered, PA Required
Utah Covered, PA Required Covered Not Covered
Vermont Covered Covered, PA Required Covered, PA Required
Virginia Covered Partial Coverage, PA Required Covered, PA Required
Washington Covered, PA Required Covered, PA Required Not Covered
West Virginia Covered Covered, PA Required Not Covered
Wisconsin Not Covered Partial Coverage, PA Required Covered
Wyoming Partial Coverage 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 required for all drugs not on the preferred drug list.
****Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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Prior Authorization (Con’t)


Anxiolytics, Prescribed
State Antihistamines Sedatives, and Hypnotics Cold Medications
Alabama Covered, PA Required Covered, PA Required Partial Coverage
Alaska Covered Covered Not Covered
Arizona* - - -
Arkansas Covered, PA Required Covered, PA Required 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 Partial Coverage, PA Required Partial Coverage, PA Required
District of Columbia Covered Covered Covered
Florida Covered Covered Partial Coverage
Georgia Covered, PA Required Partial Coverage, PA Required Partial Coverage
Hawaii Partial Coverage, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Covered
Illinois Covered, PA Required Covered Covered
Indiana** N/A N/A N/A
Iowa Covered, PA Required Covered, PA Required Covered
Kansas Covered Covered 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 Covered, PA Required
Maryland*** Covered Covered Covered
Massachusetts Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage
Michigan Covered Covered Not Covered
Minnesota Covered Covered Covered
Mississippi Covered Covered Partial Coverage
Missouri Covered Covered, PA Required Covered, PA Required
Montana Covered, PA Required Covered, PA Required Covered
Nebraska Covered, PA Required Covered Covered
Nevada Covered Covered Covered
New Hampshire Covered, PA Required Covered, PA Required Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered, PA Required Covered Partial Coverage
North Carolina Covered Covered, PA Required Covered
North Dakota Covered, PA Required Covered Covered
Ohio Partial Coverage Partial Coverage Partial Coverage
Oklahoma Partial Coverage, PA Required Covered, PA Required Not Covered
Oregon*** Covered, PA Required Covered, PA Required Covered
Pennsylvania Covered Covered Partial Coverage
Rhode Island Covered Covered Covered
South Carolina Covered Covered Covered
South Dakota Covered, PA Required Covered Covered
Tennessee Covered, PA Required Covered Not Covered
Texas Covered Covered Covered
Utah Covered, PA Required Covered Partial Coverage
Vermont Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Virginia Partial Coverage, PA Required Partial Coverage, PA Required Covered
Washington Covered Covered, PA Required Covered, PA Required
West Virginia Covered, PA Required Covered, PA Required Partial Coverage, PA Required
Wisconsin Partial Coverage, PA Required Partial Coverage, PA Required Covered
Wyoming Covered, PA Required Partial Coverage 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 required for all drugs not on the preferred drug list.
****Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Prior Authorization (Con’t)


Miscellaneous Prescribed
State Growth Hormones GI Products Smoking Deterrents
Alabama Covered, PA Required Covered, PA Required Not Covered
Alaska Covered, PA Required Covered Covered, PA Required
Arizona* - - -
Arkansas Covered, PA Required Covered, PA Required Partial Coverage, PA Required
California Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Colorado Covered, PA Required Partial Coverage, PA Required Covered, PA Required
Connecticut Covered Covered Not Covered
Delaware Partial Coverage, PA Required Covered Partial Coverage, PA Required
District of Columbia Covered Covered Covered
Florida Covered, PA Required Covered Covered
Georgia Covered, PA Required Covered, PA Required Not Covered
Hawaii Covered, PA Required Covered Covered, PA Required
Idaho Covered, PA Required Covered, PA Required Not Covered
Illinois Covered Covered Covered
Indiana** Covered, PA Required N/A N/A
Iowa Covered, PA Required Covered, PA Required Partial Coverage
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 Partial Coverage, PA Required
Michigan Covered Covered Covered
Minnesota Covered, PA Required Covered Covered
Mississippi Covered Covered Partial Coverage
Missouri Covered, PA Required Covered, PA Required Not Covered
Montana Covered, PA Required Covered, PA Required Covered, PA Required
Nebraska Covered, PA Required Covered, PA Required Not Covered
Nevada Partial Coverage, PA Required Covered Covered
New Hampshire Covered Covered, PA Required Covered
New Jersey Covered Covered Covered
New Mexico Covered Covered Covered
New York Covered, PA Required Partial Coverage, PA Required Covered
North Carolina Covered, PA Required Covered Covered
North Dakota Covered Covered, PA Required Partial Coverage
Ohio Partial Coverage, PA Required Partial Coverage Covered
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 Partial Coverage
South Carolina Covered, PA Required Covered Covered, Some require PA
South Dakota Covered, PA Required Covered, PA Required Covered
Tennessee Covered Covered Not Covered
Texas Covered, PA Required Covered Covered
Utah Covered, PA Required Covered Covered
Vermont Covered, PA Required Covered, PA Required Covered, PA Required
Virginia Covered Partial Coverage, PA Required Covered
Washington Covered, PA Required Covered, PA Required Limited Coverage
West Virginia Covered, PA Required Covered, PA Required Covered, PA Required
Wisconsin Partial Coverage, PA Required Partial Coverage, PA Required Partial Coverage, PA Required
Wyoming Partial Coverage, PA Required Covered, PA Required on PPIs Covered, PA Required
*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 required for all drugs not on the preferred drug list.
****Subject to the restrictions of the Oregon Health Plan.
PA = Prior Authorization
Source: As reported by State drug program administrators in the 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Utilization Review


In-House or PRODUR
State State Contact Telephone Contracted Implemented
Alabama Tiffany Minnifield 334-353-4596 Contracted Jul-96
Alaska Edward Bako, R.Ph. 907-334-2654 Both Jun-95
Arizona* - - - -
Arkansas Pamela Ford, Pharm.D. 501-683-4120 Contracted Mar-97
California J. Kevin Gorospe, Pharm.D. 916-552-9500 Both Aug-95
Colorado Kimberly Eggert 303-866-3176 Contracted Dec-98
Connecticut James Zakszewski, R.Ph. 860-424-5150 Contracted Sep-96
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Contracted Feb-94
District of Columbia Carolyn Rachel-Price, R.Ph. 202-442-9078 Contracted Sep-96
Florida Linda Barnes, R.Ph. 850-487-4441 Contracted Jul-93
Georgia Patricia Zeigler-Jeter, R.Ph., M.P.A. 404-656-4044 Contracted Oct-00
Hawaii Kathleen Kang-Kaulupali 808-692-8065 In-House 1997
Idaho Tami Eide, P.D., B.C.P.S., FASHP 208-364-1821 Contracted Jan-98
Illinois Lisa D. Voils 217-782-2570 In-House Jan-93
Indiana DUR Board Secretary 317-232-4307 Contracted Mar-96
Iowa Shelly Larson 515-725-1295 Contracted Jul-97
Kansas Anne S. Ferguson, R.Ph. 785-296-7788 In-House Nov-96
Kentucky Nici Gaines 502-564-7940 In-House 1987
Louisiana Mary J. Terrebonne, Pharm.D. 225-342-9768 Contracted Apr-66
Maine Kim Rackleff 207-622-7153 In-House Dec-95
Maryland Phil Cogan 410-767-5878 Both Jan-93
Massachusetts Paul L. Jeffrey 617-210-5319 Contracted Oct-95
Michigan Medical Services Administration 517-335-5181 Both Jul-00
Minnesota Mary Beth Reinke, Pharm.D., M.S.A. 651-431-2505 In-House Feb-96
Mississippi Paige Black Clayton, Pharm.D. 601-359-5253 Contracted Oct-93
Missouri Tisha A. Honse 573-751-6961 Contracted Feb-93
Montana Mark Eichler, R.Ph., FASCP 406-457-5818 Contracted Sep-94
Nebraska Marcia Mueting 402-420-1500 Contracted Apr-95
Nevada Mary Griffith 775-684-3751 Contracted 2004
New Hampshire Lise C. Farrand, RPh. 603-271-4419 Contracted Jul-95
New Jersey Kaye S. Morrow 609-631-2396 In-House Oct-96
New Mexico John Erb, Pharm.D. 505-827-3129 In-House Oct-93
New York Lydia Kosinski, R.Ph. 518-474-6866 In-House Mar-95
North Carolina Glenda Adams, Pharm.D. 919-855-4300 In-House Oct-96
North Dakota Brendan K. Joyce, Pharm.D., R. Ph. 701-328-4023 In-House Jul-96
Ohio Margaret Scott, R.Ph. 614-466-6420 In-House Feb-00
Oklahoma Ronald Graham, D.Ph. 405-271-6614 Contracted 2000
Oregon Kathy L. Ketchum, R.Ph., M.P.A 503-947-5220 Contracted Mar-94
Pennsylvania Terri Cathers 717-346-8156 In-House Jun-93
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-462-6390 Contracted Dec-94
South Carolina James M. Assey, R.Ph. 803-898-2876 In-House Nov-00
South Dakota Connie Hohn 605-773-5013 In-House 1996
Tennessee Jeffrey G. Stockard, D.Ph. 615-507-6496 Contracted Jul-01
Texas Don Valdes, R.Ph. 512-491-1157 Contracted Feb-95
Utah Tim Morley 801-538-6293 In-House 1994
Vermont Medmetrics Health Partners 802-879-5605 Contracted Nov-93
Virginia Rachel E. Cain, Pharm.D. 804-225-2873 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 Both Mar-95
Wisconsin Michael Mergener, R.Ph., Ph.D. 608-258-3350 Contracted 2001
Wyoming Aimee Lewis, Pharm.D. 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 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescribing/Dispensing Limits
Limits on
State Rx Limits on Number, Quantity, and Refills of Prescriptions
Alabama Yes 5 refills per Rx, 34 day supply per Rx, 4 brand limit per month
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, 3 claims per drug within 75 days
Colorado Yes 30 day quantity supply per Rx; 100 days maint. meds. Other limits may apply
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) or by therapeutic category
District of Columbia Yes 34 day supply per Rx, 3 refills per Rx within 4 mos. Max/min quantities for certain meds
Florida Yes Vary according to the drug
Georgia Yes 34 day supply per Rx; 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, 3 brand scripts per month, daily dosage limits
Indiana No -
Iowa Yes Maximum 30 day supply except oral contraceptives (90 days); quantity limits on some drugs
Kansas Yes 31 day supply per Rx, 5 Rx per month, other limitations specific to certain medications
Kentucky Yes 32 day supply, max. 11 refills in 12 months; 93 days/100 units for maint. medication, 4 scripts/mo.
Louisiana Yes Greater of 30 day supply or 100 unit doses; 5 refills per Rx within 6 mos., max. 8 scripts/mo./recipient
Maine Yes 34 day supply (brand), 90 day supply (generic); Max. 11 refills per Rx, 4 brand scripts per month
Maryland Yes 34 day supply/Rx; 100 day supply for maint., max. 11 refills/ Rx, refills not to exceed 360 day supply
Massachusetts Yes 30 day supply, per month limits on some drugs, maximum 5 refills per prescription
Michigan Yes 34 day supply (100 days for maintenance), quantity limits for selected drugs (e.g., sedative hypnotics)
Minnesota Yes 34 day supply, quantity limits for selected drugs (triptans, antiemetics, sedatives pregabalin)
Mississippi Yes 31 day supply; 5 Rx per month (no more than 2 brand); 11 refills maximum
Missouri No -
Montana Yes 34 day supply
Nebraska No -
Nevada Yes 34 day supply per Rx; 100 day supply for maintenance medications. 5 refills within 6 months.
New Hampshire Yes 34 day supply, 90 day supply on maintenance medications, 5 refills within 6 months
New Jersey Yes 34 day supply or 100 unit doses per Rx, 5 refills within 6 months
New Mexico No -
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; 8 Rx per month with exceptions
North Dakota Yes 34 day supply per Rx
Ohio Yes 34 day supply; 102 day supply for maintenance medications; 5 refills per Rx
Oklahoma Yes 6 Rx (incl. 3 brands) per month (21+; under 21 unlimited), 34 day supply or 100 unit doses per Rx
Oregon Yes 34 day supply (100 days for mail order and maintenance 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); quantity limits on some drugs, 4 Rx per month (adult)
South Dakota Yes Quantity limits that vary by drug
Tennessee Yes Varies by basis of eligibility
Texas Yes 3 Rx per month (unlimited Rx’s for nursing home recipients or those < 21), max 5 refills or 6 months
Utah Yes 31 day supply per Rx, max 5 refills, cumulative limit on specific drugs
Vermont Yes 34 days (102 days for maintenance medications), 5 refills per Rx
Virginia Yes 34 day supply per Rx
Washington Yes 34 day supply per Rx; 2 scripts per month; except antibiotics and schedule drugs, 4 brand cap
West Virginia Yes 34 day supply up to 11 refills, except antibiotics (14 days and 1 refill)
Wisconsin Yes 34 day supply per Rx with exceptions, 5 refills for Schedule III, IV, &V drugs, max.11 refills during
12-month period for non-schedule drugs
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 2007 NPC Survey.

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PHARMACY PAYMENT AND PATIENT COST SHARING

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

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

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

PATIENT COST SHARING

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

With the passage of the Social Security Amendments of 1972, States were empowered to impose
“nominal” cost-sharing requirements on optional Medicaid services for cash assistance recipients, and
on any services for the medically needy. Section 131 of the Tax Equity and Fiscal Responsibility Act
(TEFRA) of 1982 introduced major changes to Medicaid cost-sharing requirements. Under this act,
States may impose a nominal deductible, coinsurance, copayment, or similar charge on both
categorically needy and medically needy persons for any service offered under the State Plan. Public
Law 97-248, TEFRA, has been in effect since October 1982; it prohibits imposition of cost-sharing
on the following:
! Services furnished to individuals under 18 years of age (or up to 21 at State option);
! Pregnancy-related services (or, at State option, any service provided to pregnant women);
! Services provided to certain institutionalized individuals, who are required to spend all of
their income for medical care except for a personal needs allowance;
! Emergency services;
! Family planning services and supplies;
! Services furnished to categorically needy HMO enrollees (or, at State option, services
provided to both categorically needy and medically needy HMO enrollees).
In addition, the law prohibits imposing more than one type of charge on any service.

While emergency services are excluded from cost sharing, States may apply for waivers of nominal
amounts for non-emergency services furnished in hospital emergency rooms. Such a waiver allows
States to impose a copayment amount up to twice the current maximum for such services. Approval
of a waiver request by CMS is based partly on the State’s assurance that recipients will have access to
alternative sources of care.
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National Pharmaceutical Council Pharmaceutical Benefits 2007

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-$11.46 AWP-5% $2.00
Arizona* - - -
Arkansas $5.51 ($7.51 non-MAC generics) B: AWP-14%, G: AWP-20% $0.50 - $5.00
California $7.25 ($8.00 for LTC) AWP-17% $1.00
Colorado $4.00; $1.89 Inst. & dispensing physicians AWP-13.5% or direct pricing +18%; AWP-35% B: $3.00, G: $1.00
>25 miles from participating pharmacy (for generics)
Connecticut $3.15 AWP-14% (AAC+8% Factor 8) None
Delaware $3.65 AWP-14%, AWP-16% (LTC) $0.50 - $3.00
District of Columbia $4.50 AWP-10% $1.00
Florida $4.23 AWP-15.4%; WAC+5.75% None
Georgia $4.63 (for profit), $4.33 (non-profit) AWP-11% 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: $4.60, B: $3.40 B: AWP-12%, G: AWP-25% B: $3.00
Indiana $4.90 B: AWP-16.0%, G: AWP-20% $3.00
Iowa $4.52 AWP-12% $1.00-$3.00
Kansas $3.40 B: AWP-13%, G: AWP-27%, IV AWP-50%, blood $3.00
AWP-30%
Kentucky B: $4.50, G: $5.00 B: AWP-14%, G: AWP-15% $1.00 - $3.00
Louisiana $4.59 (avg.) to $5.77 AWP-13.5% (AWP-15% for chains) $0.50 - $3.00
Maine $3.35 AWP-15% (Retail), 17% (Spec.), 20% (Mail Order)
$3.00, Max $30/rec/pharm/mo
Maryland $2.69-$4.69 Lowest of :WAC+8%, direct+8%, AWP-12% $3.00 Brand not on PDL,
$1.00 Brand on PDL & generics
Massachusetts $3.50 - $5.00 WAC+5% B: $3.00, G and OTC: $1.00
Michigan $2.50 ($2.75 – LTC) AWP-13.5% (1-4 stores), AWP-15.1% (5+stores) B: $3.00, G: $1.00, ABW: $1.00
Minnesota $3.65 ($0.30 for legend unit dose) AWP-12% (MAC, Specialty Pharm AWP-15%) B: $3.00, G: $1.00
Mississippi $3.91 sole source, $4.91 multisource AWP-12% or WAC/WNU+9% $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, $3.50 out-of-state AWP-15% $1.00 - $5.00, $25 max/mo.
Nebraska $3.27 - $5.00 AWP-11% $2.00
Nevada $4.76 AWP-15% B: $3.00, G: $1.00, (dual eligibles)
New Hampshire $1.75 AWP-16% B: $2.00, G: $1.00
New Jersey $3.70 - $4.07 AWP-12.5% None
New Mexico $3.65 AWP-14% None (except $5.00 for SCHIP and
working disabled)
New York B: $3.50, G: $4.50 B: AWP-14%;, G: AWP-25% B: $3.00, G: $1.00, OTC: $0.50
North Carolina B: $4.00, G: $5.60 AWP-10% $3.00
North Dakota B: $4.60, G: $5.60 Lowest of AWP-10%, WAC+12.5%, FUL, or MAC $3.00 (Brand)
Ohio $3.70 WAC +7%, AWP-14.4% B: $2.00
Oklahoma $4.15 AWP-12.0% $1.00 - $2.00 dep. on Rx cost
Oregon Retail: $3.50, Inst./NF: $3.91 AWP-15% (retail), AWP-11% (inst.) B: $3.00, G: $2.00
Pennsylvania $4.00 ($5.00 for compounds) AWP-14%, WAC+7% B: $3.00, G: $1.00
Rhode Island $3.40 (LTC: $2.85) WAC None
South Carolina $4.05 AWP-10% $3.00
South Dakota $4.75 ($5.55 for unit dose) AWP-10.5% B: $3.00, G: no copay
Tennessee $2.50 AWP-13% Varies by eligibility status
Texas $5.14 AWP-15% or WAC+12%, whichever is lowest None
Utah $3.90 (urban), $4.40 (rural), $1.00 OTC AWP-15% $3.00
Vermont $4.75, $3.65 out-of-state AWP-11.9% $1.00 - $3.00 dep. on Rx Cost
Virginia $4.00 AWP-10.25% B: $3.00, G: $1.00
Washington $4.24-$5.25 (based on annual # of Rx) AWP-14%, AWP-50% (>5 labelers) None
West Virginia $2.50 - $8.25 (+ extra $1.00 for B: AWP-15%, G: AWP-30% $0.50 - $3.00
compounding)
Wisconsin $4.88 (to a maximum $40.11) AWP-13% $1.00-$3.00, max $12/rec/pharm/mo
Wyoming $5.00 AWP-11% G: $1.00, PB: $2.00, NP: $3.00
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; PB = Preferred
Brand
*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 2007 NPC Survey.

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Maximum Allowable Cost (MAC) Programs

Federal State-Specific
Upper Upper Limits
State Limits MAC Override Provisions
Alabama Yes Yes Brand medically necessary
Alaska Yes No Brand medically necessary and reason
Arizona* - - -
Arkansas Yes Yes Brand medically necessary plus MedWatch indicating why generics cannot be dispensed
California Yes Yes Medically necessary and product unavailable at MAC rate
Colorado Yes Yes Brand medically necessary
Connecticut Yes Yes No physician MAC override
Delaware Yes Yes MedWatch form for prior authorization
District of Columbia No No -
Florida Yes Yes Dispense as written plus multi-source brand drug form and prior authorization request
Georgia Yes Yes Brand medically necessary and Georgia Watch form
Hawaii Yes Yes PA plus brand medically necessary or do not substitute on script
Idaho Yes Yes Medically necessary with appropriate documentation
Illinois Yes Yes Prior authorization request by M.D. justifying need for brand
Indiana Yes Yes Brand medically necessary, prior authorization
Iowa Yes Yes Brand medically necessary and PA form
Kansas Yes Yes Prior authorization and MedWatch form
Kentucky Yes Yes Brand necessary, brand medically necessary, plus PA on some drugs
Louisiana Yes Yes Brand necessary, brand medically necessary
Maine Yes Yes Prior authorization
Maryland Yes Yes MedWatch form
Massachusetts Yes Yes Dispense as written and brand medically necessary, plus prior authorization
Michigan Yes Yes Brand medically necessary, plus prior authorization
Minnesota Yes Yes Dispense as written, brand medically necessary, must meet PA criteria
Mississippi Yes No Medically necessary, brand medically necessary, or PA for brand multi-source
Missouri Yes Yes Brand medically necessary, prior authorization and MedWatch form
Montana Yes No Brand necessary, brand required
Nebraska Yes Yes State-specific form
Nevada Yes Yes Dispense as written
New Hampshire Yes Yes Brand medically necessary
New Jersey Yes No Brand medically necessary
New Mexico Yes Yes Medically necessary, brand 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 plus prior authorization
Oregon Yes Yes Brand medically necessary plus prior authorization
Pennsylvania Yes Yes Brand medically necessary and prior authorization
Rhode Island No No Brand medically necessary with justification
South Carolina Yes Yes Brand medically necessary w/cert. by prescriber and prior authorization
South Dakota Yes No Prior authorization
Tennessee Yes Yes Dispense as written
Texas Yes Yes Brand necessary, brand medically necessary
Utah Yes Yes Dispense as written, prior approval, plus documentation
Vermont Yes Yes Dispense as written, medically necessary, brand necessary, or DAW 8 (generic not
available)
Virginia Yes Yes Brand necessary in physician’s own handwriting
Washington Yes Yes Brand medically necessary
West Virginia Yes Yes Brand medically necessary
Wisconsin No Yes Brand medically necessary plus prior authorization
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 2007 NPC Survey.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Mandatory Substitution

Incentive Fee for Dispensing of Generic Dispensing of Lowest Cost


State Generic Substitution Multi-Source Required Multi-Source Required
Alabama No Yes No
Alaska No Yes No
Arizona* - - -
Arkansas $2.00 Yes Yes
California No No Yes
Colorado No Yes No
Connecticut No Yes No
Delaware No Yes No
District of Columbia No Yes No
Florida No Yes No
Georgia No Yes No
Hawaii No Yes No
Idaho No Yes No
Illinois No No No
Indiana No Yes Yes
Iowa No No Yes
Kansas No Yes No
Kentucky No Yes Yes
Louisiana No No No
Maine No Yes (preferred generics) Yes
Maryland No Yes No
Massachusetts No Yes No
Michigan No No No
Minnesota No Yes Yes
Mississippi No Yes (if less costly) No
Missouri No Yes Yes
Montana No Yes No
Nebraska No No No
Nevada No Yes Yes
New Hampshire No Yes No
New Jersey No Yes Yes
New Mexico No No Yes
New York $1.00 Yes No
North Carolina $1.60 Yes Yes
North Dakota No Yes 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 Yes
South Dakota No Yes No
Tennessee No Yes Yes
Texas $0.50 Yes No
Utah No Yes No
Vermont No Yes Yes
Virginia No Yes No
Washington No No Yes
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 2007 NPC Survey.

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Counseling Requirements and Payment for Cognitive Services

Medicaid Patient Counseling Medicaid Payment


State Required1 for Cognitive Services2
Alabama Yes No
Alaska Yes No
Arizona Yes -
Arkansas Yes No
California Yes No
Colorado Yes No
Connecticut Yes No
Delaware Yes No
District of Columbia Yes No
Florida Only an offer to counsel is required No
Georgia Yes No
Hawaii Yes, OBRA requirements Yes (emergency contraception)
Idaho Yes No
Illinois Only an offer to counsel is required No
Indiana Only an offer to counsel is required No
Iowa Yes Yes (pharm. case management)
Kansas Yes No
Kentucky Yes No
Louisiana Yes No
Maine Yes No
Maryland Yes No
Massachusetts Only an offer to counsel is required No
Michigan Yes No
Minnesota Yes Yes (patient specific)
Mississippi Yes Yes (diabetes, asthma, coagulation, and lipids)
Missouri Yes (diabetes, asthma, heart failure, depression, sickle cell,
Yes GERD, education)
Montana Yes No
Nebraska Yes No
Nevada Yes No
New Hampshire Yes No
New Jersey Yes No
New Mexico Yes No
New York Yes No
North Carolina Yes Yes (focused risk management reviews)
North Dakota Yes No
Ohio Only an offer to counsel is required No
Oklahoma When applicable/appropriate No
Oregon Yes No
Pennsylvania Yes Yes (tobacco cessation as medical service, not pharmacy)
Rhode Island Only an offer to counsel is required No
South Carolina Yes, HHS Finance Commission
No
Regulation
South Dakota Yes No
Tennessee Yes No
Texas Yes, must post a sign in pharmacy No
Utah Yes No
Vermont Yes No
Virginia Yes No
Washington Yes Yes (emerg. contraceptive counseling, clozaril case management)
West Virginia Only an offer to counsel is required No
Wisconsin Yes Yes
Wyoming Only an offer to counsel is required No

Sources: 12007 National Association of Boards of Pharmacy Law, Survey of Pharmacy Law; 2 As reported by State drug
program administrators in the 2007 NPC Survey.

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Prescription Price Updating

State Contact Telephone Updated


Alabama Stephanie Frawley 334-353-4592 Biweekly
Alaska Dave Campana, R.Ph. 907-334-2425 Weekly
Arizona* - - -
Arkansas First DataBank 650-588-5454 Weekly
California EDS Federal Corp. 916-636-1000 Weekly
Colorado Cathy Traugott, R.Ph., J.D. 303-866-2468 Biweekly
Connecticut Mark Synol 860-255-3886 Weekly
Delaware Cynthia R. Denemark, R.Ph. 302-453-8453 Weekly
District of Columbia Carolyn Rachel-Price, R.Ph. 202-442-9078 As needed
Florida First DataBank 650-588-5454 Weekly
Georgia SXC 630-577-3120 Weekly
Hawaii ACS State Healthcare 800-358-2381 Weekly
Idaho David Mendoza 208-364-1838 Weekly
Illinois Lisa D. Voils 217-782-2570 Weekly
Indiana First DataBank 650-588-5454 Weekly
Iowa Sandy Pranger, R.Ph. 515-725-1272 Weekly
Kansas Margaret Smith 785-296-4753 Weekly
Kentucky Nici Gaines 502-564-7940 Weekly
Louisiana Maggie Vick, Unisys Corp. 225-216-6251 Weekly
Maine Marcia Pykare 207-622-7153 Weekly
Maryland Frank Tetkoski, P.D. 410-767-1460 Weekly
Massachusetts First DataBank 650-588-5454 Weekly
Michigan First Health Service Corp. 800-884-2822 Weekly
Minnesota First DataBank 800-633-3453 Weekly
Mississippi Terri R. Kirby, R.Ph. 601-359-5253 Weekly
Missouri First DataBank 650-588-5454 Weekly
Montana First DataBank 650-588-5454 Weekly
Nebraska Barbara Mart 402-471-9301 Weekly
Nevada First DataBank 650-588-5454 Monthly
New Hampshire Robert Coppola, Pharm.D. 603-224-2083 Weekly
New Jersey First DataBank 650-588-5454 Weekly
New Mexico Julie A. McKeay 505-827-6202 Weekly
New York Carl Cioppa, Pharm.D. 518-474-3209 Monthly
North Carolina Tom D’Andrea, R.Ph., M.B.A. 919-855-4300 Weekly
North Dakota Brendan K. Joyce, Pharm.D., R.Ph. 701-328-4023 Biweekly
Ohio First DataBank 650-588-5454 Monthly
Oklahoma First DataBank 800-633-3453 Weekly
Oregon Debbie L. Bishop 503-945-6291 Biweekly
Pennsylvania Terri Cathers 717-346-8156 Monthly
Rhode Island Paula Avarista, R.Ph., M.B.A. 401-462-6390 Weekly
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 Betty Wasko 512-491-1155 Weekly
Utah RaeDell Ashley, R.Ph. 801-538-6495 Biweekly
Vermont Bob Rase 913-451-9466 Monthly
Virginia Keith T. Hayashi 804-225-2773 Weekly
Washington Johnna Ziegler 360-725-1841 Weekly
West Virginia Eric N. Sears, R.Ph. 304-348-3200 Weekly
Wisconsin Carrie L. Gray 608-266-3901 Weekly
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 2007 Survey.

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Section 5:
State Pharmacy Program
Profiles

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Profiles of State Medicaid Drug Programs


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

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ALABAMA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2005 2006
Expenditures Recipients Expenditures Recipients

TOTAL $622,777,164 544,400 $462,845,776 541,235

RECEIVING CASH ASSISTANCE TOTAL $410,969,308 191,182 $318,243,346 168,015


Aged $35,915,708 17,699 $843,942 7,511
Blind/Disabled $353,786,496 138,297 $291,426,026 128,380
Child $3,692,129 10,537 $3,320,992 7,990
Adult $17,574,975 24,649 $22,652,384 24,134

MEDICALLY NEEDY, TOTAL $0 0 $0 0


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

POVERTY RELATED, TOTAL $88,675,021 272,673 $111,870,343 301,512


Aged/Blind/Disabled $4,521,741 3,022 $1,636,932 1,719
Child $0 0 $0 0
Adult $81,519,379 254,291 $106,629,875 282,467
BCCA Women $2,633,901 15,360 $3,603,534 17,325

TOTAL OTHER EXPENDITURES/RECIPIENTS* $123,132,834 80,545 $32,732,087 71,708


*Total other expenditures/recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Total expenditures do not include clawback payments.

Source: Alabama Medicaid Statistical Information System, 2005 and 2006.

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C. ADMINISTRATION
Vaccines: Vaccines reimbursable as part of the
Alabama Medicaid Agency. Vaccines for Children Program.

D. PROVISIONS RELATING TO DRUGS Unit Dose: Unit dose packaging reimbursable.

Benefit Design Formulary/Prior Authorization

Drug Benefit Product Coverage: Products covered: Formulary: Open formulary with preferred drug list.
disposable needles and syringe combinations used for Formulary managed through restrictions on use, prior
insulin; blood glucose test strips; and total parenteral authorization, preferred products, physician profiling,
nutrition. Products covered with restrictions: and academic dealing. Prior authorization required
prescribed insulin and syringe combinations used for for non-preferred drugs. Anti-psychotics and
insulin (on PDL and max units apply); and HIV/AIDs drugs are exempted from the prior
interdialytic parenteral nutrition (cert. of med. authorization requirements. (For additional
necessity on script). Products not covered: cosmetics information see: www.medicaid.alabama.gov)
(except through medical necessity); fertility drugs;
experimental drugs; urine ketone test strips; drugs for Prior Authorization: State currently has a formal
anorexia or weight gain/loss; hair growth products; prior authorization procedure. Prior authorization
and DESI drugs. decisions may be appealed by physician submitting
written notice along with medical documentation
Over-the-Counter Product Coverage: Products (i.e., peer reviewed literature and medical records) to
covered if prescribed by a physician: allergy, asthma the administrative services contractor for physician
and sinus products; analgesics; cough and cold review. The request is forwarded to the contractor’s
preparations (generics only); digestive products; Medical Director and the Agency’s Medical Director
topical products; prenatal vitamins; and hemorrhoidal for review.
products. Products not covered: feminine products;
smoking deterrent products. Prescribing or Dispensing Limitations
Therapeutic Category Coverage: Therapeutic Prescription Refill Limit: maximum of five refills for
categories covered: anablolic steroids; controlled substance, 11 for non-controlled.
anticoagulants; anticonvulsants; anti-psychotics;
chemotherapy agents; contraceptives; and thyroid Monthly Quantity Limit: 34-day supply.
agents. Partial coverage for: prescribed cold
medications. Prior authorization required for: Monthly Prescription Limit: four brand limit.
analgesics, antipyretics, and NSAIDs; anoretics;
antibiotics; antidepressants; antidiabetic agents;
Drug Utilization Review
antihistamines; antilipemic agents; anxiolytics;
sedatives, and hypnotics; cardiac drugs; ENT anti-
PRODUR system implemented in July 1996. State
inflammatory agents; estrogens; growth hormones;
currently has a DUR Board with a quarterly review.
hypotensive agents; misc. GI drugs;
sympathominetics (adrenergic); skeletal muscle
Pharmacy Payment and Patient Cost Sharing
relaxants; skin and mucous membrane agents; triptan
agents; respiratory agents; PPIs; platelet aggregation
Dispensing Fee: $5.40 (additional reimbursement for
inhibitors; Alzheimer’s Disease agents; ADHD
compounding).
agents; EENT anti-allergic agents; brand H2
antagonists; intranasal corticosteroids; narcotic
Ingredient Reimbursement Basis: AWP-10%, WAC
analgesics; specialized nutritional supplements;
+ 9.2%.
Retina A; Dipyridamole; Synagis; antihypertensive
agents; antiemetics; Xenical; and Xolair. Therapeutic
Prescription Charge Formula: Medicaid pays for
categories not covered: anoretics; prescribed smoking
prescribed legend and non-legend drugs authorized
deterrents; and OBRA 90 excludables.
under the program based upon and shall not exceed
the lowest of:
Coverage of Injectables: Injectable medicines
reimbursable through the Prescription Drug Program 1. The Federal Upper Limit or Maximum
when used in extended care facilities and home Allowable Cost (MAC) of the drug plus a
health care, and through physician payment when dispensing fee,
used in physicians’ offices.

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2. The Estimated Acquisition Cost (EAC) of the DUR Contact


drug plus a dispensing fee, or
Tiffany D. Minnifield
3. The provider’s usual and customary charge to Associate Director
the public for the drug. Pharmacy Administrative Services
Alabama Medicaid Agency
Maximum Allowable Cost: State imposes Federal 501 Dexter Avenue
Upper Limits as well as State-specific limits on P.O. Box 5624
generic drugs. Override requires “Brand Medically Montgomery, AL 36103-5424
Necessary” in the physician’s own handwriting on T: 334/353-4596
the script. Over 14,000 NDCs. F: 334/353-7014
Email: tiffany.minnifield@medicaid.alabama.gov
Incentive Fee: None.
Medicaid DUR Board
Patient Cost Sharing: Tiered copayment.
John Searcy, M.D.
Drug Ingredient Cost Copayment Jimmy Jackson, R.Ph.
$0.00 to $10.00 $0.50 Denyse Thornley-Brown, M.D.
$10.01 to $25.00 $1.00 J. Kevin Royal, M.D.
$25.01 to $50.00 $2.00 W. Kevin Green, M.D. (Chair)
$50.01 or more $3.00 Bernie Olin, Pharm.D.
Exemptions: No copayment amount is to be collected Kelli D. Littlejohn, R.Ph.
by the pharmacy or paid by the recipient for Paula Thompson, Pharm.D. (Vice Chair)
recipients under age 18, pregnant, or living in nursing B. Jerome Harrison, M.D.
facilities. Daniel Mims, R.Ph.
Rhonda Harden, Pharm.D.
Cognitive Services: Does not pay for cognitive Robert Colburn, R.Ph.
services.
New Brand Name Products Contact

E. USE OF MANAGED CARE Stephanie Frawley


FDB Contract Administrator
Alabama Medicaid Agency
Does not use MCOs to deliver pharmaceutical
501 Dexter Avenue
services to general Medicaid recipients. State does
P.O. Box 5624
have a maternity managed care waiver.
Montgomery, AL 36103-5424
T: 334/353-4592
F. STATE CONTACTS F: 334/353-7014
Email: stephanie.frawley@medicaid.alabama.gov
State Drug Program Administrator
Prescription Price Updating
Kelli D. Littlejohn, R.Ph.
Director of Pharmacy Stephanie Frawley
Alabama Medicaid Agency 334/353-4592
501 Dexter Avenue
P.O. Box 5624 Medicaid Drug Rebate Contact
Montgomery, AL 36103-5624
Lynn M. Abrell
T: 334/353-4525
Associate Director Drug Rebate
F: 334/353-5623
Alabama Medicaid Agency
E-mail: kelli.littlejohn@medicaid.alabama.gov
501 Dexter Avenue
Internet address: www.medicaid.alabama.gov
P.O. Box 5624
Montgomery AL 36103-5624
Prior Authorization Contact T: 334/242-2326
Kelli D. Littlejohn, R.Ph. F: 334/353-7014
334/353-4525 E-mail: lynn.abrell@medicaid.alabama.gov

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Title XIX Medical Care Advisory Committee


Claims Submission Contact
Jim Carnes
Susan Jones
Pattisue Carrenza
Fiscal Agent Liaison (EDS)
Irene Collins
Alabama Medicaid Agency
Louis E. Cottrell, Jr.
501 Dexter Avenue
Joe Decker
P.O. Box 5624
Al Fox
Montgomery, AL 36103-5624
Jean Fulton
T: 334/242-5553
Lawrence F. Gardella
F: 334/242-7014
A.Z. Holloway, M.D.
E-mail: susan.jones@medicaid.alabama.gov
Mike Horsley
John Houston
Medicaid Managed Care Contact
Jolene James
Kelli D. Littlejohn, R.Ph. Louise Jones
334/353-4525 Cary Kuhlman
Linda Lee
Mail Order Pharmacy Program Roosevelt McCorvey, M.D.
Holley Midgley
None J.A. Powell, M.D.
Marsha D. Raulerson, M.D.
Disease Management/Patient Education Steve Shivers
Programs Wilburn Smith, Jr., M.D.
Disease/Medical State: PCCM Page Walley
Program Name: Patient First Donald Williamson, M.D.
Program Manager: Paige Clark, Medical Services
Program Sponsor: Univ. of South Alabama/Alabama Pharmacy and Therapeutics Committee
Dept. of Public Health. A. Z. Holloway, M.D.
Richard Freeman, M.D.
Disease Management Program/Initiative Ben Main, R.Ph.
Contact Lucy Culpepper, M.D.
Kathy Hall W.Thomas Geary, Jr., M.D. (Chair)
Deputy Commissioner Program Administration Vickie Litte, R.P.h.
Alabama Medicaid Agency Sheri Lynn Boston, R.Ph.
501 Dexter Avenue Mary McIntyre, M.D.
PO Box 5624 Lucien Newman, III, M.D.
Montgomery, AL 36103-5624 Joseph Thomas, M.D.
334/242-5007
E-mail: Kathy.Hall@medicaid.alabama.gov Pharmacy Advisory Committee
Danny Cottrell, R.Ph.
Alabama Medicaid Agency Officials Alabama Pharmacy Association
Carol Herrmann-Steckel, M.P.H.
Commissioner John Carpenter, R.Ph.
Alabama Medicaid Agency Alabama Pharmacy Association
501 Dexter Avenue
P.O. Box 5624 Louise Jones
Montgomery, AL 36103-5624 Alabama Pharmacy Association
T: 334/242-5600
F: 334/242-5097 Dan McConaghy, R.Ph.
E-mail: Almedicaid@medicaid.state.al.us Alabama Pharmacy Association
Internet address: www.medicaid.state.al.us
Vickie Little, R.Ph.
Alabama Pharmacy Association

Alison Wingate
Alabama Retail Association

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Steve Frawley, R.Ph. Alabama State Board of Pharmacy


Alabama Retail Association Henry Bobo
Executive Secretary
Kenny Sanders, R.Ph. 10 Inverness Center, Suite 110
American Pharmacy Cooperative, Inc. Birmingham, AL 35242
T: 205/981-2280
Bob Hager, R.Ph. F: 205/981-2330
American Pharmacy Cooperative, Inc. E-mail: hbobo@albop.com
Internet address: www.albop.com
Sharon Taylor
Alabama Independent Drug Store Association Alabama Independent Drugstore Association (AIDA)
Sharon Taylor, Executive Director
Norman Davis, R.Ph. 600 Interstate Park Drive
Alabama Independent Drug Store Association Suite 609
P.O. Box 240336
Cary Kuhlmann Montgomery, AL 36109
Medical Association of Alabama T: 334/213-2432
F: 334/213-2406
Cyndi Crocket
E-mail: Sharon@aidarx.org
EDS
Internet address: www.aidarx.org
Stuart A. Capper, Dr.Ph.
Alabama Hospital Association
McWhorter School of Pharmacy
Mike Horsley, CEO
500 North East Blvd.
Executive Officers of State Medical and
Montgomery, AL 36117
Pharmaceutical Societies
T: 334/272-8781
Medical Association of the State of Alabama (MASA) F: 334/270-9527
James Chambers, III, M.D. E-mail: webmaster@alaha.org
President-Elect Internet address: www.alaha.org
P.O. Box 1900
Montgomery, AL 36102-1900
T: 334/954-2500
F: 334/269-5200
E-mail: MASA@masalink.org
Internet address: www.masalink.org

Alabama Osteopathic Medical Association


J. Mark Bailey, D.O., Ph.D.
President-Elect
200 Carraway Drive, Suite 1
P.O. Box 1857
U.S. Highway 43
Winfield, AL 35594
T: 205/487-3625
F: 205/487-7559
E-mail: Mark.Bailey@bhsala.com
Internet address: www.aloma.org

Alabama Pharmacy Association (APA)


Louise F. Jones
Executive Director
1211 Carmichael Way
Montgomery, AL 36106-3672
T: 334/271-4222
F: 334/271-5423
E-mail: LJones@aparx.org
Internet address: www.aparx.org

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ALASKA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

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

B. DRUG PAYMENTS AND RECIPIENTS


2005 2006
Expenditures Recipients Expenditures Recipients

TOTAL $127,792,222 76,557 $90,991,988 747,747

RECEIVING CASH ASSISTANCE TOTAL $97,510,121 35,046 $66,967,520 34,596


Aged $17,960,921 5,267 $6,788,329 4,899
Blind/Disabled $65,660,858 10,895 $45,911,511 10,942
Child $2,796,568 8,937 $2,842,016 8,678
Adult $11,091,774 9,947 $11,425,664 10,077

MEDICALLY NEEDY, TOTAL $14,966,546 35,337 $13,712,497 34,027


Aged $36,526 8 $3,186 4
Blind/Disabled $29,360 6 $25 1
Child $13,283,959 31,237 $12,294,987 29,963
Adult $1,616,701 4,086 $1,414,297 4,059

POVERTY RELATED, TOTAL $13,385,244 4,647 $10,311,969 6,151


Aged $4,323,747 787 $1,784,914 768
Blind/Disabled $6,018,580 963 $3,187,029 935
Child $2,119,077 1,908 $2,413,110 1,841
Adult $923,840 989 $950,629 957
BCCA Women $0 0 $0 0

TOTAL OTHER EXPENDITURES/RECIPTENTS* $1,930,311 1,527 $1,976,285 1,650

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: Alaska Medicaid Management Information System, FY 2005 and 2006.

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C. ADMINISTRATION Formulary/Prior Authorization


Department of Health and Social Services, Division of Formulary: Open formulary with preferred drug list
Health Care Services. (PDL). PDL managed by exclusion of products based
on contracting issues and preferred products.
D. PROVISIONS RELATING TO DRUGS
Prior Authorization: State currently has a formal prior
Benefit Design authorization procedure. Request for fair hearing
required for appealing coverage of an excluded
Drug Benefit Product Coverage: Products covered: product and PA decision. Medical necessity form
cosmetics (covered with restrictions- non hair growth required.
products); prescribed insulin. Covered under DME:
disposable needles and syringe combinations used for Prescribing or Dispensing Limitations
insulin; blood glucose test strips; urine ketone test
strips. Products covered under home infusion therapy: Monthly Quantity Limit: Prescriptions are limited to
total parenteral nutrition; and interdialytic parenteral 30-day supplies (except family planning drugs).
nutrition. Prior authorization required for: Clozaril; Dispensing of generic multi-source product is required.
Lupron Depot; some DME; Synagis; Panretin; PPIs; Maximum number of units for about 50 therapeutic
Botox; Byetta; Clozapine; Revatio; Carisoprodol; and classes and 40 narcotic analgesics.
Actig Naltrexone. Products not covered: fertility
drugs; anoretics; drugs to grow hair; and experimental Drug Utilization Review
drugs.
PRODUR system implemented in June 1995. State
Over-the Counter Product Coverage: Products currently has a 6-member DUR Board that meets six
covered: Smoking deterrent products. Products times per year.
covered with restrictions: feminine products
(spermicides and vaginal miconazole and Pharmacy Payment and Patient Cost Sharing
clotrimazole); topical products (Bacitracin ointment
only). Products not covered: allergy, asthma, and sinus Dispensing Fee: $3.45 - $11.46 based on pharmacy
products; analgesics; cough and cold preparations; and volume.
digestive products.
1) $23,192 added to the number resulting from
Therapeutic Category Coverage: Categories covered: multiplying total prescriptions filled by that
anabolic steroids; analgesics, antipyretics, and pharmacy in the previous calendar year by 5.070;
NSAIDs; antibiotics; anticoagulants; anticonvulsants;
anti-depressants; antidiabetic agents; antihistamines; 2) to 1), add the result of multiplying total Medicaid
antilipemic agents; anti-psychotics; anxiolytics, prescriptions filled in the previous calendar year
sedatives, and hypnotics; cardiac drugs; chemotherapy by 12.44;
agents; contraceptives; ENT anti-inflammatory agents; 3) from 2), subtract the result of multiplying the total
estrogens; hypotensive agents; misc. GI drugs; floor space volume of the pharmacy in sq. ft. by
sympathominetics (adrenergic); and thyroid agents. 2.103;
Prior authorization required for: growth hormones; and
prescribed smoking deterrents. Categories not covered: 4) divide 3) by total prescriptions filled by that
anoretics; prescribed cold medications; amphetamines pharmacy
(except for narcolepsy and hyperactivity); cough
5) add $0.73 to 4).
suppressants; DESI drugs; vitamins (except prenatal);
and vitamins with fluoride.
Extra fee for compounding:
Coverage of Injectables: Injectable medicines
Long-term care pharmacies receive highest dispensing
reimbursable through both the Prescription Drug
fee once per month per NDC.
Program and physician payment when used in
physicians’ offices.
Ingredient Reimbursement Basis: EAC = AWP-5%, or
FUL + dispensing fee.
Vaccines: Vaccines reimbursable at cost as part of
EPSDT services and the Vaccines for Children
Maximum Allowable Cost: State imposes Federal
Program.
Upper Limits on generic drugs. Override requires
“Brand Medically Necessary” and the reason of
Unit Dose: Unit dose packaging reimbursable.
necessity.

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Incentive Fee: None. DUR Contact


Edward Bako, R.Ph.
Cognitive Services: Does not pay for cognitive
Medicaid Pharmacist
services.
Division of Health Care Services
4501 Business Park Boulevard
Patient Cost Sharing: $2.00 copayment for branded
Suite 24
and generic products.
Anchorage, AK 99503
T: 907/334-2654
E. USE OF MANAGED CARE F: 907/561-1684
E-mail: edward.bako@alaska.gov
Does not use MCOs to deliver services to Medicaid
recipients. New Brand Name Products Contact
Dave Campana, R.Ph.
F. STATE CONTACTS 907/334-2425

Medicaid Drug Program Administrator Prescription Price Updating

Dave Campana, R.Ph. Dave Campana, R.Ph.


Pharmacy Program Manager 907/334-2425
Division of Health Care Services
4501 Business Park Blvd., Suite 24 Medicaid Drug Rebate Contact
Anchorage, AK 99503 Dave Campana, R.Ph.
T: 907/334-2425 907/334-2425
F: 907/561-1684
E-mail: david.campana@alaska.gov Claims Submission Contact
Internet Address: www.hss.state.ak.us/dhcs
First Health Services Corporation
Health and Social Services Department 4300 Cox Road
Officials Glen Allen, VA 23060
800/965-7400
Karleen Jackson, Commissioner
Department of Health and Social Services Disease Management Program/Initiative
P.O. Box 110601 Contact
Juneau, AK 99811-0601
T: 907/465-3030 Nancy Cornwell
F: 907/465-3068 Medicaid Administrator IV
E-mail: karleen.jackson@ alaska.gov Division of Health Care Services
4501 Business Park Blvd., Suite 24
Bill Streur, Director Anchorage, AK 99503
Division of Health Care Services, DHSS 907/269-8868
4501 Business Park Boulevard E-mail: nancy.cornwell@alaska.gov
Suite 24
Anchorage, AK 99503 Mail Order Pharmacy Benefit
T: 907/334-2520 Yes, for all Medicaid recipients, mostly rural
F: 907/561-1684 recipients participate.
E-mail: william.streur@alaska.gov
Alaska DUR Committee
Prior Authorization Contact
Ed Bako, R.Ph. (Coordinator)
Dave Campana, R.Ph. Anchorage, AK
907/334-2425
Heide Brainerd, R.Ph.
Anchorage, AK

Greg Polston, M.D.


Fairbanks, AK

Amber Briggs, Pharm.D.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Soldotna, AK St. Michaels, AK

Alexander von Hafften, M.D. John Bringhurst


Anchorage, AK Petersburg, AK

Vincent Greear, R.Ph. Kathy Kraft (Coordinator)


Homer, AK
Jerry Fuller (Commissioner’s designee non-voting)
Pharmacy and Therapeutics Committee
Executive Officers of State Medical and
Marvin Bergeson, M.D.
Pharmaceutical Societies
Mark Borher, R.Ph.
Heidi Brainerd, R.Ph. Alaska State Medical Association
Richard E. Brodsky, M.D. (Chair) Jim Jordan, Executive Director
Robert H. Carlson, M.D. 4107 Laurel Street
Kelly C. Conright, M.D. Anchorage, AK 99508
Jeffrey Demain, M.D. T: 907/562-0304
Tracy Gale, R.Ph. F: 907/561-2063
Andrej Maciejewski, M.D. E-mail: aksma@alaska.net
Amber Briggs, Pharm.D. Internet address: www.aksma.org
Vincent Greear, R.Ph.
R. Duane Hopson, M.D. Alaska Osteopathic Medical Association
Thomas Hunt, M.D. Holly Macriss
Dan Kiley, D.D.S., M.P.H. AOA Northwest Regional Manager
Diane Liljegren, M.D. 1900 Point West Way, Suite 188
Dan Kiley, D.D.S., M.P.H. Sacramento, CA 95815-4705
Gregory R. Polston, M.D. T: 800/891-0333
Sherrie D. Richey, M.D. F: 916/564-5105
Janice L. Stables, M.S.N, A.N.P. E-mail: hmcriss@osteopathic.org
Trish D. White, R.Ph.
Alaska Pharmacists Association
Medical Care Advisory Committee Nancy Davis, Executive Director
4107 Laurel Street, Suite 101
David Alexander, M.D. (Chair)
Anchorage, AK 99508-5334
Anchorage, AK
T: 907/563-8880
F: 907/563-7880
Gary Givens, R.Ph.
E-mail: akphrmcy@alaska.net
Anchorage, AK
Internet address: www.alaskapharmacy.org
Todd Wortham, D.D.S.
Alaska State Board of Pharmacy
Kenai, AK
Sher Zinn, Licensing Examiner
P.O. Box 110806
Deborah Kiley, A.N.P.
Juneau, AK 99811-0806
Anchorage, AK
T: 907/465-2589
F: 907/465-2974
Karen Sidell (Vice Chair)
E-mail: sher_zinn@commerce.state.ak.us
Bethel, AK
Internet address: www.dced.state.ak.us/occ/ppha.htm
Lavada “Sam” Bush
Alaska State Hospital and Nursing Home Association
Fairbanks, AK
Rod L. Betit, President/CEO
426 Main Street
Marie Darlin
Juneau, AK 99801
Juneau, AK
T: 907/586-1790
F: 907/463-3573
Tracy Smith
E-mail: rodbetit@msn.com
Fairbanks, AK
Internet address: www.ashnha.com

Ursula Lockwood

Alaska-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

ARIZONA
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
(AHCCCS - PRONOUNCED "ACCESS")
skyrocketed and the high costs of the programs
AHCCCS FEATURES forced the counties to turn to the Legislature for help.
In response, the Arizona Health Care Cost
The Arizona Health Care Cost-Containment System Containment System (AHCCCS), developed in
(AHCCCS), Arizona’s Medicaid program, is a Title Senate Bill 1001, was passed by the Legislature and
XIX (Medicaid) 1115 Research and Demonstration signed by the Governor in November 1981. On
Waiver project, jointly funded by the federal October 1, 1982, AHCCCS became the first
government and the State of Arizona. AHCCCS is an statewide managed care system in the nation. It
innovative program designed to deliver quality, contained six major mechanisms for restraining
defraying the cost of indigent health care. health care costs at the same time ensuring that
Implemented in October 1982, it serves as a model appropriate levels of quality health care services are
for providing medical services to the indigent in a provided to eligible persons in a dignified fashion.
managed care system rather than through fee-for- The goal of these 6 items was to contribute to the
service arrangements. Typically, Medicaid programs establishment of health care financing that is less
have incorporated the traditional hallmarks of the expensive than conventional fee-for-service systems.
U.S. health care system: namely, independent The six mechanisms were:
providers and fee-for-service reimbursement. In
contrast, organized health plans and capitation mark ! Primary Care Physicians Acting as
the AHCCCS model. This capitated model, although Gatekeepers
new to Medicaid in 1982, was patterned on the way ! Prepaid Capitated Financing
many consumers paid for private healthcare ! Competitive Bidding Process
insurance. ! Cost Sharing
! Limitations on Freedom-of-Choice
AHCCCS is a partnership between the State and ! Capitation of the State by the Federal
private and public managed care health plans, Government.
opening up the private physician network to
Medicaid recipients and allowing AHCCCS members Primary Care Physicians as Gatekeepers
to choose a primary care provider who acts as a
gatekeeper and case manager. In traditional Medicaid AHCCCS legislation provided that all members must
programs, the States assume responsibility for be under the care and supervision of a primary care
contracting with individual pharmacies and physician who assumed the role of gatekeeper. A
reimbursing them. In the AHCCCS model however, statewide network of primary care physicians was
the State contracts, instead, with pre-paid health established to perform the gatekeeping function for
plans, HMOs and HMO-like entities. These plans the system and manage all aspects of a member’s
are paid on a capitation basis and are responsible for medical care.
providing all of the services covered by the program.
Thus, with the exception of behavioral health drugs Prepaid Capitated Financing
which are carved out of managed care, the delivery
of pharmacy services is the responsibility of each It was the intent of the AHCCCS legislation that
prepaid plan. 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
GENERAL INFORMATION allowed for the establishment of a statewide bidding
process to accomplish this. Services are provided on
Prior to 1982, Arizona was the only State in the a county-by-county basis, by prepaid health plans.
nation that was not participating in the Medicaid Providers may bid on a prepaid capitated basis for
program. State leaders avoided the national program covered services to be provided within a particular
primarily because of concerns about high costs and county. The law allows for expansion and
big bureaucracies. Instead of accepting Federal contraction of bids to achieve the best possible
funds for healthcare, Arizona retained its system of system. In the event there are insufficient bids for a
indigent health care provided by individual counties given area, the legislation permits capped fee-for-
as they saw fit and could afford. However, by 1980, service arrangements. It is intended, however, that
health care costs for poor Arizona residents had

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National Pharmaceutical Council Pharmaceutical Benefits 2007

capped fee-for-service will be authorized as a last completely blanketed with prepaid capitated
resort only. arrangements. Members are linked to selected or
assigned plans for definite durations of time.
In essence, AHCCCS prepaid health plans (PHPs), Freedom-of-choice is permitted to the extent
health maintenance organizations (HMOs), and other practicable for members to select the particular group
types of organized health delivery systems charge a with which to enroll, as well as the primary care
fixed fee per individual enrolled (i.e., a capitation physician within the selected group. Capped fee-for-
rate) and assume responsibility for providing a broad service health service arrangements are used as a last
array of health care services to members. The plan or resort, and only in areas not covered by prepaid
contractor is then “at risk” to deliver the necessary capitated plans.
services within the capitated amount. AHCCCS
receives Federal, State, and county funds to operate, CAPITATION BY THE FEDERAL
plus some monies from Arizona’s tobacco tax. GOVERNMENT
Competitive Bidding Process The State of Arizona will itself be capitated by the
Federal government and therefore will be at financial
The statewide competitive aspect of the bid process risk for containing health care costs. Capitation rates
for selecting providers and offering prepaid capitated are established according to sound actuarial
services is the most unique feature of the AHCCCS principles, and represent no more than 95 percent of
model. A competition of this magnitude had never the estimated cost of services delivered in Arizona
been attempted in any other State. The AHCCCS under conventional fee-for-service arrangements.
administration believes competitive bidding for Capitation provides a key incentive for the State to
health care service contracts, as opposed to monitor health care costs on a careful and continuous
conventional negotiation processes, provides basis.
accessible cost-effective delivery of health care
without sacrificing quality performance. IMPLEMENTATION OF AHCCCS
The AHCCCS administration issues an invitation to AHCCCS is based on plans that have been tested, in
qualified health plans once every five years. part, on smaller scales in different areas of the
Qualified health plans may bid to offer the full range country. By combining a number of key mechanisms
of AHCCCS services in one or more counties. on a statewide basis, AHCCCS represents a novel
health care model. The purpose of this section is to
Cost Sharing present a discussion of how the key concepts
embodied in the AHCCCS legislation will be
The fourth major device for containing costs in the implemented and rendered operational.
AHCCCS model is a provision for cost sharing by
users. A statewide copayment schedule was Provider Participation
developed for this purpose, and the medically needy
participate in coinsurance cost sharing. It is expected Providers may participate in AHCCCS in 2 different
that the imposition of nominal copayments will ways. First, they may contract with prepaid capitated
ensure optimal effectiveness in the area of service plans as either full or partial benefit providers.
utilization. The copayment schedule accomplishes
three objectives: curtailment of over-utilization; The second mode of participation is on a capped fee-
enhancement of patient dignity; and service for-service basis. Here, providers agree to accept
utilization by members for truly needed health care. capped fee payments as payments in full for services
There is no copayment for drugs and medication, provided on a FFS basis.
prenatal care including all obstetrical visits, members
in long care facilities and for visits scheduled by the Functions of the AHCCCS Administration
primary care physician or practitioner, and not at the
request of the member. The Arizona Health Care Containment System
Administration (AHCCCSA) contracts health plans
Limitations On Freedom-of-Choice and other program contractors to serve AHCCCS
members through a network of providers, paying
The fifth major item for containing costs is a them a monthly capitation amount prospectively for
restriction on provider/physician selection by each enrolled member. The plan or contracor is then
AHCCCS members. Unlike conventional delivery “at risk” to deliver the necessary services within that
models, Arizona does not rely on fee-for-service
arrangements. The goal is to have the State

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National Pharmaceutical Council Pharmaceutical Benefits 2007

amount. AHCCCS receives Federal, State, and ! Provider, Member Call Center
county funds to operate. ! Grievances and Complaints
! Fee-for-Service for IHS
Contracting Health Plans
AHCCCS became effective December 1, 1981, and
Under the Contracting Health Plan arrangement, services commenced October 1, 1982. Services
plans are defined in terms of explicit groups of include: inpatient, outpatient, laboratory, long-term
providers organized as entities that are more formal. care, x-ray, prescription drugs, medical supplies,
These consortia, or formal entities, are capable of prosthetic devices, emergency dental care including
providing the full range of AHCCCS benefits within extractions and dentures, treatment of eye conditions
a defined service area for all AHCCCS members who and EPSDT.
elect to join the plans, up to a predetermined
capacity. This is the dominant mode of operation From the beginning, AHCCCS has operated under an
within AHCCCS -- with two or more competing 1115 Research and Demonstration waiver granted by
plans wherever possible. the U.S. Department of Health and Human Services.
Though AHCCCS was a three-year experiment that
The Contracting Health Plans are delivery systems, was to end in October 1985, the Federal government
not simply insurance plans, but they need not be continues to extend funding for the program. In
Health Maintenance Organizations by any legal or 1988, AHCCCS received a five-year extension from
conventional definition of the term. The AHCCCS the Federal government and in 1993, it received an
legislation provides for the creation of provider additional one-year extension. In 1994, AHCCCS
consortia for the purpose of participation in the received a three-year extension and in 1998, it
program. The Contracting Health Plan may be a received a one-year extension. Since then, AHCCCS
loosely organized system, but it must be capable of has received additional extensions. Currently,
providing the full range of AHCCCS benefits to a AHCCCS is operating under a five year waiver
defined population at a capitation rate. extension that will expire on September 30, 2011.
Some 25 years after it first began, AHCCCS has
The Organizational Role of AHCCCS grown in numbers from the first wave of 180,000
Administration enrollees to over 1 million beneficiaries, representing
18 percent of Arizona’s population. The program
The AHCCCS Administration has been charged with covers all mandatory Medicaid eligibility groups, 12
the general implementation and monitoring of the optional groups and 4 expansion groups. AHCCCS
AHCCCS program. has evolved into a mature, well-respected health care
system and has become a model as managed care is
The AHCCCS Administration develops the Rules increasingly by being implemented in other States’
and Regulations; manages the health plan bidding Medicaid programs.
processes; awards the contracts; provides technical
assistance to providers for the purpose of forming (Additional information about AHCCCS can be
consortia to contract with AHCCCS; and monitors found on the agency’s website at
the overall operation of the program. The State also www.ahcccs.state.az.us)
provides regulatory oversight, including operational
and financial oversight of the plans and contract MEDICAL PLANS AND
monitoring to ensure quality of care. ADMINISTRATORS

The Operational Role of the AHCCCS AHCCCS Contracted Health Plans


Administration
Arizona Physicians IPA (APIPA)
3141 North 3rd Avenue
Organizationally, the AHCCCS Administration
Phoenix, AZ 85013
assumes responsibility for the oversight of every day
800/445-1638
operations.
Care1st Health Plan of Arizona, Inc.
The AHCCCS Administration has overall
2355 E. Camelback Rd.
responsibility for the following activity areas:
Suite 300
! Eligibility Oversight Phoenix, AZ 85016
! Procurement of Health Plans T: 866/560-4042
! Quality Management F: 602/778-1863
! Health Plan Oversight

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Health Choice Arizona


Suite 260 Cochise Health Systems
1600 West Broadway Cochise County Health & Social Services
Tempe, AZ 85282 1415 West Melody Lane, Building A
T: 800/322-8670 P.O. Box 4249
F: 800/784-2933 Bisbee, AZ 85603-4249
800/285-7485
Maricopa Health Plan
2502 East University Drive DES/DDD (Central Office)
Suite 125 1789 West Jefferson, 4th Floor
Phoenix, AZ 85034 Phoenix, AZ 85005
800/582-8686 T: 866/229-5553
F: 602/542-6870
Mercy Care Plan
Suite 400 Evercare Select
2800 North Central 314 N. 3rd Avenue, Suite 100
Phoenix, AZ 85004 Phoenix, AZ 85013
800/624-3879 800/293-0039

Phoenix Health Plan/Community Connection Mercy Care Plan


7878 North 16th Street, Suite 105 Suite 400
Phoenix, AZ 85020 2800 North Central
800/747-7997 Phoenix, AZ 85004
800/624-3879
Pima Health System
Herbert K. Abrams Public Health Center Pima Long Term Care
3950 S. Country Club Road, Suite 400 Pima Health System
Tucson, AZ 87514 Herbert K. Abrams Public Health Center
800/423-3801 3950 S. Country Club Road, Suite 400
Tucson, AZ 87514
University Family Care 800/423-3801
575 East River Road
Tucson, AZ 85704 Pinal/Gila LTC
888/708-2930 P.O. Box 2140
971 N. Jason Lopez Circle
Phoenix Area Indian Health Services (IHS) Building D
Two Renaissance Square Florence, AZ 85232
40 N. Central Avenue T: 800/831-4213
Phoenix, AZ 85004-5036 F: 520/866-6720
602/364-5039
SCAN Long Term Care
Tucson Area Indian Health Services (IHS) 2702 N. 44th Street
7900 South J. Stock Road Suite B-200
Tucson, AZ 85746 Phoenix, AZ 85008
520/295-2405 602/417-6600

Navajo Area Indian Health Services (IHS) Yavapai County LTC


P.O. Box 9020 Yavapai County Department of Medical Assistance
Window Rock, AZ 86515-9020 6717 East Second Street, Suite D
928/871-5811 Prescott Valley, AZ 86314
T: 800/850-1020
Long-Term Care Contractor List F: 928/771-3542
Bridgeway Health Solutions
1501 W. Fountainhead Corporate Park, Suite 201
Tempe, AZ 85282
866/475-3129

Arizona-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

STATE CONTACTS Executive Officers of State Medical and


Pharmaceutical Societies
AHCCCS Officials Arizona Medical Association
Anthony D. Rodgers, Director Chic Older
AHCCCS Executive Vice President
801 E. Jefferson Street 810 West Bethany Home Road
Phoenix, AZ 85034 Phoenix, AZ 85013
T: 602/417-4111 T: 602/246-8901
F: 602/252-6536 F: 602/242-6283
E-mail: anthony.rodgers@ahcccs.state.az.us E-mail: chicolder@azmedassn.org
Internet address: www.ahcccs.state.az.us Internet address: www.azmedassn.org

Del Swan Arizona Pharmacy Alliance


Pharmacy Program Administrator Kathy Boyle
AHCCCS Executive Director
701 East Jefferson Street 1845 E. Southern Ave.
MD 8000 Tempe, AZ 85282-5831
Phoenix, AZ 85034 T: 480/838-3385
T: 602/417-4726 F: 480/838-3557
F: 602/254-1769 E-mail: azpa@azpharmacy.org
E-mail: del.swan@azahcccs.gov Internet address: www.azpharmacy.org

State Medical Advisory Committee Arizona Osteopathic Medical Association


Amanda Weaver
Provider/Professional Members Executive Director
Joseph Coatsworth 5150 N. 16th St., Suite A-122
Arizona Association of Community Health Phoenix, AZ 85016
Centers T: 602/266-6699
Jeffrey T. Erickson, D.M.D. F: 602/266-1393
Central Tooth Doctor for Kids E-mail: mweaver@az-osteo.org
Internet address: www.az-osteo.org
Kathy Byrne
El Rio Community Health Center Arizona State Board of Pharmacy
Veronica Peña Hal Wand
Regional Center for Border Health Executive Director
4425 W. Olive Avenue, Suite 140
Public Members Glendale, AZ 85302
David Hughes T: 623/463-2727
AHCCS Member Freedom to Work Client F: 623/934-0583
Donna Kruck E-mail: hwand@azpharmacy.gov
Arizona Bridge for Independent Living Internet address: www.pharmacy.state.az.us

Dr. Leonard Kirschner Arizona Hospital and Healthcare Association


Arizona Perinatal Trust John R. Rivers, FACHE
Jill Rissi President/CEO
St. Lukes’ Health Initiative 2901 North Central Avenue
Suite 900
Lupe Solis Phoenix, AZ 85012
AARP T: 602/445-4300
Ex-Officio Members F: 602/445-4299
Anthony D. Rodgers, Director E-mail: jrivers@azha.org
AHCCCS Administration Internet address: www.azha.org

Jeannie Harmon, DES/AHCCCS Liaison


Arizona Department of Economic Security
Sundin Applegate, MD.., Medical Director
Arizona Department of Health Services

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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National Pharmaceutical Council Pharmaceutical Benefits 2007

ARKANSAS

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2004 2005
Expenditures Recipients Expenditures Recipients

TOTAL $393,948,896 422,424 $437,398,315 439,712

RECEIVING CASH ASSISTANCE, TOTAL $210,757,332 120,252 $229,296,123 119,986


Aged $17,902,594 10,591 $18,518,342 10,070
Blind/Disabled $177,381,172 75,271 $194,181,644 77,138
Child $6,721,539 20,653 $6,658,600 18,899
Adult $8,752,027 13,737 $9,926,118 13,879

MEDICALLY NEEDY, TOTAL $6,902,864 7,885 $7,602,500 7,792


Aged $163,862 287 $147,264 249
Blind/Disabled $3,665,426 2,627 $3,909,767 2,570
Child $528,868 1,386 $575,270 1,274
Adult $2,544,708 3,585 $2,957,202 3,676

POVERTY RELATED, TOTAL $62,141,754 184,557 $71,854,729 196,000


Aged $4,253,583 3,247 $5,631,949 3,810
Blind/Disabled $1,524,348 971 $1,799,938 1,026
Child $54,878,958 171,130 $62,059,015 181,286
Adult $1,484,865 9,209 $1,562,246 9,877
BCCA Women $0 0 $0 0

TOTAL OTHER EXPENDITURES/RECIPIENTS* $114,146,946 109,730 $128,657,957 115,957

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

Source: Arkansas Medicaid Statistical Information System, FY 2004 and FY 2005.

Arkansas-1
National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION Vaccines: Vaccines reimbursable as part of EPSDT


services, the Children’s Health Insurance Program,
Department of Human Services, Division of Medical and the Vaccines for Children Program.
Services, Pharmacy Program.
Unit Dose: Unit dose packaging not reimbursable.
D. PROVISIONS RELATING TO DRUGS
Formulary/Prior Authorization
Benefit Design
Formulary: State has a preferred drug list (PDL).
Drug Benefit Product Coverage: Products covered Covers outpatient drugs whose manufacturers have
with restrictions: prescribed insulin; disposable signed a rebate agreement with CMS. General
needles and syringe combinations used for insulin. exclusions include:
Products not covered: blood glucose test strips; urine
ketone test strips; total parenteral nutrition, 1. Agents used for hair growth.
interdialytic parenteral nutrition; cosmetics; fertility
drugs; experimental drugs; and vitamins (other than 2. Vitamin products except prescription prenatal
prenatal vitamins for pregnant women). Prior vitamins.
authorization required for: nitroglycerin patches; 3. Drugs determined by the FDA to be ineffective
agents for impotence; Synagis; Respigam; Xenical- (DESI drugs).
hyperlipidemia; Remicade; Regranex; Kineret;
Enbrel; Xolair; Humira, and Xopenex. Some self – 4. Sedatives and hypnotics in the benzodiazepine
administered injectables may also require prior category (partial coverage).
authorization. 5. Compounded prescriptions (mixtures of two or
more ingredients). States are not allowed to
Over-the-Counter Product Coverage: Limited have state codes such as 99999-9999-99. All
coverage for: allergy, asthma and sinus products; drugs reimbursed by the State must be traced by
analgesics; cough and cold preparations (under 21 NDC code and appear on the utilization report.
years and long-term care limited needs); digestive
products; feminine products; and topical products. Drug utilization managed by preferred products,
Products covered with restriction: smoking deterrent physician profiling, restrictions on use, and prior
products. authorization (requires a Federal MedWatch form to
document why a generic can not be dispensed rather
Therapeutic Category Coverage: Therapeutic than a brand-name product).
categories covered: anabolic steroids; antibiotics; Prior Authorization: State currently has a prior
anticoagulants; anticonvulsants; anti-psychotics; authorization procedure. Beneficiaries have a right to
contraceptives; and thyroid agents. Prior appeal prior authorization decisions. Physician must
authorization required for: analgesics, antipyretics, submit letter and accredited literature explaining
NSAIDs; anti-depressants; antidiabetic agents; medical necessity leading to the request for the
antihistamines; antilipemic agents; anxiolytics, medication. For off-label use, the appeal must
sedatives, and hypnotics; cardiac drugs; ENT anti- document the medical necessity of all failed
inflammatory agents; estrogens; growth hormones; treatments leading to the request for the medication.
hypotensive agents; misc. GI drugs; and
sympathominetics (adrenergic). Partial coverage for: Prescribing or Dispensing Limitations
chemotherapy agents; prescribed cold medications;
and prescribed smoking deterrents (PA required). Prescription Refill Limit: 5 refills within 6 months
Therapeutic categories not covered: anoretics; are allowed. New Rx required every 6 months.
prescription drugs for cosmetic use and vitamin
products (other than prenatal). Monthly Quantity Limit: 31-day supply.

Coverage of Injectables: Injectable medicines are Monthly Prescription Limit: Three prescriptions per
reimbursable through the Prescription Drug Program month per recipient, except unlimited for certified
when used in home health care and extended care LTC recipients and recipients under 21 years old.
facilities, and through physician payment when used Others can receive extension of three more per month
in physicians offices (if reimbursed through the for maintenance medications.
physician’s office). Some products may require prior
authorization.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Utilization Review E. USE OF MANAGED CARE

PRODUR system implemented in March 1997. State An estimated 338,000 Medicaid recipients were
currently has a DUR Board with a quarterly review. enrolled with Primary Care Physicians at the end of
2006. Pharmaceutical benefits are provided through
Pharmacy Payment and Patient Cost Sharing the State.

Dispensing Fee: $5.51 effective 3/1/02. Non-MAC


generics receive an additional $2.00 dispensing fee. F. STATE CONTACTS
LTC pharmacies generally receive one dispensing fee
per NDC per month. Medicaid Drug Program Administrator
Suzette Bridges, Pharm.D., Administrator
Ingredient Reimbursement Basis: EAC = AWP-14% Pharmacy Program
(Brand), AWP-20% (Generic). Division of Medical Services
Dept. of Human Services
Prescription Charge Formula: Legend drugs: lower P.O. Box 1437, Slot S 415
of the EAC plus a dispensing fee or CFA/state upper Little Rock, AR 72203-1437
limit plus a dispensing fee. Total charge may not T: 501/683-4120
exceed provider’s charge to the self-paying public. F: 501/683-4124
E-mail: suzette.bridges@arkansas.gov
Maximum Allowable Costs: State imposes Federal
Upper Limits as well as State-specific limits on Prior Authorization Contact
generic drugs. State-specific MAC list contains 800
drugs (see www.medicaid.ar.us). Override requires Suzette Bridges, Pharm.D.
“Brand Medically Necessary” plus physician 501/683-4120
documentation on MedWatch form as to why the
generic cannot be dispensed. DUR Contact
Pamela Ford, Pharm.D.
Incentive Fee: $2.00 additional dispensing fee on Pharmacist II
non-MAC generics. Division of Medical Services
Dept. of Human Services
Patient Cost Sharing: Effective 9/1/92, for each P.O. Box 1437, Slot S 415
prescription reimbursed, the Medicaid recipient is Little Rock, AR 72203-1437
responsible for paying a copayment based on the T: 501/683-4120
following: F: 501/683-4124
E-mail: pamela.ford@arkansas.gov
State Payment Copay
DUR Board
$10.00 or less $0.50
Steve Bryant, Pharm.D.
$10.01 to $25.00 $1.00 Gary Bass, Pharm.D.
Ken Lancaster, Pharm.D.
$25.01 to $50.00 $2.00 Debbie Hayes, Pharm.D.
Thomas Lewellen, D.O.
$50.01 or more $3.00 Michael N. Moody, M.D.
Laurence Miller, M.D.
P. Justin Boyd, Pharm.D.
ArKids $5.00
Jill Johnson, Pharm.D.
Services to individuals under 18, pregnant women,
New Brand Name Products Contact
nursing home residents, emergency services, family
planning services, and services provided by an HMO Pamela Ford, Pharm.D.
to its enrollees are excluded from the Medicaid copay 501/683-4120
policy.

Cognitive Services: Does not pay for cognitive


services.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescription Price Updating Department of Human Services Officials


First DataBank John Selig, Director
1111 Bay Hill Drive, Suite 350 Department of Human Services
San Bruno, CA 94066 P.O. Box 1437, Slot S 201
T: 650/588-5454 Little Rock, AR 72203-1437
F: 650/588-4003 T: 501/682-8999
F: 501/682-6836
Medicaid Drug Rebate Contacts E-mail: john.selig@state.ar.us
Internet address: www.arkansas.gov/dhhs
Audits: Suzette Bridges, Pharm.D.
501/683-4120
Roy Jeffus, Director
Division of Medical Services
Dispute Resolution: Shirley Harrell
P.O. Box 1437, Slot S 401
Rebate Analyst
Little Rock, AR 72203-1437
EDS
T: 501/682-8740
500 President Clinton Ave, Suite 400
F: 501/682-1197
Little Rock, AR 72201
E-mail: roy.jeffus@medicaid.state.ar.us
T: 501/374-6608
F: 501/372-2971
Executive Officers of State Medical and
E-mail: shirley.harrell@eds.com
Pharmaceutical Societies
Claims Submission Contact Arkansas Hospital Association
Phil E. Matthews
John Herzog
President/CEO
Account Manager
419 Natural Resources Drive
EDS
Little Rock, AR 72205
500 President Clinton Ave, Suite 400
T: 501/224-7878
Little Rock, AR 72201
F: 501/224-0519
T: 501/374-6608
E-mail: philmatthews@arkhospital.org
F: 501/372-2971
Internet address: www.arkhospitals.org
E-mail: john.herzog@eds.com
Arkansas Pharmacists Association
Medicaid Managed Care Contact
Mark Riley, Pharm.D.
Kellie Phillips, Administrator Executive Vice President
Division of Medical Assistance 417 S. Victory Street
Division of Medicaid Services Little Rock, AR 72201-2932
Dept. of Human Services T: 501/372-5250
P.O. Box 1437, Slot S 410 F: 501/372-0546
Little Rock, AR 72203 E-mail: mriley@arpharmacists.org
T: 501/682-8306 Internet address: www.arpharmacists.org
F: 501/682-1197
E-mail: kellie.phillips@arkansas.gov Arkansas State Board of Pharmacy
Charles S. Campbell, Pharm.D.
Disease Management/Patient Education Executive Director
Programs 101 E. Capitol, Suite 218
Little Rock, AR 72201
None T: 501/682-0190
F: 501/682-0195
Disease Management/ Patient Education E-mail: charlie.campbell@mail.state.ar.us
Contact Internet address: www.state.ar.us/asbp
Suzette Bridges, Pharm.D.
501/683-4120

Mail Order Pharmacy Benefit


None

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National Pharmaceutical Council Pharmaceutical Benefits 2007

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


David Wroten
Executive Vice President
P.O. Box 55088
Little Rock, AR 72215
T: 501/224-8967
F: 501/224-6489
E-mail: dwroten@arkmed.org
Internet address: www.arkmed.org

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National Pharmaceutical Council Pharmaceutical Benefits 2007

CALIFORNIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

Prescribed Drugs ! ! ! ! ! ! ! !
Inpatient Hospital Care ! ! ! ! ! ! ! !
Outpatient Hospital Care ! ! ! ! ! ! ! !
Laboratory & X-ray Service ! ! ! ! ! ! ! !
Nursing Facility Services ! ! ! ! ! ! ! !
Physician Services ! ! ! ! ! ! ! !
Dental Services ! ! ! ! ! ! ! !
Note: Certain classifications of aliens in the above categories are eligible only for emergency and pregnancy-related benefits.

B. EXPENDITURES FOR DRUGS


2003 2004
Expenditures Recipients Expenditures Recipients

TOTAL $4,019,645,375 2,868,468 $4,611,537,385 3,173,811

RECEIVING ASSISTANCE, TOTAL $2,934,313,712 1,411,255 $3,352,065,513 1,498,982


Aged $690,209,433 285,497 $804,237,761 294,162
Blind/Disabled $2,076,614,397 609,850 $2,354,260,143 630,867
Children $57,005,005 309,177 $65,385,783 349,188
Adult $110,484,877 206,731 $128,181,826 224,765

MEDICALLY NEEDY, TOTAL $526,234,297 266,330 $572,891,127 250,983


Aged $276,961,622 126,340 $307,526,174 126,903
Blind/Disabled $218,003,802 48,821 $233,760,443 48,987
Children $11,719,250 54,739 $13,126,252 48,767
Adults $19,549,623 36,430 $18,478,258 26,326

POVERTY RELATED, TOTAL $216,900,380 173,508 $333,401,301 210,473


Aged $78,787,478 46,534 $125,309,195 62,473
Disabled $122,373,649 32,105 $188,865,056 44,545
Children $7,306,335 55,378 $7,915,918 61,419
Adults $3,286,279 36,543 $3,614,378 37,955
BCCA Women $5,146,639 2,948 $7,696,754 4,081

TOTAL OTHER EXPENDITURES/RECIPIENTS* $342,196,986 1,017,375 $353,179,444 1,213,373

*Total Other Expenditures/ Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Note: California estimates drug expenditures to be approximately $5.4 billion in 2005 and $2.6 billion in 2006. The number of
Medicaid drug recipients is estimated to be 3.6 million in 2005 and 3.3 million in 2006.

Source: CMS, MSIS Report, FY 2003 and CMS FY 2004.

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C. ADMINISTRATION Patients can get prior authorization for unlisted drugs


or for listed drugs that are restricted to specific
Under the Health and Human Services Agency with use(s), if medically justified. Manufacturers
direct administration by the Department of Health frequently petition Medi-Cal to add drugs to the List.
Care Services. Based on Medi-Cal’s five criteria (safety, efficacy,
misuse potential, essential need, and cost), a drug
D. PROVISIONS RELATING TO DRUGS may be added to the List by contractual agreement
with the manufacturer to provide the State a
Benefit Design negotiated rebate. The Medi-Cal website at:
http://www.dhs.ca.gov/mcs/mcpd/MBB/contracting/h
Drug Benefit Product Coverage: The Medi-Cal tml/faqpage.htm has details of how the drug
pharmacy benefit covers practically all FDA- contracting process works.
approved drugs, including both legend and over-the-
counter products. There are very few drugs or Examples of general limitations and exclusions
classes of drugs that are non-benefits. Non-benefits (other uses require prior authorization):
include common household remedies; combination
1. CNS stimulants, e.g., amphetamines and
non-legend analgesics and time-released cough/cold
methylphenidate, are restricted to attention
medications, except when specifically listed;
deficit disorder in individuals between 4 and 16
multivitamin preparations, except certain pre-natal
years of age.
and pediatric products; cosmetics; fertility drugs;
experimental drugs, and interdialytic parenteral 2. Diazepam is restricted to use in cerebral palsy,
nutrition. Most other products are potential benefits. athetoid states, and spinal cord degeneration.
3. Most non-steroidal anti-inflammatory agents are
In general, products that are listed on the Medi-Cal
restricted to use for arthritis.
List of Contract Drugs (List) do not require prior
authorization. Those not on the List do require prior 4. Some antibiotics have diagnostic and/or age
authorization. restrictions.
5. Acyclovir capsules are restricted to herpes
Physician-administered drugs: The Medi-Cal List
genitalis, immunocompromised, and herpes
applies to drugs dispensed from pharmacies to
zoster (shingles) patients.
patients. Drugs administered directly in a
physician's, dentist's, or podiatrist's office are not 6. Codeine Combinations: payment to a pharmacy
bound by it. for aspirin or acetaminophen with codeine 30 mg
is limited to a maximum dispensing quantity of
Coverage of Injectables: Injectable medicines are 45 tablets or capsules and a maximum of 3
reimbursable through the Prescription Drug Program claims for the same beneficiary in any 75-day
when used in extended care facilities, through period.
physician payment when used in physician offices,
7. Enteral nutritional supplements or replacements
and through both the prescription drug program and
are covered, subject to prior authorization, if
physician payment when used in home health care.
used as a therapeutic regimen to prevent serious
disability or death in patients with medically
Vaccines: Vaccines are reimbursable by schedule as
diagnosed conditions that preclude the full use of
part of the Vaccines for Children Program. Vaccines
regular foodstuffs.
for adults are covered through the prescription drug
program or as administered in a physician's office. 8. Cancer, AIDS, and DESI Drugs: Any
antineoplastic drug approved by FDA for the
Unit Dose: Unit dose packaging is generally treatment of cancer and any drug approved by
reimbursed at the bulk container rate, like all other FDA for the treatment of AIDS or AIDS-related
products. condition is covered through the Medi-Cal List
of Contract Drugs; most DESI drugs rated less-
Formulary/Prior Authorization than-effective by FDA are not covered.

Formulary: The List contains over 600 drugs, in Prior Authorization: Nearly all drugs not included on
differing strengths and dosage forms, listed the Medi-Cal list of Contract Drugs require prior
generically. The PDL is managed through preferred authorization. State currently has a formal prior
products, exclusion of products based on contracting authorization procedure to appeal prior authorization
issues, restrictions on use, and prior authorization. decisions.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

The patient’s physician or pharmacist may request Hospital Discharge Medications: Quantities
prior authorization from the field office Medi-Cal furnished as discharge medications are limited to no
consultant for approval of unlisted drugs or for listed more than a 10-day supply. Charges are incorporated
drugs that are restricted to specific use(s). This is in the hospital’s claims for inpatient services.
done by completing a Treatment Authorization
Request (TAR) form. Providers may appeal prior Drug Utilization Review
authorization decisions within 60 days of notification
Prospective DUR system implemented in August
to the local field office and then to field services
1995. State currently has a DUR Board with a
headquarters if necessary. Beneficiaries also have the
quarterly review.
ability to request a hearing to review the denial and
must do so within 90 days of notification.
Pharmacy Payment and Patient Cost Sharing
TARs may be approved for: covered items or Dispensing Fee: $7.25 ($8.00 LTC), effective 9/1/04.
services not included on the Medi-Cal List of
Contract Drugs (including special circumstance such Ingredient Reimbursement Basis: EAC = AWP-17%
as the need to override multiple source drug price
ceilings or minimum quantity/ frequency of billing Prescription Charge Formula: Reimbursement is
limitations); and for patients exceeding the 6 Rx per based on the lowest of:
month limit. Statewide mail and fax requests are
accepted in the Stockton and Los Angeles Medi-Cal 1. Estimated Acquisition Cost (EAC) plus current
Field Offices. Requests must include adequate professional fees
information and justification. Authorization may 2. Federal Upper Limit (FUL) plus current
only be given for the lowest cost item or service that professional fees
meets the patient’s medical needs. 3. State Maximum Allowable Ingredient Cost
(MAIC) plus current professional fees
Beneficiary or Prescriber Prior Authorization: On a 4. Pharmacy’s usual price to general public.
case by case basis, the Dept. of Health Care Services
restricts, through the requirements of prior State law requires that reimbursement for blood
authorization, the availability of designated factors be by NDC and not exceed 120 percent of the
prescription drugs to certain beneficiaries or average selling price during the preceding quarter or
prescribers found by the Department to abuse those the provider’s usual and customary charge.
benefits.
Maximum Allowable Cost: State imposes a
Prescribing or Dispensing Limitations combination of Federal and State-specific limits on
generic drugs. Maximum Allowable Ingredient Costs
Prescription Refill Limit: A prescription refill can be (MAICs) are established for about 50 multi-source
dispensed as authorized by prescriber. An exception items. Override requires “Medically Necessary” or
is allowed for refill of a reasonable quantity when unavailability of drug products at or below MAC.
prescriber is unavailable (pursuant to California law). List is periodically revised and price limits changed
Fee is to be pro-rated so that total fee (for partial to reflect current market conditions.
quantity and balance of the prescription after
prescriber is contacted) does not exceed the fee for Incentive Fee: None.
the same prescription when refilled as a routine
service. Many drugs are limited to 3 claims in a 75 Patient Cost Sharing: $1.00 copayment for branded
day period. and generic products.

Monthly Quantity Limit: This is flexible, but should Cognitive Services: Does not pay for cognitive
be consistent with the medical needs of the patient. services, but this is under consideration.
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.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

E. USE OF MANAGED CARE Contra Costa Health Plan


595 Center Avenue, Suite 100
Approximately 3.3 million Medicaid recipients were Martinez, CA 94553
enrolled in MCOs in FY 2006. Recipients receive 925/313-6008
pharmaceutical benefits through the State and
managed care plans. Certain psychiatric drugs Family Mosaic Project
(antipsychotics, lithium, MAO inhibitors), some anti- 1309 Evans Avenue
Parkinson drugs, and many HIV drugs are carved out San Francisco, CA 94124
of managed care. 415/206-7600

AIDS Healthcare Foundation Health Net of California


Positive HealthCare State Health Programs
6255 W. Sunset Blvd., 21st Floor 11971 Foundation Place, GPD1
Los Angeles, CA 90028 Rancho Cordova, CA 95670
323/860-5231 800/675-6110

Alameda Alliance for Health Health Plan of San Joaquin


1240 South Loop Road 1550 W. Fremont Street, Suite 200
Alameda, CA 94502 Stockton, CA 95203-2643
510/747-4500 800/932-7526

Altamed Senior BuenaCare Health Plan of San Mateo


5425 East Pomona Boulevard 701 Gateway Blvd., Suite 400
Los Angeles, CA 90022 South San Francisco, CA 94080
323/728-0411 650/616-0050

Blue Cross of California Inland Empire Health Plan


P.O. Box 9054 303 East Vauderbilt Way, Suite 400
Oxnard, CA 93031 San Bernardino, CA 92408
800/407-4627 909/890-2000

CalOPTIMA Kaiser Foundation Health Plan, Inc.


1120 West La Veta Ave. 393 E. Walnut Street
Orange, CA 92868 Pasadena, CA 91188
714/246-8400 800/390-3510

Care 1st Health Plan Kern Health Systems


800 Howe Avenue, Suite 420 Kern Family Health Care
Sacramento, CA 95825 1600 Norris Road
800/605-2556 Bakersfield, CA 93308
661/391-4036
Center for Elders Independence
1955 San Pablo Avenue LA Care Health Plan
Oakland, CA 94612 555 W. Fifth Street, 20th Floor
510/433-1150 Los Angeles, CA 90013
213/694-1250
Central Coast Alliance for Health
375 Encinal Street, Suite A Molina Healthcare of California
Santa Cruz, CA 95060 One Golden Shore Drive
800/700-3874 Long Beach, CA 90802
562/432-3666, ext. 1128
Community Health Group
740 Bay Blvd. On Lok Senior Health Services-Alameda
Chula Vista, CA 91910 159 Washington Boulevard
619/498-6457 Fremont, CA 94539
415/292-8888

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National Pharmaceutical Council Pharmaceutical Benefits 2007

On Lok Senior Health Services-SF New Brand Name Products Contact


1333 Bush Street
J. Kevin Gorospe, Pharm.D.
San Francisco, CA 94109
916/552-9500
415/292-8888
Prior Authorization Contact
Partnership Health Plan of California
360 Campus Lane, Suite 100 J. Kevin Gorospe, Pharm.D.
Fairfield, CA 94534 916/552-9500
707/863-4100
DUR Contact
San Francisco Health Plan
568 Howard Street, Fifth Floor J. Kevin Gorospe, Pharm.D.
San Francisco, CA 94105 916/552-9500
415/547-7800
Medi-Cal Drug Utilization Review Board (DUR
Santa Barbara Regional Health Authority Board)
Santa Barbara Health Initiative Timothy E. Albertson, M.D., Ph.D.
110 Castilian Drive Davis, CA
Goleta, CA 93117
805/685-9525 (Northern CA) Patrick Finley, Pharm.D.
800/421-2560 (Southern CA) San Francisco, CA

Santa Clara Family Health Plan Janeen G. McBride, R.Ph.


210 E Hacienda Ave San Diego, CA
Campbell, CA 95008
408/376-2000 Ross Miller, M.D.
Los Angeles, CA
Senior Care Action Network (SCAN)
P.O. Box 22616 Robert Mowers, Pharm.D.
3780 Kilroy Airport Way, Suite 600 Sacramento, CA
Long Beach, CA 90801
562/989-5100 Kenneth Schell, M.D.
San Diego, CA
Sutter Senior Care
1234 U Street Stephen M. Stahl, M.D., Ph.D.
Sacramento, CA 95818 Carlsbad, CA
916/446-3100
Marilyn Stebbins, Pharm.D.
Western Health Advantage Rancho Cordova, CA
1331 Garden Highway Suite 100
Sacramento, CA 95833 Andrew L. Wong, M.D.
916/563-3189 Northridge, CA

F. STATE CONTACTS Prescription Price Updating


EDS Federal Corp.
State Drug Program Administrator
P.O. Box 13029, MS 4604
J. Kevin Gorospe, Pharm.D. Sacramento, CA 95813-4029
Chief, Pharmacy Policy Unit 916/636-1000
California Department of Health Care Services
Medi-Cal Policy Division
Pharmacy Contracting and Policy Section
1501 Capitol Ave., P.O. Box 997417, MS 4604
Sacramento, CA 95899-7417
T: 916/552-9500
F: 916/552-9563
E-mail: kgorospe@dhs.ca.gov
Internet Address: www.dhs.ca.gov/pharmacy

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Stan Rosenstein
Medicaid Drug Rebate Contact
Deputy Director
Craig Miller Medical Care Services
Chief, Drug Rebate and Vision Section California Department of Health Care Services
California Department of Health Care Services 1501 Capitol Ave.
Medi-Cal Policy Division P.O. Box 942732
Pharmacy Contracting and Policy Section Sacramento, CA 95814
1501 Capitol Ave. T: 916/ 440-7800
P.O. Box 997417, MS 4604 F: 916/ 440-7805
Sacramento, CA 95813-4029 E-mail: srosenst.dhs.ca.gov
T: 916/552-9500
F: 916/552-9563 Medi-Cal Contract Drug Advisory Committee
E-mail: cmiller2@dhs.ca.gov
Paul Drogichen, Pharm.D.
Samuel McAlpine, M.D.
Claims Submission Contact
Bruce K. Uyeda, Pharm.D.
EDS Federal Corp. Ross Miller, M.D., M.P.H.
P.O. Box 13029, MS 4604 Wendy Ring, M.D., M.P.H.
Sacramento, CA 95813-4029 Clifford Wang, M.D.
916/636-1000 Adrian M. Wong, Pharm.D.

Medicaid Managed Care Contact Executive Officers of State Medical and


Pharmaceutical Associations/Boards
Ronald Sanui, Pharm D.
Pharmaceutical Consultant II California Medical Association
California Department of Health Care Services Joe Dunn
Medi-Cal Managed Care Division Executive Vice-President and CEO
1501 Capitol Ave. 1201 J Street, Suite 200
P.O. Box 997417, MS 4404 Sacramento, CA 95814
Sacramento, CA 95899-7417 T: 916/444-5532
916-449-5138 F: 415/882-3349
E-mail: rsanui@dhs.ca.gov E-mail: soehler@cmanet.org
Internet address: www.cmanet.org
Disease Management Program/Initiatives
Contact Osteopathic Physicians & Surgeons of California
Kathleen S. Creason, M.B.A.
J. Kevin Gorspe, Pharm.D.
Executive Director
916/552-9500
1900 Point West Way, Suite 188
Sacramento, CA 95815-4703
Mail Order Drug Benefit T: 916/561-0724
State currently has a mail order pharmacy capability F: 916/561-0728
in the Medi-Cal program. All fee-for-service E-mail: opsc@opsc.org
beneficiaries are entitled to participate. Internet address: www.opsc.org

Department of Health Services California Pharmacists’ Association


Lynn Rolston, CEO
Sandra Shewry, Director 4030 Lennane Drive
Department of Health Care Services Sacramento, CA 95834
1501 Capitol Ave. T: 916/779-1400
Sacramento, CA 95899 F: 916/779-1401
T: 916/440-7400 E-mail: lrolston@cpha.com
F: 916/440-7404 Internet address: www.cpha.com
E-mail address: sshewry@dhs.ca.gov

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National Pharmaceutical Council Pharmaceutical Benefits 2007

California State Board of Pharmacy


William Powers
President
1625 N. Market Boulevard, Suite N219
Sacramento, CA 95834
T: 916/574-7900
F: 916/574-8617
E-mail: phystatus@dca.ca.gov
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

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National Pharmaceutical Council Pharmaceutical Benefits 2007

COLORADO

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2003 2004
Expenditures Recipients Expenditures Recipients

TOTAL $251,367,181 197,128 $294,954,808 239,881

RECEIVING CASH ASSISTANCE, TOTAL $164,866,818 106,909 $197,377,625 147,635


Aged $46,725,879 19,790 $56,704,837 22,047
Blind/Disabled $98,976,390 30,526 $110,823,742 34,210
Child $6,172,988 28,687 $13,954,066 57,880
Adult $12,988,766 27,902 $15,894,705 33,496
Unknown $2,795 4 $275 2

MEDICALLY NEEDY, TOTAL $0 0 $0 0


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

POVERTY RELATED, TOTAL $11,666,708 54,647 $12,504,481 55,045


Aged $218,561 172 $269,721 210
Blind/Disabled $480,936 180 $429,688 167
Child $8,134,392 41,240 $8,023,606 38,975
Adult $2,629,527 12,944 $3,542,192 15,563
BCCA Women $203,292 111 $239,274 130

TOTAL OTHER EXPENDITURES/RECIPIENTS* $74,833,655 35,572 $85,072,702 37,201


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

Source: CMS, MSIS Report, FY 2003 and FY 2004.

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National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION in physician offices. Prior authorization is required


for self-administration at home.
Colorado Department of Health Care Policy and
Financing administers the drug program. Eligibility Vaccines: Vaccines reimbursable as part of the
is determined by 63 County Departments of Social EPSDT Program.
Services and the Department.
Unit Dose: Unit dose packaging not reimbursable.
D. PROVISIONS RELATING TO DRUGS
Formulary/Prior Authorization
Benefit Design
Formulary: Open formulary with generic mandate.
Drug Benefit Product Coverage: Products covered: Managed through restrictions on use and prior
prescribed insulin; total parenteral nutrition; and authorization.
interdialytic parenteral nutrition. Products not
covered: cosmetics; DESI drugs; fertility drugs; Prior Authorization: State currently has a formal
prescribed vitamins (except prenatal); experimental prior authorization procedure. There is an appeal
drugs; products for weight gain/loss; and hair growth process and re-review when appealing coverage of an
paroducts. Disposable needles and syringe excluded product and prior authorization decisions.
combinations used for insulin; blood glucose test
strips; and urine ketone test strips are considered Prescribing or Dispensing Limitations
DME and do not fall under the State’s drug benefit.
Monthly Quantity Limit: New prescriptions for
Over-the-Counter Product Coverage: Products chronic or acute conditions are prescribed at the
covered with restrictions: allergy, asthma, and sinus discretion of the physician. Normal quantity limit is
products (PA and must be medically necessary); a 30-day supply. Maintenanace medications can
analgesics (aspirin only without PA); cough and cold receive up to a 100 day supply.
preparations (for chronic respiratory conditions);
digestive products (PA and must be medically Other Limits: Additional quantity limits may be
necessary); and smoking deterrent products (prior applied to certain drugs. Oxycontin: 2 tablet (any
authorization, once in a lifetime benefit, 90-day strength) per day limit without prior authorization.
supply in conjunction with smoking cessation
program). Products not covered: H2 antagonists; Drug Utilization Review
feminine products; and topical products.
PRODUR system implemented in December 1998.
Therapeutic Category Coverage: Therapeutic DUR Board meets quarterly.
categories covered: analgesics, antipyretics, and
NSAIDs (partial coverage, PA required); antibiotics;
Lock-In Review Procedures: The Department
anticoagulants; anticonvulsants; antidepressants;
receives computer processed printouts designed to
antidiabetic agents; antihistamines; antilipemic
discover over-utilization of drugs prescribed by
agents; anxiolytics, sedatives and hypnotics; cardiac
physicians, dispensed by vendors, and received by
drugs; chemotherapy agents; contraceptives; ENT
eligible recipients.
anti-inflammatory agents; estrogens; hypotensive
agents; sympathominetics (adrenergic); and thyroid
Pharmacy Payment and Patient Cost Sharing
agents. Prior authorization required for: anabolic
steroids; anti-psychotics (partial coverage);
Dispensing fee: $4.00 as of July 1, 2001.
prescribed cough and cold medications; growth
Institutional pharmacies receive a dispensing fee
hormones; misc. GI drugs (partial coverage); PPIs;
equal to $1.89. Dispensing physicians shall not
Leukotriences; Epoetin; COX-2 inhibitors;
receive a dispensing fee unless their offices or sites
Bactroban; brand name drugs; acne products, Revia;
of practice are located more than 25 miles from the
Xenical; and prescribed smoking deterrents.
nearest participating pharmacy. In the latter case,
Products not covered: anoretics; erectile dysfunction
physicians receive a fee equal to $1.89.
drugs.
Ingredient Reimbursement Basis: EAC = AWP-
Coverage of Injectables: Injectable medicines
13.5%, State MAC, or direct pricing plus 18%.
reimbursable through the Prescription Drug Program
when used in home health care and extended care
facilities, and through physician payment when used

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National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescription Charge Formula: Benefit drugs shall be prescription stating that he/she is willing to pay the
reimbursed at the lesser of the Medicaid allowable difference in ingredient cost to the pharmacy. The
reimbursement charge, or the provider’s usual and pharmacy will be paid MAC plus a dispensing fee or
customary charge or whatever is accepted from any reimbursement charges, whichever is lower.
third party, discounts, rebates, etc.
High volume Estimated Acquisition Cost (EAC):
The Medicaid allowable reimbursement charge is the Reimbursement for single source drugs or certain
sum of the ingredient cost of the drug dispensed and multiple source drugs which are most frequently
the provider’s dispensing fee. prescribed will be based upon average wholesale
prices (AWP) minus 13.5%, or direct manufacturers’
Ingredient cost for retail pharmacies (estimated prices for package sizes containing quantities greater
acquisition cost) is the price of the drug actually than 100 dosage units or less if not available in
dispensed as defined below or the MAC or the high 100’s.
volume EAC, whichever is less.
Basis for inclusion in the high volume estimated
The ingredient cost for institutional and government acquisition cost list includes but is not limited to:
pharmacies is defined as the actual cost of acquisition
for the drug dispensed or the MAC, or the high (1) Single source manufacturers;
volume EAC, whichever is less. (2) High volume Medicaid recipient utilization;

Maximum Allowable Cost: State imposes Federal (3) Interchangeability problems with multiple source
Upper Limits as well as State-specific limits on drugs;
generic drugs. Override requires “Brand Medically
Necessary.” (4) Package sizes in excess of 100.

Drug Pricing: The Department will maintain a drug-


The State MAC is the maximum ingredient cost
pricing file that will be updated biweekly. The
allowed by the Department for certain multiple-
average wholesale price of a drug as determined by
source drugs. The establishment of a MAC is
the Department, MAC, and high volume EAC, will
subject, but not limited to, the following
be the basis for setting the prices in the drug pricing
considerations:
file.
(1) Multiple manufacturers;
The Department will determine the average
(2) Broad wholesale price span; wholesale price that will be placed in the drug-
(3) Availability of drugs to retailers at the selected pricing file as follows:
cost;
(1) The average wholesale price as it appears in the
(4) High volume of Medicaid recipient utilization; Red Book, its supplements, and Medi-Span will be
(5) Bioequivalence or interchangeability. the first source. However, if there is a difference
between the two published average wholesale prices,
When Federal MAC limits for multiple source drugs the Department will set the price as the published
are announced, they will be adopted if they are less amount which is the closest to the lowest average
than State MACs or if no State MACs exist. price charged by two drug wholesalers doing
business in Colorado.
The ingredient cost of any drug subject to MAC shall
be limited to MAC or wholesale price as determined (2) If there is a price change which does not appear
by the Department, whichever is less. Exceptions immediately in the Red Book, its supplements, or in
that will allow reimbursement greater than MAC for Medi-Span, then the Department will set the average
a drug entity are obtained through a prior wholesale price by averaging the wholesale prices of
authorization mechanism. An exception will be three drug wholesalers doing business in Colorado,
granted if the patient’s response to the generic drug is until the price is published in the Red Book, its
not therapeutic, an allergic reaction is involved, or supplements, or in Medi-Span.
any similar situation exists.
(3) If the prices or changes do not appear in the
If a recipient requests a brand name for a prescription publications or the wholesalers’ records, then the
that is subject to MAC, then he/she may pay the distributors’ or manufacturers’ prices will be adjusted
ingredient cost difference between the MAC and to the wholesale pricing level and used in the drug
brand name drug. The recipient must sign the pricing file as the price of the drug.

Colorado-3
National Pharmaceutical Council Pharmaceutical Benefits 2007

If the difference between the pharmacist’s invoice F. STATE CONTACTS


purchase price and the average wholesale price which
appears in the Red Book, its supplements, or Medi- Medicaid Drug Program Administrator
Span exceeds 18%, then the Department may adopt a
lower price after a survey is conducted to determine Catherine Traugott, R.Ph., J.D.
the validity of the published prices. The price from Pharmacy Supervisor
the distributor or manufacturer will be adjusted the Department of Health Care Policy and Financing
same as in 3 above. 1570 Grant Street
Denver, CO 80203
Special Note: The Maximum Allowable Cost shall be T: 303/866-2468
determined by the Division of Medical Assistance, F: 303/866-3552
based upon professional determination of a quality E-mail: catherine.traugott@state.co.us
product available at the least expense possible. Internet Address:
Exceptions to the above are: www.chcph.state.us/hcpf/pharmacy/pharmindex.asp
- Shelf package size oral liquid medications, in pint DUR Contact
size only, or smaller package size when not packaged
in pint size. Kimberly Eggert
Medicaid Pharmacist
- Shelf package size oral tablet and capsule Department of Health Care Policy and Financing
medications in quantities of 100 only or smaller 1570 Grant Street
when not available in package size of 100. Denver, CO 80203
- Prescriptions for less than minimum amounts will T: 303/866-3176
be denied reimbursement of the professional fee F: 303/866-3552
unless the physician notified the Department in E-mail: kimberly.eggert@state.co.us
writing of the medical need for amounts less than a
30-day supply. Medical consultation determines the DUR Board
decision. James R. Kant, R.Ph.
Incentive Fee: None. James R. Regan, M.D., F.A.C.P.
Jeffrey Almony, M.D.
Patient Cost Sharing: Brand: $3.00; Generic: $1.00 Robert D. McCartney, M.D., F.A.C.P.
Mary Newell, R.Ph.
Cognitive Services: Does not pay for cognitive Robert Lee Page, II, Pharm.D., F.A.S.C.P., B.C.P.S.
services. Terrie A. Sajbel, Pharm.D.
Edra B. Weiss, M.D., F.A.A.P.
Kristen Andrews
E. USE OF MANAGED CARE
New Brand Names Products Contact
Approximately 24,000 Medicaid recipients were
Catherine Traugott, R.Ph., J.D.
enrolled in MCOS in FY 2007. Recipients receive
303/866-2468
pharmaceutical benefits through the Managed Care
Organization. Beneficiaries enrolled in behavioral
Prescription Price Updating
health organizations receive drugs through the FFS
program or other Medicaid HMOs. Catherine Traugott, R.Ph., J.D.
303/866-2468
Managed Care Organizations
Medicaid Drug Rebate Contacts
Rocky Mountain HMO
2775 Crossroads Boulevard Vince Sherry
P.O. 10600 Drug Rebate Manager
Grand Junction, CO 81502-5600 Department of Health Care Policy and Financing
T: 800/843-0719 1570 Grant Street
F: 970/244-7880 Denver, CO 80203
T: 303/866-5408
Denver Health F: 303/866-3552
777 Bannock Street E-mail: vince.sherry@state.co.us
Denver, CO 80204
303/436-6000

Colorado-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

Claims Submission Contact Health Care Policy & Financing Department


Officials
Susan Pfau, Account Manager
ACS State Healthcare Joan Henneberry
600 17th Street Executive Director
Suite 600 North Department of Health Care Policy and Financing
Denver, CO 80202 1570 Grant Street
T: 800/237-0757 Denver, CO 80203-1818
F: 303/534-0439 T: 303/866-2993
F: 303/866-4411
Medicaid Managed Care Contact E-mail: joan.henneberry@state.co.us
Internet address: www.chcpf.state.co.us
Jerry Smallwood
Managed Care Manager
Barbara Prehmus, Director
Department of Health Care Policy and Financing
Office of Medical Assistance
1570 Grant Street
Department of Healthcare Policy and Financing
Denver, CO 80203
1570 Grant Street
T: 303/866-2416
Denver, CO 80203
F: 303/866-2573
T: 303/866-5929
E-mail: jerry.smallwood@state.co.us
F: 303/866-3476
E-mail: barbara.prehmus@state.co.us
Disease Management/Patient Education
Programs
Medical Services Board
Disease/Medical State: Asthma
Jeffrey Cain, M.D.
Program Name: Asthma Management Program
Julie Reiskin
Program Manager: Christy Hunter
Richard Markley (Vice President)
Program Sponsor: National Jewish Medical and
Joan M. Johnson (President)
Research Center
Wendell Phillips
Kathleen Chitty
Disease/Medical State: Diabetes
Maguerite Salazar
Program Name: Diabetes Disease Management
Byron Geer
Program
Dr. Paul Melinkovich
Program Manager: Christy Hunter
Sally Schaefer
Program Sponsor: McKesson Health Solutions, Inc.
Ginny Riley
Disease Management/Patient Education
Executive Officers of State Medical and
Contact
Pharmaceutical Societies
Christy Hunter
Colorado Medical Society
Department of Health Care Policy and Financing
Alfred Gilchrist
1570 Grant Street
Executive Director
Denver, CO 80203T: 303/866-2993
7351 Lowry Boulevard, Suite 110
F: 303/866-2524
Denver, CO 80230
E-mail: christy.hunter@state.co.us
T: 720/859-1001
F: 303/771-8659
Mail Order Pharmacy Program
E-mail: alfred_gilchrist@cms.org
None Internet address: www.cms.org

Colorado-5
National Pharmaceutical Council Pharmaceutical Benefits 2007

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 510
Denver, CO 80246
T: 303/322-1752
F: 303/322-1956
E-mail: coloradodo@aol.com
Internet address: www.coloradodo.org

Colorado State Board of Pharmacy


Susan L. Warren
Program Director
1560 Broadway, Suite 1350
Denver, CO 80202
T: 303/894-7800
F: 303/894-7692
E-mail: pharmacy@dora.state.co.us
Internet address: www.dora.state.co.us/pharmacy

Colorado Health and Hospital Association


Steven J. Summer
President and CEO
7335 East Orchard Road, Suite 100
Greenwood Village, CO 80111-2512
T: 720/489-1630
F: 720/489-9400
E-mail: steven.summer@cha.com
Internet address: www.cha.com

Colorado-6
National Pharmaceutical Council Pharmaceutical Benefits 2007

CONNECTICUT

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2003 2004
Expenditures Recipients Expenditures Recipients

TOTAL $402,380,645 119,698 $445,816,745 120,373

RECEIVING CASH ASSISTANCE, TOTAL $84,167,387 22,699 $88,072,956 21,933


Aged $17,057,734 5,405 $18,014,759 5,175
Blind/Disabled $66,520,564 13,267 $69,318,147 12,548
Child $185,220 2,170 $189,100 2,131
Adult $403,869 1,857 $550,950 2,079

MEDICALLY NEEDY, TOTAL $131,121,087 33,976 $81,194,097 19,235


Aged $29,422,998 11,041 $22,757,258 7,738
Blind/Disabled $101,367,440 22,291 $57,929,394 10,716
Child $155,709 386 $160,420 441
Adult $174,940 258 $347,025 340

POVERTY RELATED, TOTAL $6,406,870 6,541 $7,571,351 7,640


Aged $1,122,306 797 $1,435,796 924
Blind/Disabled $3,674,106 1,381 $3,987,144 1,436
Child $1,328,035 3,249 $1,597,801 3,954
Adult $85,618 999 $131,741 1,168
BCCA Women $196,805 115 $418,869 158

TOTAL OTHER EXPENDITURES/RECIPIENTS* $180,685,301 56,482 $268,978,341 71,565

*Total Other Expenditures/Recipients includes foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, MSIS Report, FY 2003 and FY 2004.

Connecticut-1
National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION Unit Dose: Unit dose packaging not reimbursable.


Formulary/Prior Authorization
State of Connecticut Department of Social Services
through three regional offices and twelve sub-offices. Formulary: Open formulary with PDL. Managed
through prior authorization and preferred products.
D. PROVISIONS RELATING TO DRUGS However, the following products are excluded from
Medicaid prescription coverage: experimental drugs,
Benefit Design
cosmetics, fertility drugs; smoking cessation products;
Drug Benefit Product Coverage: Products covered: DESI drugs, and drugs available free from the
prescribed insulin, disposable needles and syringe Department of Health Services.
combinations for insulin; blood glucose test strips;
urine ketone test strips. Products not covered: Prior Authorization: State currently has a prior
cosmetics; fertility drugs; experimental drugs; total authorization procedure. Clients can request an
parenteral nutrition; interdialytic parenteral nutrition; administrative hearing to appeal prior authorization
and weight loss products. decisions.

Over-the-Counter Product Coverage: Products Prescribing or Dispensing Limitations


covered: allergy, asthma, and sinus products; Prescription Refill Limit: 5 refills per prescription
digestive products (H2 antagonists); and topical except for oral contraceptives, which have a 12-
products. Products covered with restrictions: cough month limit.
and cold preparations (children < 19 years); digestive
products (non H2 antagonists) – liquid generics only Monthly Quantity Limit: Maximum 240 tablets or
(legend drugs not covered). Products not covered: capsules/30-day supply. Oral contraceptives: 3
smoking deterrent products; analgesics; feminine months supply may be dispensed at one time.
products; iron; calcium; and some trace elements. For
nursing home patients, the department will not pay for Physicians are encouraged to prescribe drugs
OTC drugs used in nursing facilities (such drugs are generically, when possible.
covered in the per diem rate). Some drugs require
diagnosis for reimbursement such as CNS stimulants Drug Utilization Review
for ADD and narcolepsy. Pro-DUR system implemented September 1996.
Therapeutic Category Coverage: Therapeutic Retro-DUR since September 1991; the State
categories covered: anabolic steroids; analgesics, currently has a 9 member DUR Board with a
antipyretics, NSAIDs; antibiotics; anticoagulants; quarterly review.
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; antilipemic agents; anti- Pharmacy Payment and Patient Cost Sharing
psychotics; anxiolytics, sedatives, and hypnotics;
cardiac drugs; chemotherapy agents; prescribed cold Dispensing Fee: $3.15, effective 7/1/04.
medications; contraceptives; ENT anti-inflammatory Ingredient Reimbursement Basis: EAC = AWP-14%.
agents; estrogens; hypotensive agents; misc. GI Special rules for Factor VIII (AAC + 8%).
drugs; sympathominetics (adrenergic); thyroid
agents; and growth hormones. Therapeutic Prescription Charge Formula: Federal MAC or EAC
categories not covered: anorectics and prescribed plus dispensing fee; or usual and customary if lower.
smoking deterrents. Prior authorization required for; Special rules for blood factor VIII.
Brand Medically Necessary prescriptions; early
refills; prescriptions costing more than $500, and Maximum Allowable Cost: State imposes a
drugs not on the preferred drug list (PDL). A combination of Federal and State-specific Upper
complete listing of the drugs on the PDL can be Limits on generic drugs. Effective 1/1/2003, the
found at www.ctmedicalprogram.com. Department implemented a state MAC to include
additional multi-source generic products that are not
Coverage of Injectables: Injectable medicines on the FUL list. The State MAC reimbursement is
reimbursable through physician payment when used in AWP-40%.
home health care, extended care facilities, and in
physicians offices. Patient Cost Sharing: None.

Vaccines: Vaccines reimbursable as part of the Cognitive Services: Does not pay for cognitive
Children Health Insurance Program. services.

Connecticut-2
National Pharmaceutical Council Pharmaceutical Benefits 2007

E. USE OF MANAGED CARE Department of Social Services Officials


Michael P. Starkowski, Commissioner
Connecticut had approximately 293,000 Medicaid Department of Social Services
recipients enrolled in managed care in 2006 and 25 Sigourney Street
297,000 enrolled in 2007. Beneficiaries receive Hartford, CT 06016-5033
pharmaceutical services through managed care plans. T: 860/424-5008
F: 860/566-2022
Managed Care Organizations E-mail: commiss.dss@ct.gov
Anthem Blue Cross/Blue Shield of CT
Blue Care Family Plan David Parrella, Director
Theresa Rugens Medical Care Administration
BCFP Liaison Department of Social Services
370 Bassett Road 25 Sigourney Street
North Haven, CT 06473-4201 Hartford, CT 06106
860/424-5156 T: 860/424-5116
F: 860/424-5114
Community Health Network of CT E-mail: david.parvella@ct.gov
Erica Garcia
CHN Liaison DUR Contact
11 Fairfield Boulevard James R. Zakszewski, R.Ph.
Wallingford, CT 06492 Pharmacy Consultant
860/424-5670 Department of Social Services
Medical Operations Unit
Health Net 25 Sigourney Street
Janice Perkins, Vice President Hartford, CT 06106-5033
One Far Mill Crossing, Box 904 T: 860/424-5150
Shelton, CT 06484-0944 F: 860/951-9544
800/441-5741 E-mail: james.zakszewski@ct.gov
First Choice of CT, Preferred One Connecticut DUR Board
David Smith, Chief Operating Officer
23 Maiden Lane Kenneth Fisher, R.Ph. (Chair)
North Haven, CT 06473 Brooks Pharmacy
203/239-7444
Arturo Morales, M.D.
St. Francis Hospital
F. STATE CONTACTS
Lori Jane Duntz Lord, R.Ph.
Medicaid Drug Program Administrator Greenville Drug
Evelyn A. Dudley
Pharmacy Manager Dennis J. Chapron, M.S., R.Ph.
Department of Social Services Pharmokinetics Lab
Medical Operations Unit
25 Sigourney Street Keith Lyke, R.Ph. (Vice Chair)
Hartford, CT 06106 Pelton’s Pharmacy
T: 860/424-5654
F: 860/951-9544 Frederick N. Rowland, M.D., Ph.D.
E-mail: evelyn.dudley@ct.gov St. Francis Hospital and Medical Center
Internet address: www.ct.gov/dss
Richard Gannon, Pharm.D.
Hartford Hospital

Bhupesh Mangla, M.D., M.P.H.


Community Health Services

Michael Moore, R.Ph.


Hebrew Home Hospital

Connecticut-3
National Pharmaceutical Council Pharmaceutical Benefits 2007

Prescription Price Updating Richard Carbray, Jr., R.Ph.


Newington, CT
Mark Synol
Staff Pharmacist
Kenneth Marcus, M.D.
EDS
195 Scott Swamp Road
Steve Marchan, R.Ph.
Farmington, CT 06032
Vernon, CT
860/255-3886
E-mail: mark.synol@eds.com
Peggy Memoli, R.Ph.
Stratford, CT
Medicaid Drug Rebate Contacts
Evelyn A. Dudley (Audits) Joseph Misiak, M.D.
860/424-5654 Windsor, CT

Pat Bartolatta (Disputes) Carl Sherter, M.D.


EDS Southbury, CT
195 Scott Swamp Road
Farmington, CT 06032 Lawrence Sobel, R.Ph.
860/255-3934 West Hartford, CT
E-mail: pat.bartolatta@eds.com
Robert Zavoski, M.D.
West Simsbury, CT
Claims Submission Contact
Ellen Arce Executive Officers of State Medical and
Pharmacy Manager Pharmaceutical Societies
EDS 195 Scott Swamp Road
Connecticut State Medical Society
Farmington, CT 06032
Matthew C. Katz, Executive Director
860/255-3822
160 St. Ronan Street
E-mail: ellen.arce@eds.com
New Haven, CT 06511-2390
T: 800/635-7740
Medicaid Managed Care Contact
F: 203/865-0587
Rose Ciarcia E-mail: mkatz@csms.org
Director, Managed Care Internet address: www.csms.org
Department of Social Services
25 Sigourney Street Connecticut Pharmacists Association
Hartford, CT 06106 Margherita R. Guiliano, R.Ph. Executive V.P.
T: 860/424-5139 35 Cold Spring Road, Suite 121
F: 860/951-9544 Rocky Hill, CT 06067-3161
E-mail: rose.ciarcia@ct.gov T: 860/563-4619
F: 860/257-8241
Mail Order Pharmacy Program E-mail: mguiliano@ctpharmacists.org
Internet address: www.ctpharmacists.org
None
Connecticut Osteopathic Medical Society
Disease Management Contact Bridget Price, Executive Director
David Parrella Chicago Office – Main Headquarters
Director, Medical Care Administration 142 East Ontario Street
860/424-5116 Chicago, IL 60611800-0487
T: 800/621-1773, Ext. 8101
Pharmaceutical and Therapeutics Committee T: 312/202-8000
F: 312/202-8200
Holly Bessoni-Lutz, R.N. E-mail: Bprice@osteopathic.org
Farmington, CT Email: Connecticut@osteopathic.org
Internet address: www.osteopathicct.org/
Stella Cretella
West Haven, CT

Connecticut-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

Connecticut Commission of Pharmacy


deLinda Brown-Jagne
Pharmacy Board Administrator
Pharmacy Commission
Department of Consumer Protection
165 Capitol Avenue, Room 147
Hartford, CT 06106
T: 860/713-6065
F: 860/713-7242
E-mail: deLinda.Brown-Jagne@ct.gov
Internet address:
www.ct.gov/dcp/site/cwp/

Connecticut Hospital Association, Inc.


Jennifer Jackson
President and CEO
110 Barnes Road
Wallingford, CT 06492-0090
T: 203/265-7611
F: 203/284-9318
E-mail: jackson@chime.org
Internet address: www.chime.org

Connecticut-5
National Pharmaceutical Council Pharmaceutical Benefits 2007

Connecticut-6
National Pharmaceutical Council Pharmaceutical Benefits 2007

DELAWARE1

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2003 2004
Expenditures Recipients Expenditures Recipients

TOTAL $110,942,313 99,634 $120,225,182 104,380

RECEIVING CASH ASSISTANCE, TOTAL $60,394,685 52,905 $64,721,068 55,615


Aged $6,909,645 2,420 $6,941,679 2,456
Blind/Disabled $35,384,126 10,654 $37,046,322 11,070
Child $7,031,481 25,755 $8,581,150 27,233
Adult $11,069,433 14,076 $12,151,917 14,856

MEDICALLY NEEDY, TOTAL $0 0 $0 0


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

POVERTY RELATED, TOTAL $2,161,008 4,531 $3,144,816 4,467


Aged $240,523 172 $262,811 215
Blind/Disabled $838,384 400 $1,907,468 642
Child $947,632 3,629 $844,438 3,337
Adults $65,487 297 $41,378 239
BCCA Women $68,982 33 $88,721 34

TOTAL OTHER EXPENDITURES/RECIPIENTS* $48,386,620 42,198 $52,359,298 44,298


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

Source: CMS, MSIS Report, FY 2003 and FY 2004.


1
The State of Delaware did not participate in the 2007 NPC Survey. Using data from CMS, the State’s website, and other source
materials, we have, to the extent possible, updated the profile and the tables in other sections of the Compilation. Users should contact
the Delaware Medicaid program to assess the accuracy and currency of the information included.

Delaware-1
National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION Prior Authorization: State currently has a formal


prior authorization procedure. Standard procedures
Division of Medicaid and Medial Assistance, for clients to request a fair hearing to appeal prior
Department of Health and Social Services, through authorization decisions.
three county offices of the State agency.
Prescribing or Dispensing Limitations

D. PROVISIONS RELATING TO DRUGS Monthly Limit on Scripts: 15 medications per 30


days.
Benefit Design Prescription Refills: Prescription blank has space for
physician to authorize renewals.
Drug Benefit Product Coverage: Products covered:
prescribed insulin; disposable needles and syringe Monthly Quantity Limit: Greater of 34-day supply or
combinations used for insulin; blood glucose test 100 dosing units. May vary depending on
strips; urine ketone test strips; total parenteral therapeutic category.
nutrition; and interdialytic parenteral nutrition.
Products not covered: cosmetics; fertility drugs; Monthly Dollar Limits: None.
experimental drugs; and quality of life medications.
Drug Utilization Review
Over-the-Counter Product Coverage: Products
covered: allergy, asthma and sinus products; PRODUR system implemented in August 1994. State
analgesics; cough and cold preparations; digestive has a DUR Board that meets bimonthly.
products; and topical products. Products covered
with restrictions: smoking deterrent products (prior Pharmacy Payment and Patient Cost Sharing
authorization and quantity limits); feminine products. Dispensing Fee: $3.65.
Therapeutic Category Coverage: Therapeutic Ingredient Reimbursement Basis: EAC = AWP-
categories covered: anabolic steroids; anticoagulants; 14.0%. (AWP-16% for LTC)
anticonvulsants; antidepressants; antidiabetic agents;
antihistamine drugs; chemotherapy agents; Prescription Charge Formula: Payment is based on
contraceptives; ENT anti-inflammatory agents; AWP-14.0% or maximum allowable cost (MAC)
estrogens; hypotensive agents; misc. GI drugs; plus a dispensing fee, or the usual and customary cost
sympathominetics (adrenergic); and thyroid agents. to the general public, whichever is lower.
Partial coverage and prior authorization required for:
analgesics, antipyretics, and NSAIDs; anoretics; Maximum Allowable Cost: State imposes Federal
antibiotics; antilpemic agents; anti-psychotics; Upper Limits as well as State-specific limits on
anxiolytics, sedatives, and hypnotics; cardiac drugs; generic drugs. Override requires completion of an
prescribed cold medications; growth hormones; FDA MedWatch form. Over 1,000 drugs on State
prescribed smoking deterrents; Regranex; Zyvox; MAC list.
Soma Accutane Cipro; Cholinesterase inhibitors;
Modafanil; and Epoetin. Incentive Fee: None.
Coverage of Injectables: Injectable medicines Patient Cost Sharing: $0.50-$3.00 (based on the cost
reimbursable through the Prescription Drug Program of the prescription).
when used in extended care facilities, and through
both the prescription drug program and physician
Cognitive Services: Does not pay for cognitive
payment when used in physicians’ offices.
services.
Vaccines: Vaccines reimbursable under the CHIP
Program and Vaccines for Children program. E. USE OF MANAGED CARE

Unit Dose: Unit dose packaging not reimbursable. Approximately 99,000 Medicaid recipients were
enrolled in MCOs in FY 2006. Recipients receive
Formulary/Prior Authorization pharmaceutical benefits through the State.
Formulary: Open formulary with preferred drug list.
Managed Care Organizations
PDL managed through preferred products and prior
authorization. Diamond State Partners

Delaware-2
National Pharmaceutical Council Pharmaceutical Benefits 2007

P.O. Box 907 Medicaid Drug Rebate Contacts


Manor Branch
Cynthia R. Denemark, R.Ph.
New Castle, DE 19720
302/453-8453
800/390-6093
Claims Submission Contact
F. STATE CONTACTS Cynthia R. Denemark, R.Ph.
302/453-8453
State Drug Program Administrator
Cynthia R. Denemark, R.Ph. Medicaid Managed Care Contact
Director of Pharmacy Services Mary Marinari
DSS/EDS Health Policy Analyst
248 Chapman Road, Suite 100 Managed Care/QA
Newark, DE 19702 Division of Social Services
T: 302/453-8453 Herman Holloway Campus
F: 302/454-0224 Lewis Building
E-mail: cynthia.denemark@eds.com 1901 North DuPont Highway
Internet address: www.dmap.state.de.us New Castle, DE 19720
T: 302/255-9548
Prior Authorization Contact F: 302/255-4481
Cynthia R. Denemark, R.Ph. E-mail: mary.marinari@state.de.us
302/453-8453
Mail Order Pharmacy Benefit
DUR Contact None
Cynthia R. Denemark, R.Ph.
302/453-8453 Health and Social Services Department
Officials
DUR Board Vincent P. Meconi
Calvin Freedman, R.Ph. (Chair) Secretary
Scott Harrison, D.O. Dept. of Health & Social Services
Phillip Anderson, R.Ph. 1901 North DuPont Highway-Main Bldg.
Susan Fullerton, A.P.N. New Castle, DE 19720
Mark Borer, M.D. T: 302/255-9040
Nadia Helenga, Pharm.D. F: 302/255-4429
Joseph Peoples, R.Ph. E-mail: vmeconi@state.de.us
Frank Falco, M.D. (Vice Chair) Internet address: www.state.de.us/dhhs
Howard Simon, R.Ph.
Albert Rizzo, M.D. Harry Hill
Michael Marcus, M.D. Director
Division of Medicaid and Medical Assistance
New Brand Name Products Contact Dept. of Health & Social Services
1901 North DuPont Highway-Lewis Bldg.
Joli Martini New Castle, DE 19720
Pharmacist Consultant-Clinical Reviews T: 302/255-9500
EDS F: 302/255-4454
248 Chapman Road, Suite 100 E-mail: harry.hill@state.de.us
Newark, DE 19702
T: 302/453-8453 Pharmaceutical and Therapeautics
F: 302/454-0224 Committee
E-mail: joli.martini@eds.com
Cedric T. Barnes, D.O.
Louis Bartoshesky, M.D.
Renee Beaman, R.N.
Prescription Price Updating Calvin Freedman, R.P.h.
Cynthia R. Denemark, R.Ph. Danielle Nordone, D.O.
302/453-8453 Pat Klishevich, R.Ph.
James Lafferty

Delaware-3
National Pharmaceutical Council Pharmaceutical Benefits 2007

Brian Levine, M.D. E-mail: judy.letterman@state.de.us


Michael N. Marcus, M.D. Internet address:
M. Diana Metzger, M.D. www.dpr.delaware.gov/boards/pharmacy
Tamara J. Newell, A.P.N.
Obi Onyewu, M.D. Delaware Healthcare Association
Michael J. Pasquale, M.D. Wayne A. Smith
Albert A. Rizzo, M.D. President and CEO
1280 South Governors Avenue
Executive Officers of State Medical and Dover, DE 19904-4802
Pharmaceutical Societies T: 302/674-2853
F: 302/734-2731
Medical Society of Delaware
E-mail: wayne@deha.org
Mark Meister
Internet address: www.deha.org
Executive Director
131 Continental Drive, Suite 405
Newark, DE 19713
T: 302/658-7596
F: 302/658-9669
E-mail: mam@medsocdel.org
Internet address: www.msdhub.com

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: depharmacy@verizon.net
Internet address: www.depharmacy.net

Delaware Osteopathic Medical Society


Edward Sobel, D.O.
Executive Director
1513 Spring Lane
Wilmington, DE 19809
T: 302/764-1198
F: 302/764-1322
E-mail: info@deosteopathic.org
Internet address: www.deosteopathic.org

Delaware State Board of Pharmacy


Judy Letterman
Staff Contact
Division of Professional Regulation
Cannon Building
861 Silver Lake Boulevard, Suite 203
Dover, DE 19904
T: 302/744-4504
F: 302/739-2711

Delaware-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

DISTRICT OF COLUMBIA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


Type of Benefit Categorically Needy Medically Needy (MN)
Aged Blind/ Child Adult Aged Blind/ Child Adult
Disable Disabled
d
Prescribed Drugs ! ! ! ! ! ! ! !
Inpatient Hospital Care ! ! ! ! ! ! ! !
Outpatient Hospital Care ! ! ! ! ! ! ! !
Laboratory & X-ray Service ! ! ! ! ! ! ! !
Nursing Facility Services ! ! ! ! ! ! ! !
Physician Services ! ! ! ! ! ! ! !
Dental Services ! ! ! ! ! ! ! !

B. EXPENDITURES FOR DRUGS


2003 2004
Expenditures Recipients Expenditures Recipients

TOTAL $82,817,543 34,424 $102,118,065 35,939

RECEIVING CASH ASSISTANCE TOTAL $53,222,752 19,684 $65,860,996 20,065


Aged $4,425,219 2,094 $4,527,738 2,004
Blind/Disabled $46,095,123 14,083 $54,070,510 14,437
Child $229,105 1,111 $202,979 986
Adult $2,473,305 2,396 $7,059,769 2,638

MEDICALLY NEEDY, TOTAL $13,633,119 5,787 $16,165,020 6,544


Aged $2,159,397 849 $2,159,152 754
Blind/Disabled $10,172,238 2,760 $11,723,477 3,257
Child $145,060 645 $170,652 746
Adult $1,156,424 1,533 $2,111,739 1,787

POVERTY RELATED, TOTAL $11,017,308 4,869 $13,857,549 4,936


Aged $3,749,974 1,809 $4,270,248 1,774
Blind/Disabled $7,057,759 1,945 $9,386,104 2,202
Child $173,664 960 $176,586 817
Adult $35,911 155 $24,611 143
BCCA Women
$4,944,364 4,084 $6,234,500 4,394
TOTAL OTHER EXPENDITURE/RECIPIENTS* $82,817,543 34,424 $102,118,065 35,939

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

Source: CMS, MSIS Report, FY 2003 and FY 2004.

District of Columbia-1
National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION Vaccines: Vaccines reimbursable at cost as part of


the EPSDT service and The Vaccines for Children
The District of Columbia Department of Health Program.
(DOH), Medical Assistance Administration.
Unit Dose: Unit dose packaging reimbursable
D. PROVISIONS RELATING TO DRUGS
Formulary/Prior Authorization
Benefit Design
Formulary: Open formulary with preferred drug list.
Drug Benefit Product Coverage: Products covered: PDL managed through restrictions on use, prior
prescribed insulin and disposable needles and syringe authorization, therapeutic substitution, preferred
combinations used for insulin. Products covered products, and physician profiling. Appeals for
with restrictions: blood glucose test strips; total coverage of an excluded product can be made by
parenteral nutrition; and interdialytic parenteral submission of medically relevant information to the
nutrition. Prior authorization required for: all self- Medicaid pharmacist and Medical Director for
administered injectable drugs except insulin; review.
anorexic drugs for treatment of narcolepsy and
minimal brain dysfunction in children; acute anti- Prescribing or Dispensing Limitations
ulcer drugs; brand NSAIDs and non-preferred drugs
on the PDL. Products not covered: cosmetics; Monthly Quantity Limit: In general, amounts
fertility drugs; experimental drugs; urine ketone test dispensed are to be limited to quantities sufficient to
strips; anesthetics; infant formulas; cold tar treat an episode of illness. Maintenance drugs such
preparations; reusable needles/syringes (non-insulin); as thyroid, digitalis, etc. may be dispensed in
and all other non-legend items. amounts up to a 34-day supply with 3 refills that
must be dispensed within 4 months. Antibiotic
medications used in treatment of acute infections are
Over-the-Counter Product Coverage: Products
not to be dispensed in excess of a 10-day supply.
covered with restrictions: allergy, asthma, and sinus
Birth control tablets may be dispensed in 3-cycle
products; analgesics, digestive products; topical
units with a maximum of 3 refills within one year.
products; cough and cold preparations; contraceptive
Other limits on specific products.
foams and jellies; prenatal, pediatric and geriatric
vitamins; and bowel preparation kits. Products not Monthly Dollar Limits: $1,500 limit. Physicians are
covered: feminine products and smoking deterrent to request prior authorization for prescriptions that
products. exceed this amount.

Therapeutic Category Coverage: Therapeutic Drug Utilization Review


categories covered: analgesics, antipyretics, and
NSAIDs; antibiotics; anticoagulants; anticonvulsants; PRODUR system implemented in September 1996.
anti-depressants; antidiabetic agents; antihistamines; The District currently has a DUR Board that meets
antilipemic agents; anti-psychotics; anxiolytics; monthly.
sedatives; and hypnotics; cardiac drugs;
chemotherapy agents; prescribed cold medications; Pharmacy Payment and Patient Cost Sharing
contraceptives; ENT anti-inflammatory agents;
estrogens; growth hormones; hypotensive agents; Dispensing Fee: $4.50, ($10.00 for specialized 1115
misc. GI drugs; prescribed smoking deterrents; HIV AIDS/HIV waiver program).
sympathominetics (adrenergic); and thyroid agents.
Partial coverage and prior authorization required for: Ingredient Reimbursement Basis: AWP-10%.
anoretics; erectile dysfunction products; Brand
Medically Necessary drugs; immunosuppressants; Prescription Charge Formula: The lesser of: FUL or
amphetamines; Stadol; Levocamitine; Hepatitis C the AWP-10% plus the dispensing fee or usual and
medications; and Synagis. Therapeutic categories not customary to the public.
covered: anabolic steroids.
Maximum Allowable Cost: The District does not
Coverage of Injectables: Injectable medicines impose MAC limits on generic drugs.
reimbursable through the Prescription Drug Program
when used in home health care and through physician Incentive Fee: None.
payment when used in physicians’ offices and
extended care facilities.

District of Columbia-2
National Pharmaceutical Council Pharmaceutical Benefits 2007

District of Columbia DUR Board


Patient Cost Sharing: $1.00 copay by recipient.
Does not apply to recipients under 18, prescriptions Christopher Keeyes, Pharm.D. (Chair)
for family planning, nursing home patients, or Martin Dillard, M.D. (Vice Chair)
pregnancy related. Howard Robinson, R.Ph.
Dr. Kim Bullock
Cognitive Services: Does not pay for cognitive Dr. Stephen Steury
services.
Prior Authorization Contacts
E. USE OF MANAGED CARE Carolyn C.Rachel-Price, R.Ph.
202/442-9078
Approximately 114,000 Medicaid recipients were
enrolled in managed care in 2006. Recipients Medicaid Drug Rebate Contact
enrolled in managed care receive pharmaceutical
benefits through managed care plans. Jeffrey Dzieweczynski, R.Ph., M.S.
Clinical Manager
Managed Care Organizations ACS State Healthcare
750 First Strweet, NE, Suite 1020
D.C. Chartered Health Plan Washington, DC 20002
1025 15th Street, N.W. T: 202/906-8353
Washington, DC 20005 F: 202/906-8399
202/408-4720 E-mail: jeffrey.dzieweczynski@acs-inc.com
Amerigroup New Brand Name Products Contact
750 First Street, NE, Suite 1120
Washington, DC 20002 Carolyn C. Rachel-Price, R.Ph.
800/600-4441 202/442-9078

Health Right, Inc. Prescription Price Updating Contact


1101 14th Street, NW, Suite 900
Carolyn C. Rachel-Price, R.Ph.
Washington, DC 20005
202/442-9078
202/418-0380
Claims Submission Contact
Health Services for Children with Special Needs, Inc.
11731 Bunker Hill Road, NE Kathryn Novak
Washington, DC 20017 Account Manager
202/467-2737 First Health Services Corporation
4300 Cox Road
Glen Allen, VA 23060
F. STATE CONTACTS T: 443/263-8669
F: 443/263-7062
State Drug Program Administrator E-mail: kathryn.novak@fhsc.com
Carolyn C. Rachel-Price, R.Ph.
Pharmacy Director Medicaid Managed Care Contact
Department of Health Maude R. Holt, Administrator
Medical Assistance Administration Medicaid Managed Care
825 North Capitol Street, NE Department of Health
Suite 5136 Medical Assistance Administration
Washington, DC 20002 825 North Capitol Street, NE, Suite 4202
T: 202/442-9078 Washington, DC 20002
F: 202/442-4790 T: 202/724-7491
E-mail: carolyn.rachel@dc.gov F: 202/478-1397
E-mail: maude.holt@dc.gov
DUR Contact
Carolyn C. Rachel-Price, R.Ph.
202/442-9078

District of Columbia-3
National Pharmaceutical Council Pharmaceutical Benefits 2007

Osteopathic Association of the District of Columbia


Disease Management Program/Initiatives
K. Joseph Heaton, D.O., President
Contact
2517 North Glebe Road
Medical Director Arlington, VA 22207
Department of Health T: 703/522-8404
Medical Assistance Administration F: 703/522-2692
825 North Capitol Street, NE, 5th Floor
Washington, DC 20002 DC Board of Pharmacy
202/671-5000 Marcia Wooden
Executive Director
Mail Order Pharmacy Program 717 14th Street, NW, Suite 600
Washington, DC 20005
None
T: 202/724-4900
F: 202/727-8471
Department of Human Services Officials E-mail: marcia.wooden@dc.gov
Gregory Pane, M.D. Internet address:
Director http://hpla.doh.dc.gov/hpla/cwp/view,A,1195,Q,4884
Department of Health 14,hplaNav,1306611,.asp
825 North Capitol Street, NE
Fourth Floor District of Columbia Hospital Association
Washington, DC 20002 Robert Malson, President
T: 202/442-5955 1250 Eye Street, NW, Suite 700
F: 202/442-4788 Washington, DC 20005
E-mail: gregory.pane@dc.gov T: 202/682-1581
Internet Address: www.dchealth.dc.gov F: 202/371-8151
E-mail: rmalson@dcha.org
Robert T. Maruca Internet address: www.dcha.org
Senior Deputy Director
Department of Health
Medical Assistance Administration
825 North Capitol Street, NE, Suite 5136
Washington, DC 20002
T: 202/442-5988
F: 202/442-4790
E-mail: Robert.maruca@dc.gov

Executive Officers of District Medical and


Pharmaceutical Societies
Medical Society of the District of Columbia
K. Edward Shanbacker
Executive Director
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: 301/593-3292
F: 301/593-7125
E-mail: midpharm@aol.com

District of Columbia-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

FLORIDA

A. BENEFITS PROVIDED AND GROUPS ELIGIBLE


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

B. EXPENDITURES FOR DRUGS


2004 2005
Expenditures Recipients Expenditures Recipients

TOTAL $2,447,168,182 1,211,983 $1,418,223,186 1,216,491

RECEIVING CASH ASSISTANCE TOTAL $1,328,470,812 520,894 $880,002,105 542,759


Aged $242,258,142 81,355 $79,003,123 77,163
Blind/Disabled $979,299,650 241,552 $682,224,082 230,456
Child $54,107,384 135,944 $59,196,332 155,825
Adult $52,805,636 62,043 $59,578,568 79,315

MEDICALLY NEEDY, TOTAL $263,409,550 48,912 $118,155,662 45,518


Aged $41,773,891 7,504 $13,173,517 6,551
Blind/Disabled $183,384,716 19,800 $67,364,815 18,879
Child $5,581,940 3,090 $6,080,823 2,839
Adult $32,668,638 18,516 $31,536,507 17,249

POVERTY RELATED, TOTAL $518,316,936 443,931 $249,942,656 429,052


Aged $191,895,894 68,370 $64,078,091 59,598
Blind/Disabled $214,231,198 47,179 $80,132,403 43,495
Child $97,474,208 240,919 $91,933,069 234,317
Adult $14,715,636 87,463 $13,799,093 91,642

TOTAL OTHER EXPENDITURE/RECIPIENTS $336,970,884 198,246 $170,122,763 199,162

*Total other Expenditures/Recipients include foster care children, 1115 demonstration participants, other recipients, and unknown.
Source: CMS, Florida Medicaid Statistical Information System, FY 2004 and FY 2005.

Florida-1
National Pharmaceutical Council Pharmaceutical Benefits 2007

C. ADMINISTRATION Formulary/Prior Authorization

Agency for Health Care Administration. Claims Formulary: Preferred Drug List (PDL) with
processing and payment by contract with fiscal agent. mandatory limits and exclusions. All covered drugs
are available through the preferred drug process.
D. PROVISIONS RELATING TO DRUGS PDL managed by excluding products based on
contracting issues, restrictions on use, prior
Benefit Design authorization, therapeutic substitution, preferred
products, physician profiling and supplemental
Drug Benefit Product Coverage: Products covered: rebates. Specific limits and exclusions include:
prescribed insulin; total parenteral nutrition; and 1. Vitamins and phosphate binders only for dialysis
interdialytic parenteral nutrition. Products covered patients.
with restrictions: non-PDL products require prior 2. Prostheses; appliances; devices; and personal
authorization. Products not covered: cosmetics; care items.
fertility drugs; experimental drugs; disposable 3. Non-legend drugs (except for prescribed insulin,
needles and syringe combinations used for insulin; pancreatic enzymes, buffered and enteric coated
blood glucose test strips; and urine ketone test strips. aspirin when prescribed as an anti-inflammatory
agent only, and single entity hematinics).
Over-the-Counter Product Coverage: Products 4. Anorexants unless the drug is prescribed for an
covered with restrictions: allergy, asthma, and sinus indication other than obesity (i.e., narcolepsy,
products; analgesics (selected aspirin and Tylenol hyperkinesis).
products); cough and cold preparations (select 5. Drugs with questionable efficacy as rated by
products); digestive products (non-H2 antagonists); FDA (DESI).
feminine products; and smoking deterrent products. 6. Investigational and experimental items.
Products not covered: digestive products (H2 7. Oral vitamins with exception of fluorinated
antagonists); topical products. pediatric vitamins prescribed for pediatric
patients, vitamins for dialysis patients, prenatal
Therapeutic Category Coverage: Therapeutic vitamins.
categories covered: anabolic steroids; analgesics, 8. Nursing home floor stock drugs.
antipyretics, and NSAIDs; antibiotics;
anticoagulants; anticonvulsants; anti-depressants; Prior Authorization: State currently has a formal
antidiabetic agents; antihistamines; antilipemic prior authorization procedure. Direct appeal to
agents; antipsychotics; anxiolytics, sedatives, and AHCA and/or formal request for administrative
hypnotics; cardiac drugs; chemotherapy agents; hearing required to appeal prior authorization
contraceptives; ENT anti-inflammatory agents; decisions.
estrogens; hypotensive agents; misc. GI drugs;
prescribed smoking deterrents; sympathominetics Prescribing or Dispensing Limitation
(adrenergic); and thyroid agents. Partial coverage for:
prescribed cold medications. Prior authorization Prescription Refill Limit:
required for: growth hormones; mental health drugs;
drugs not included on the Medicaid preferred drug 1. Variable quantity limits per prescription
list; and brand name prescriptions beyond the four according to the drug.
brand cap unless exempted. Therapeutic categories 2. Drugs not included in the Preferred Drug list
not covered: anoretics; anti-retrovirals for HIV. (PDL) require PA.
3. Maintenance medication should be dispensed
Coverage of Injectables: Injectable medicines and billed for at least a one-month supply.
reimbursable through the Prescription Drug Program 4. Refills must be authorized by the prescriber
when used in home health care and extended care and can be made for up to one year, except that
facilities, and through both the Prescription Drug controlled substances can be refilled only in
Program and physician payment when used in accordance with Federal and State regulations.
physicians’ offices. 5. Nutritional supplements are covered with prior
authorization when the patient is otherwise at
Vaccines: Vaccines reimbursable as part of the risk of hospitalization.
Vaccines for Children Program. 6. Other third parties, including Medicare, must be
billed first.
Unit Dose: Unit dose packaging reimbursable.

Florida-2
National Pharmaceutical Council Pharmaceutical Benefits 2007

Drug Utilization Review Buena Vista Medicaid


Vista Health Plan, Inc.
PRODUR system implemented in July 1993. State (FKA Beacon and Discovery)
currently has a DUR board with a quarterly review. 300 South Park Road
Retrospective Drug Utilization Review has been in Hollywood, FL 33021
place since 1982. The State Medicaid agency and the 866/847-8235
Florida Pharmacy Association, which performs the
reviews, share the administration of the program. Citrus Health Care, Inc.
5420 Bay Center Drive, Suite 250
Heritage Information Systems contracts to provide Tampa, FL 33609
DUR and prescriber pattern profiling and clinical T: 877/624-8787
review assistance. F: 813/490-8907
F: 813/490-8909
Pharmacy Payment and Patient Cost Sharing
EverCare
Dispensing Fee: $4.23, effective 3/11/86. 601 Brooker Creek Blvd.
Oldsmar, FL 33609
Ingredient Reimbursement Basis: AWP-15.40 % or 813/818-3300
WAC+5.75%. (effective 7/1/04)
Healthease of Florida, Inc.
Prescription Charge Formula: Lower of: 8735 Henderson Road, Ren 2
Tampa, FL 33634
1. FUL (Federal Upper Limits or State MAC) plus T: 800/278-0656
dispensing fee. F: 813/290-6332
2. EAC plus dispensing fee.
3. Usual and customary charge. Humana Family
4. In-house unit dose diff. + 0.015/dose. c/o Humana Medical Plan, Inc.
3501 SW 160th Street
Maximum Allowable Cost: State imposes Federal Miramar, FL 33027
Upper Limits as well as State-specific limits on T: 800/488-6262
generic drugs. MAC override by physicians requires F: 305/626-5086
“Dispense as written” plus a completed Multi-Source
Brand Drug form and prior authorization. Jackson Memorial Health Plan
1801 NW 9th Ave., Suite 700
Incentive Fee: No incentive fee. Miami, FL 33136
T: 800/721-2993
Patient Cost Sharing: No copayment F: 305/545-5212

Cognitive Services: Does not pay for cognitive Personal Health Plan
services. 324 Datura Street, Suite 401
West Palm Beach, FL 33401
E. USE OF MANAGED CARE T: 866/930-0035
F: 561/833-9786
Approximately 740,000 Medicaid recipients received
Preferred Medical Plan, Inc.
pharmaceutical benefits through managed care plans
4950 SW 8th Street
(inclusion of such benefits is mandated under State
Coral Gables, FL 33134
law) in FY 2006.
T: 305/447-8373
F: 305/648-4094
Managed Care Organizations
Amerigroup Florida, Inc. StayWell Health Plan of Florida, Inc.
(FKA Physicians Health Care Plans, Inc.) 8735 Henderson Road, Ren 2
4200 W. Cypress Street, Suite 900 Tampa, FL 33634
Tampa, Fl 33607-4173 T: 813/935-5227
T: 813/830-6900 T: 866/334-7927
T: 800/600-4441 F: 813/290-6332
F: 813/314-2045

Florida-3
National Pharmaceutical Council Pharmaceutical Benefits 2007

Total Health Choice Medicaid DUR Board


8701 SW 137th Avenue, Suite 200
Adam Golden, M.D., M.B.A.
Miami, FL 33183
Miami Beach, FL
T: 305/408-5739
F: 305/408-5880
Anna Hayden, D.O.
Fort Lauderdale, FL
United Healthcare of Florida, Inc.
13621 N.W. 12th Street
Yolangel Hernandez Suarez, M.D., FAOG
Sunrise, FL 33323
Miami, FL
T: 800/910-3145
Leanne Lai, Ph.D.
Universal HealthCare, Inc.
Ft. Lauderdale, FL
150 Second Avenue North, Suite 400
St. Petersburg, FL 33701
Larry Mattingly, D.O.
T: 727/456-6519
Fleming Island, FL
F: 727-823-3840
Lawrence Mobley, M.D.
Vista South Florida
Pensacola, FL
(FKA Foundation Health Plan)
300 South Park Road
Lesia Oliver, R.Ph.
Hollywood, FL 33021
Quincy, FL
T: 800/441-5501
F: 954/986-6082
Kevin Olson, Pharm.D.
Tampa, FL
F. State Contacts
Richard Roberts, Pharm.D.
State Drug Program Administrator Jacksonville, FL
Jerry F. Wells, Bureau Chief
Gina White, Pharm.D., M.B.A.
Medicaid Pharmacy Services
Miami, FL
Agency for Health Care Administration
2728 Mahan Drive, MS 38
Prescribing Pattern Review Panel
Tallahassee, FL 32308
T: 850/487-4441 Joshua Leuchus, D.O., R.Ph.
F: 850/922-0685 Plantation, FL
E-mail: wellsj@ahca.myflorida.com
Internet address: ahca.myflorida.com Anil Mandal
St. Augustine, FL
Prior Authorization Contact
Stephen Melvin, Pharm.D.
Talisa Hardy, Pharm.D.
Tampa, FL
Pharmacy Program Manager
Agency for Health Care Administration
Dennis Penzell, D.O.
2728 Mahan Drive, MS 38
Tampa, FL
Tallahassee, FL 32308
T: 850/487-4441
Timothy Sternberg, D.M.D., M.D.
F: 850/922-0685
Jacksonville, FL
E-mail: hardyt@ahca.myflorida.com
Pharmaceutical and Therapeutics Committee
DUR Contact
Carl Brueggemeyer, M.D.
Linda G. Barnes, R.Ph.
Ponte Verda Beach, FL
Pharmacy Program Manager
Agency for Health Care Administration
Lisa Cosgrove, M.D. (Chair)
2728 Mahan Drive, MS 38
Cocoa Beach, FL
Tallahassee, FL 32308
T: 850/487-4441
Martin Lazoritz, M.D.
F: 850/922-0685
Gainesville, FL
E-mail: barnesl@ahca.myflorida.com

Florida-4
National Pharmaceutical Council Pharmaceutical Benefits 2007

John Lelekis, R.Ph., M.B.A. (Vice Chair) Medicaid Managed Care Contact
Belleair, FL
Melanie Brown-Woofter
AHCA Administrator
Shawn Myers, R.Ph., M.B.A.
Agency for Health Care Administration
Largo, FL
2727 Mahan Drive, MS 8
Tallahassee, FL 32308
Ronald Renaurt, D.O.
T: 850/487-2355
Ponte Verda Beach, FL
F: 850/410-1676
E-mail: brownme@ahca.myflorida.com
Frank Schwerin, Jr., M.D.
Naples, FL
Mail Order Pharmacy Program
William Torres, Pharm.D. State has a mail order pharmacy benefit under its
Valrico, FL diabetes demonstration waiver.

Ann C. Wells, Pharm.D. Disease Management/Patient Education


Gainesville, FL Programs

Gina E. White, Pharm.D., M.B.A. Disease/ Medical State: AIDS/HIV


Coconut Grove, FL Program Manager: Rachel Lacroix
Program Sponsor: AIDS Healthcare Foundation
New Brand Name Products Contact
Disease/ Medical State: Asthma, Hypertension,
Jerry F. Wells Renal Disease, Congestive Heart Failure, Diabetes,
850/487-4441 Sickle Cell, COPD
Program Manager: Rachel Lacroix
Prescription Price Updating Program Sponsor: Pfizer Health Solutions
First DataBank
Disease Management Program/Initiative
1111 Bayhill Drive, Suite 350
Contact
San Bruno, CA 94066
T: 650/588-5454 Rachel Lacroix
F: 650/827-5454 Program Manager
Agency for Health Care Administration
Medicaid Drug Rebate Contacts 2727 Mahan Drive, MS 20
Tallahassee,FL 32308
Carla G. Sims
T: 850/487-2355
Rebate Coordinator
F: 850/410-1676
Agency for Health Care Administration
E-mail: lacroixr@ahca.myflorida.com
2728 Mahan Drive, MS 38
Tallahassee, FL 32308
Agency for Health Care Administration
T: 850/487-4441
Officials
F: 850/922-0685
E-mail: simsc@ahca.myflorida.com Dr. Andrew Agwunobi
Secretary
Claims Submission Contact Agency for Health Care Administration
2727 Mahan Drive, MS 1
Kevin Whittington
Tallahassee, FL 32308
Clinical Program Coordinator
T: 850/922-3809
ACS State Healthcare
F: 850/488-0043
904 Roswell Road
E-mail: agwunoba@myflorida.com
Roswell, GA
850/201-1111

Florida-5
National Pharmaceutical Council Pharmaceutical Benefits 2007

Thomas W. Arnold Florida State Board of Pharmacy


Deputy Secretary for Medicaid Dana Droz, R.Ph., J.D.
Agency for Health Care Administration Executive Director
2727 Mahan Drive, MS 8 4052 Bald Cypress Way, Bin C04
Tallahassee, FL 32308 Tallahassee, FL 32399-3254
T: 850/413-9660 T: 850/245-4292 ext. 3600
F: 850/488-2520 F: 850/413-6982
E-mail: thomas.arnold@myflorida.com E-mail: mqa_pharmacy@doh.state.fl.us
Internet address: www.doh.state.fl.us/mqa/pharmacy
Sybil Richard
Assistant Deputy Secretary for Medicaid Operations Florida Hospital Association
Agency for Health Care Administration Wayne N. Nesmith
2727 Mahan Drive, MS8 President
Tallahassee, FL 32308 306 East College Avenue
T: 850/488-3560 Tallahassee, FL 32301-1522
F: 850/488-2520